Military Trauma

1. Military Trauma Fostering Peer Support: Results from a group-based intervention John Whelan, PhD. & Jean Guy Trudel, CWO (Ret’d) 29 April, 2014 Disclaimer- No interests to disclose

2. Purpose • Outline the development of a peer supported treatment intervention for traumatized veterans. • Describe the necessity of co-leadership and supervision of peers in trauma work. • Describe the contribution of peer support for continuing growth and trauma repair following formal treatment.

4. PTSD in Canada • Prevalence rate of lifetime PTSD in Canada estimated at 9.2% and rate of current (1-month) PTSD of 2.4%. • Traumatic exposure to at least one event sufficient to cause PTSD (Amerigen, Mancini, Patterson, Boyle, 2008). • Developmental abuse predictive of adult PTSD in numerous recent studies (e.g., ACE Study). http://www.traumaline1.com/node/74

5. Individual Trauma Therapy • Cognitive-behavioural therapies (e.g., PE, CPT) and EMDR have proven effectiveness in the treatment of PTSD. Even so, trauma symptoms can persist at rates of up to 50 percent in some populations (Nilamadhab, 2011; Wampoldet al, 2010). • Social isolation and lack of supports often continue following successful individual interventions (Rademaker et al., 2009). • Post-treatment declines common for co-occurring PTSD, substance abuse, and developmental abuse (Whelan, 2013).

6. The Comorbidity Problem • Up to 80% of PTSD comorbid with other disorders (e.g., addiction, mood and anxiety disorders, PD). (Ouimette at al., 2003; Dragan & Turlesejska, 2007). • PTSD and Addiction -60% - 80% of cases (Ouimette et al., 2003; Norman et al., 2007). • PTSD and Developmental Abuse - Up to 90% in some populations (Felitti, & Anda, 2010; Forbes et al, 2013; Kozaric-Kovacic, 2008; Schumacher, Coffey, & Stasiewicz, 2006) • Combinations of PTSD, SUD, ACE among Canadian veterans (Whelan, 2013)

7. Meeting the Challenge • Develop an integrated, emotion-focussed, group intervention to address comorbid problems (DND-VAC RFP; TARP, 2005; Whelan, 2003). • Restructured as an outpatient group program in 2007 to address PTSD, SUD, and developmental trauma. • An intervention that could provide possibility of improvements beyond symptom management - Posttraumatic Growth (Tedeschi &Colhoun, 2004).

8. Why Group Therapy? • Natural fit: Military personnel function in groups beginning with basic training and onward. • Utilizes the power of mutuality and shared experiences as a curative agent. • Counters social isolation/emotional avoidance • Normalizes experiences • Re-establish shared values/goals/ hope • Group as client not individuals • Peers are guided to connecting/witnessing/challenging

9. Emotional-Focussed Therapy • Unresolved childhood trauma highly related to substance abuse. • Learned emotional avoidance as adaptive coping. • Inability for adults to process emotional aspects of adult PTSD (e.g., high avoidance, dissociative behaviours, aggression).

10. Role of Group Leaders • Leaders assume directive and transparent roles in maintaining psychological safety while guiding each person through the details of their stories. • Maintain agreed up on rules and structure. • Model empathy, attunement, genuine emotional disclosure. • Psycho-education and body-focussed interventions, as needed. • Focus on relational repair and respectful boundaries.

11. Group Leader Challenges • Avoid tendency to act as expert knows best • Resist doing individual therapy in a group room • Limited place for lecturing and psychoeducation. • Need to tolerate own emotions without dissociating or distracting the group’s work. • Open and honest relationship between co-leaders and regular, ongoing debriefings.

12. Importance of Culture • High sensitivity to military language/culture by group leaders. • Paraprofessional peer as a co-leader. • Peer-identification (military self-esteem) as a regulating and resource structure (support and challenge) for relational repair (trust in others). • Clear structure, consent, shared rules, goals, empathic and attuned leaders, and non-pathologizing language (e.g., dissociation as a learned behaviour)

13. Using power of group therapy to foster a Peer Network • Importance of regulated emotional expression in healthy relationships. “Admitting that I can be vulnerable is tough but I need to lower my shield” • Support and challenge from peers. “I know that these guys have my back and that’s a good feeling” • Process reactions of betrayal/mistrust. “I just wish somebody would have asked me what I wanted” • To re-establish positive connection to military identity. “I feel like I am part of a unit again” • OSI within the context of military careers. “There were many good times, too, that I miss” • Address retirement and abandonment reactions. “I would go back in a heartbeat but I have to accept that it is over”

14. Trauma Relapse Prevention Group • Approved in 2007 with referrals from VAC, RCMP, and DND. • Psychologist led, 8-week, developmentally-focussed program addressing operational PTSD, SUD, and early life abuse. • Manual-assisted, structured treatment program . • Strict inclusion criteria based on standardized evaluation. • Primary focus on mutual trust and psychological safety. • Trauma processing sessions across the lifespan aimed at expanding emotional tolerance and reappraisal of critical events (3-sided window). • Supported, emotional exposure forms the base from which members can revisit distressing memories without being overwhelmed or feeling shamed.

15. Reconnection through Story • The challenge was to create a setting and conditions to help re-establish “psychological sense of community” (Sarason, 1988). • Trust as earned right; not assumed as a given. • Relational repair as a component of trauma treatment.

16. Trauma Peer Support • Establishing trust and mutuality: • “I can tell my story to peers who understand it and can handle it” • “They did not judge me and helped me hold it together when I started to fall apart.” • ** Only after hearing other peers stories and seeing that other soldiers ‘are backed’ by fellow soldiers that the peer network functions effectively.

17. Program Outcomes: Participants • History of operational PTSD • Clients of Veterans Affairs/RCMP/DND. • Approximately 50 male military veterans with a 94% retention rate (Groups of 6-7). • Average age 48 years (36 to 63); • 20.5 years service (5 to 37); • Retired for 5.8 years (2 to 25). • 55% - history of adolescent substance abuse, • 81% - military substance abuse • 23% - childhood sexual abuse • 68% -childhood physical abuse.

18. Results

19. Results

20. Results

21. Feedback from Participants • Guided review of life story/critical points within a peer-supported, structured, military-sensitive environment appears to be an essential step in resolving longstanding mistrust, betrayal, shame, and emotional disconnection. • Emphasis on central role of presence of military peers in being able to tell their full stories. • Leaders important in providing education, maintaining safety, and an emotionally-focussed environment. • Strong level of group cohesion (outside social events; “I have a new unit”; “I found a friend here”; “I am not alone or crazy”). • Need for continued contact with the group.

22. Beyond the Therapy Room • Outside activities/gatherings • Monthly follow-up sessions (1 year) • Conduct maintenance groups for 1 year to re-enforce continued interpersonal engagement, address potential setbacks, and review updates on relational, social, and recreational goals. • Moving maintenance groups into a larger self-managed support network. • Therapist as back-up support to the group • Based in shared experiences • Present-focussed • Peer driven priorities

23. Peer Co-leader • Importance of credibility • Have addressed their own mental health and trauma • Have established ‘back-up’ • Clear boundaries • Exemplify hope though lived recovery experience • Imperative of knowing when to step back or to step-out • Integrity above all else.

24. QUESTIONS/COMMENTS Thank You Presentation: whelanpsych.com