Interpersonal Violence in Military Families

Transcription

1 Interpersonal Violence in Military Families Brian L. Meyer, Ph.D. PART 2

2 What We Need to Do for Children of Veterans

3 What We Need to Do: Identify the Children Most state and local agencies that serve veterans in the general population (such as child support and child welfare) do not collect information about veterans status We need to create a box on the form to determine how many veterans are in these agencies caseloads or how many children of veterans may need or receive services related to their parent s deployment

4 What We Need to Do: Conduct the Research There is very little research on children of veterans who have completed military service We need to conduct research on child outcomes: Child maltreatment Mental health Behavioral problems Education

5 What We Need to Do: Pre- and Post-Natal Family Visitation Children of multiply-deployed veterans may be a high-risk population Nurse-Family Partnerships involving pre-natal and post-natal visitation for up to years show: Fewer behavioral problems Less child maltreatment Fewer juvenile arrests Less alcohol use Fewer runaways Lower rate of teen pregnancy Olds et al., 1994; Olds et al., 1997

6 What We Need to Do: Screening and Assessment Community needs assessments for children of veterans should be conducted Local agencies need to screen and assess the needs of children of veterans so they can respond

7 What We Need to Do: Treat Secondary Traumatization Use Trauma-Focused Cognitive Behavioral Therapy (Cohen, Mannarino & Deblinger, 2006) Teach self-care skills: Deep breathing Progressive muscle relaxation Engage in a hobby Smile Do yoga Sing out loud Drop 3 Exercise Listen to soothing music Listen to happy music Play with friends Create art Dance

8 What We Need to Do: Develop School Supports Schools with more than 10% of students from military and Veterans families should: Provide training for teachers Have specially trained counselors Run groups for those children Meet with parents to identify particular needs Maintain relationships with community agencies This is being done in a community outside Ft. Hood, TX

9 What We Need to Do: Create Service Networks Link the VA and DOD systems of care to Wounded Warriors and networks of state and local agencies to provide services to children of veterans This may require start-up funding

10 What We Need to Do for Veterans Treatment of Co-Occurring PTSD and Substance Abuse in Veterans

11 Why Should We Treat Co-Occurring Disorders Integratively? Mental health problems do not go away with abstinence Improved mental health does not bring about abstinence from substance use Separate treatment is at best uncoordinated and at worst countertherapeutic Integrated treatment leads to better outcomes

12 The Importance of Integrated Treatment for PTSD and SUDs Treating one disorder without treating the other is ineffective Sequential treatment (usually SUD first) is ineffective Fully integrated treatment is optimal Simultaneous treatment is next best

13 The Importance of Integrated Treatment for PTSD and SUDs Recent evidence on integrated and simultaneous treatment (Hien et al., 2010) suggests: - If PTSD symptoms decline, so do SUDs - If SUDs decline, PTSD symptoms do not Therefore, treating substance abuse without treating PTSD will fail This includes ASAP programs

14 Some Barriers to Integrated Treatment Most insurance does not pay for substance abuse treatment Separate payment streams Separate treatment systems Professional training biases Lack of dually trained clinicians These may be overcome by referring veterans to VHA treatment

15 PTSD and Substance Abuse Treatment PTSD symptoms may worsen in the early stages of abstinence PTSD exposure therapies may trigger substance abuse relapses Some aspects of 12-Step groups are difficult for some trauma patients Powerlessness Higher Power Issues of forgiveness

16 Phases of Integrated Treatment Phase I: Safety and Stabilization Phase II: Remembrance and Mourning Phase III: Reconnection After Herman, 1992

17 Treatment of Substance Use Disorders Medications: Alcohol: Antabuse (Disulfiram) Naltrexone Acamprosate Opiates: Methadone Buprenorphine

18 Treatment of Substance Use Disorders Evidence-Based Treatments: Motivational Interviewing Motivational Enhancement Therapy Cognitive-Behavioral Therapy (CBT) Contingency Management Twelve-step Facilitation Therapy Behavioral Couples Therapy

19 Treatment of PTSD: Medication Medication for trauma symptom management and co-morbid disorders Antidepressants Mood stabilizers Atypical antipsychotics Anticonvulsants Anxiolytics not benzodiazepines Sleep aids There is no medication that specifically treats PTSD; only Prozac, Paxil, and Prazosin have been approved

20 Treatment of PTSD and SUDs Evidence-Based Psychotherapies for Integrated Phase I Treatment: Seeking Safety Dialectical Behavior Therapy (DBT) Therapies for specific problems Imagery Rehearsal Therapy Cognitive-Behavioral Therapy EMDR resource building, safe place, etc.

21 Treatment of PTSD Evidence-Based Psychotherapies for Phase II Trauma Treatment: Cognitive Processing Therapy (CPT) Prolonged Exposure (PE) Eye Movement Desensitization and Reprocessing (EMDR) STAIR Narrative Therapy holds promise; it sequences Phase I and Phase II treatment

22 Treatment of PTSD and SUDs There are no Evidence-Based Psychotherapies for Phase III trauma treatment but couples and/or family therapy may be helpful Cognitive-Behavioral Conjoint Therapy for PTSD shows promise (Monson and Fredman, 2012)

23 Integrated Treatment for PTSD and Substance Abuse Seeking Safety is the only empiricallysupported integrated treatment for both PTSD and Substance Abuse But it is only a Phase I treatment for Safety and Stabilization

