James S. Bastien, LICSW, MHD Director, Uniformed Services Program Brattleboro Retreat, Brattleboro, VT

1. Mindfulness & Acceptance-Based Group Treatment for Uniformed Services Professionals with Complex Trauma: Rationale, Program Description, & Preliminary Evaluation James S. Bastien, LICSW, MHD Director, Uniformed Services Program Brattleboro Retreat, Brattleboro, VT Barbara A. Hermann, PhD Associate Director of Research and Education National Center for PTSD Veterans Administration, White River Junction, VT Dana C. Moore, MAR, MA Program Clinician Brattleboro Retreat, Brattleboro, VT 8th Annual World Conference of the Association for Contextual Behavioral Science June, 2010

2. Program Rationale • There is an estimated 1 million plus uniformed services workers who witness critical incidents throughout their careers (National Institute of Justice, 1999). • Emergency service workers are at risk for developing PTSD & other psychiatric symptoms (depression) as unanticipated side effects of their employment (Clohessy & Ehlers, 1999). • Professionals who witness trauma may experience a disruption in major beliefs regarding personal safety, vulnerability, benevolence of the world & feelings of powerlessness (Palm, Polusny, & Follette, 2004). • The very characteristics that are valued & reinforced by the professional culture act to dissuade them from seeking help (Wester & Lyubelsky, 2005). • Uniformed service workers are more likely to die from suicide than from work related injuries (Hackett & Violanti, 2003). • PTSD is an inherent “occupational hazard” experienced by a significant number of uniformed service workers (Brough, 2004). • Given the characteristics associated with uniformed services culture, treatment of PTSD for this population presents its own unique set of challenges (Fay, 2006).

3. Uniformed Service Program • Partial Hospitalization & Therapeutic Community Residence program. • Designed specifically for uniformed professionals; i.e., veterans, firefighters, police, correctional officers, emergency medical personnel (EMTs), dispatchers, critical care nurses. • Group treatment model based on “Third Wave” clinical technologies; ACT, MBSR, & DBT. • Clinical focus on trauma & addiction. • Rolling admissions. • Funded via private insurance, Medicare, & Tri-care. • Co-ed program.

4. Clinical Program Components • Acceptance & Commitment Therapy • Mindfulness Based Stress Reduction Training • Dialectical Behavior TherapySkillsGroups • Culture specific psycho-education classes. • Substance abuse psycho-education classes. • Trauma informed yoga. • Daily aerobic exercise. • Peer “Council” practice. • AA Meetings

5. BE HERE NOW Staying Grounded in Present Moment Awareness vs. Constantly Living in Your Head STAY WITH IT Willingness to Experience Emotions vs. Trying to Escape & Avoid Them CHOOSE A PATH Choosing a Direction for Your Life vs. Aimless Meandering Psychological Flexibility JUST DO IT Taking Committed Action to Move in Valued Directions vs. Repetition of Unworkable Patterns of Behavior LET IT GO Seeing Thoughts as Just Thoughts vs. “The Truth” of My Experiences JUST NOTICE IT Buying Into & Living Out of Your Self Story vs. Detached Observation of Your Internal & External Experiences

6. Uniformed Services Daily Program Schedule

7. Resident Demographics (n=18) Uniformed Service Type Primary Diagnosis Home State

8. Program Evaluation (N = 34) • Pre- to post-treatment changes in outcome and process measures (t-tests and effect size calculation) • Process-to-outcome associations (correlational analyses) • Outcome Measures: • PCL-C (PTSD Scale-Civilian Version) • PHQ-9 (Patient Health Questionnaire-9 Item Version) • Process Measures: • AAQ-2 (Acceptance & Action Questionnaire-2) • FFMQ (The Five Facet Mindfulness Questionnaire) • CFQ-28 (Cognitive Fusion Questionnaire-28) • VLQ (Valued Living Questionnaire) • Descriptive analysis ofSocial Validity Measures: • POC (Perceptions of Care Questionnaire).

9. Changes in Outcomes Age (n = 31): M = 46.00, SD = 12.27 Length of stay (n = 34): M = 11.12, SD = 2.73 * p < .004, with Bonferroni correction

10. Changes in Process Variables * p < .004 with Bonferroni correction

11. Process Analyses • Two multiple regression analyses were conducted to evaluate how well the post-treatment process measures predicted PCL-C and PHQ-9 scores. • At post-treatment, the linear combination of process measures was significantly related to: • posttraumatic stress, F(10, 21) = 7.16, p = .000, • depression, F(10, 21) = 4.10, p = .001. • The sample multiple correlation coefficient for posttraumatic stress symptoms was .89(79% of the variance). • The sample multiple correlation coefficient for depression symptoms was .81 (66% of the variance).

12. Process Analyses (cont’d) Table 2. Bivariate and Partial Correlations of the Main Process Measures and Outcomes at Post-Treatment (PCL-C: n = 32, PHQ-9: n = 33) *p < .005 for r, ^p < .008 for partial r, with Bonferroni correction

13. Perceptions of Care n = 31

14. Perceptions of Care Items 8 & 9, n = 31; Items 10-14, n = 30

15. Perceptions of Care • Top notch! Outstanding support, compassion, knowledge! • This program is ‘hands down’ the best care I have ever received! I have a complete new outlook on life. • Was very needed for me and the program was very focused on issues that I was dealing with THANK YOU! • Way beyond my expectations. Thank you all very much! I’m grateful + ‘mindful’ for what took place with the team! • Best program I have ever had, there is no question they have changed my life for the good thank you! • This program is outstanding, If I can ever be of assistance promoting it, please call on me. • This program offered a wonderful education about my issues and a great number of tools for me to continue to live a balanced, healthy and happy life moving forward from here. • I feel again. Thanks to this program.

16. Discussion • These preliminary data indicate that the treatment program produced changes in outcome and process measures as predicted. • The process measures explained a significant portion of the variance in • the post treatment outcome measures. • On the basis of the correlational analysis, it may be tempting to conclude that the only possible mediator of change in post-treatment PTSD & Depression symptoms is experiential avoidance as measured by the AAQ-2. • However, judgments about the relative importance of experiential avoidance as a predictor are difficult due to the high correlations between AAQ-2, CFQ-28, & FFMQ. • Its possible that experiential avoidance may effectively encompass the other constructs or more efficiently account for the processes hypothesized to drive the present intervention. • The lack of a unique contribution of the VLQ was an unexpected outcome. • The program’s participants are reporting high levels of satisfaction with the treatment they received.

17. Limitations/Future Directions • Need to collect formal follow-up data. • Treatment effectiveness may not hold up as clinical group sizes increase with increased census. • Majority of patients were male (92%). • Need to collect treatment integrity measures. • Absence of session-by-session assessment. • Correlation is not a “true” test of mediation as we did not establish that process measures changed before outcomes. Need repeated measures of process variables during treatment. • Limited description of sample characteristics due to program evaluation nature of investigation.