24 DOD and VA Responses to Problems in Military Families

25 Responses to Family Violence in the Armed Services In 1974, CAPTA required each armed service to develop programs to respond to child maltreatment Soon after they also began responding to spouse abuse In 1982, Congress provided funds for Family Advocacy Programs (FAPs) in all four branches of the military

26 Responses to Family Violence: Family Advocacy Programs FAPS are on all 300 military bases with families FAPS have case review committees that make determinations about substantiation of child maltreatment and spouse abuse FAPS work with military command, military law enforcement, medical staff, family center staff, chaplains, and civilian organizations to coordinate responses to family maltreatment

27 Recent Responses to Family Problems The 2010 National Defense Authorization Act (NDAA) created the Office of Community Support for Military Families with Special Needs (OSN), requiring military branches to expand community support for families with special-needs members, including referrals and assistance in obtaining services The 2013 NDAA creates Special Victims Units to improve investigation, prosecution and victim support for child abuse and domestic violence cases in military families, as well as sexual assault cases

28 Recent Changes at the VHA The Support and Family Education (SAFE) program (Sherman, 2003) 18 session program developed for caregivers of veterans with PTSD or other mental illnesses Available for free download at w3.ouhsc.edu/safeprogram The Family-to-Family Education Program, developed with the National Alliance on Mental Illness, trains family members to lead groups There is at least one program in a VA Medical Center in every state (Makin-Byrd et al., 2011)

29 Recent Changes at the VHA August, 2010, VHA directive allows provision of mental health services to family members if the mental health of the family member directly impacts the mental health of the veteran January, 2012, Caregivers and Veterans Omnibus Health Services Act requires VA to provide mental health treatment for O/O/O Veterans and their families for 3 years after return from deployment Staff training has begun or is planned for: Integrative Behavioral Couples Therapy Behavioral Couples Therapy for Substance Use Cognitive-Behavioral Couples Therapy for PTSD Behavioral Family Therapy for Serious Psychiatric Disorders

30 Recent Changes at the VHA Beginning in 2013, every VA Medical Center was required to hold a Community Mental Health Summit Starting in 2014, summits must be held annually Many summits, including the one in Richmond, initiated collaborative regional workgroups to address child and family issues This can be done in your region; ask for an invitation

31 Why Use VAMCs and Vet Centers? Evidence-based treatments are trained and mandated PTSD Prolonged Exposure Cognitive Processing Therapy Substance abuse Motivational Interviewing Motivational Enhancement Therapy Behavioral Couples Therapy

32 Why Use VAMCs and Vet Centers? Costs are usually minimal: Billed to insurance if they have it Many veterans don t have insurance Means test: reduces or eliminates costs Service-connection for PTSD results in free treatment for PTSD plus travel costs

33 A Proposal: Military/Veterans Family Dependency Courts We have Veterans Treatment Courts and Family Dependency Treatment Courts We need to develop hybrid Military/ Veterans Family Dependency Treatment Courts (Committee on Military Families, National Council of Juvenile and Family Court Judges, 2010)

34 Military/Veterans Family Dependency Courts For areas with a high density of current military and veteran families It would integrate dependency hearings with treatment using a special focus on military families Send Veterans to treatment services to rehabilitate underlying problems Regular court appearances Required attendance at treatment Random drug testing

35 Military/Veterans Family Dependency Courts Involve child welfare, mental health and substance abuse counseling, VAMCs, Veterans support organizations, Veterans Centers, and volunteer Veteran mentors

36 Military/Veterans Family Dependency Courts: Participants Judge Attorneys for parent(s) & state GAL & CASA Child Welfare worker Therapists, including military or VA For VA, it might be the Veterans Justice Outreach Specialist instead Military or Veteran Peer Recovery Advocate Someone who has been through a similar experience

37 Military/Veterans Family Dependency Courts: Training In Child Welfare In Substance Abuse In Mental Health Including Combat Stress and PTSD, TBI, Chronic Pain, Insomnia, and Depression In Military Culture In effects of deployment on children Including secondary traumatization

38 Resources

39 Resources What It Is Like to Go to War by Karl Marlantes Once a Warrior--Always a Warrior: Navigating the Transition from Combat to Home--Including Combat Stress, PTSD, and mtbi by Charles Hoge After the War Zone: A Practical Guide for Returning Troops and Their Families by Matthew Friedman and Laurie Slone

40 Resources When Someone You Love Suffers from Posttraumatic Stress: What to Expect and What You Can Do by Claudia Zayfert and Jason Deviva The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms by Mary Beth Williams and Soili Poijula Finding My Way: A Teen s Guide to Living with a Parent Who Has Experienced Trauma by Michelle Sherman and DeAnne Sherman

41 Internet Resources Military culture: coursemodules/military_culture.asp PTSD: PTSD 101 courses: coursemodules/course-modules.asp to_the_home_front_supporting_the_mental_health_of_veteran

42 Internet Resources PTSD 101 course about treating PTSD and SUDs: ptsd101/course-modules/sud.asp Practice recommendations for treating cooccurring PTSD and SUDs: va.gov/professional/pages/handoutspdf/sud_ptsd_practice_recommend.pdf

43 Internet Resources Parenting in military families: Age-based parenting tool kits for OEF/OIF veterans and their partners: Operation Enduring Families A 5-session family education and support program for veterans who have recently returned from a combat theater and their family members.

44 Internet Resources Helping family members get veterans into treatment: Coaching Into Care Adjustment after deployment PTSD treatment can help

45 Internet Resources More resources for parenting in military families: Free online parenting course for veterans: Teaches problem-solving skills for families

46 Internet Resources Children in military families: MilitaryFamilies and Military Child Education Coalition /home.aspx