SUPPORTING THOSE WHO SERVED: SUBSTANCE USE AND ... · Moral Injury can be defined as...

NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6

8/24/2019

Presented by Duane K.L. France, MA, MBA, LPC 1

SUPPORTING THOSE WHO SERVED: SUBSTANCE USE AND

COMPREHENSIVE MENTAL HEALTH FOR MILITARY

AFFILIATED POPULATIONS

PRESENTED BY DUANE K. L. FRANCE, MA, MBA, LPC

SAMSON TEKLEMARIAM, MA, LPC, CPTM

• Director of Training and Professional Development

• NAADAC, the Association for Addiction Professionals

• www.naadac.org

• [email protected]

2

PRODUCED BY

NAADAC, THE ASSOCIATION FOR ADDICTION PROFESSIONALS

WWW.NAADAC.ORG/WEBINARS

1

2

3


8/24/2019


4

WWW.NAADAC.ORG/WEBINARS

5

WWW.NAADAC.ORG/MILITARY‐VET‐TRAINING‐WEBINAR‐SERIES

CE CERTIFICATE

6

CE HOURS AVAILABLE:1.5 CE

REGISTRATION TO ATTEND:

$25

CE CERTIFICATE:INCLUDED

1. Watch and listen to this entire webinar.

2. Pass the online CE quiz, which is posted at: www.naadac.org/supporting‐those‐who‐served‐webinar

3. Maintain records of your invoice/receipt of payment and any CE certificate received from this series.

4. Email [email protected] if you experience any difficulty with this process.

To obtain a CE Certificate for the time you spent watching this webinar:

4

5

6


8/24/2019


7

Using GoToWebinar –(Live Participants Only)

Control Panel

Asking Questions

Audio (phone preferred)

Polling Questions

WEBINAR PRESENTER

• Duane K. L. France, MA, MBA, LPC

• www.veteranmentalhealth.com

• [email protected]

8

Family Care Center, LLC

WEBINAR LEARNING OBJECTIVES

9

Describe the different aspects

of the psychological

impact of military service

1 2 3

List at least three orientations or interventions addressing

different domains of veteran mental

health

Articulate how substance use

disorders interact and influence the different domains

7

8

9


8/24/2019


POLLING QUESTION #1

In addition to substance use disorders, the military affiliated population

struggles most with:

10

A. Posttraumatic Stress DisorderB. Traumatic Brain Injury C. Emotional DysregulationD. Lack of Purpose and MeaningE. Disrupted Relationships

COMPREHENSIVE VETERAN MENTAL HEALTH

11

Situational and Systematic Causes

of behavior

Stigma against help-seeking

Societal Judgement

Peer Judgement

Stereotypes: Villain, Victim, Hero

Barriers to Care

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury

EmotionDysregulation

StigmaWarrior Ethos

“Suck It Up and Drive On”

COMPREHENSIVE VETERAN MENTAL HEALTH

12

Purpose and

Meaning Relationships

Needs Fulfillment

Moral Injury

Unique to Military (First Responders)No DSM5 Diagnoses

No medication

Addiction TBI

PTSD


Not Military ExclusiveDSM 5 Diagnoses

Medication

10

11

12


8/24/2019


POLLING QUESTION #2

If a veteran is experiencing difficulty in one or more of these domains, they also likely have a substance use disorder:

13

A. Strongly AgreeB. AgreeC. Neither Agree or DisagreeD. DisagreeE. Strongly Disagree

POSTTRAUMATIC STRESS DISORDER

• Exposed to death, actual or threatened serious injury, or actual or threatened sexual violence

• Intrusive symptoms

• Avoidance

• Negative alterations in thoughts and mood

• Arousal and reactivity

• Last longer than 1 month

• Creates impairment

• Not due to medications

14

Posttraumatic Stress Disorder is a cognitive, behavioral, and neurological reaction of exposure to traumatic events. For an individual to be diagnosed with PTSD, the following

criteria must be met:

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


TRAUMATIC BRAIN INJURY

• Different types: focal and diffuse

• Different severities: Mild, Moderate, Severe

• Symptoms can be cognitive, physical, behavioral

• PTSD Trauma and TBI Trauma can be the same

• Closely mimics PTSD, with the exception ofnightmares and intrusiveness

15

Traumatic Brain Injury is a physical injury to the brain that is the result of a blow or jolt to the head, an object penetrating the brain, or widespread injury

across the brain.

15

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


13

14

15


8/24/2019


ADDICTION

• Normalization (glorification?) of drinking culture in the military

• Chronic pain resulting from constant physical stress and injuries

• Opioid dependence due to access to prescription pain relief while in the military

• Process addictions

16

Up to 75 percent of veterans with a history of PTSD in their lifetime met criteria for substance abuse or dependence

(Kulka et al., 1990)

16

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


EMOTION DYSREGULATION

• Anger, Anxiety, Depression

• Not adjusting from protective behavior while deployed or in the military to maladaptive behavior when in different environments

• Lack of ability to achieve desired goals through individual effort

• Toxic leadership and unavoidable aversive stimuli while in the military leads to assumption of helplessness after the military

17

While many veterans are resilient and adaptive, often the constant barrage of negative experiences can wear down

even the most hardy of service members.

17

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


PURPOSE AND MEANING

• In the military, service members were part of something larger than themselves

• Loss of camaraderie and mutual connection can lead to disengagement

• Confusion and anger about the loss of purpose and meaning is not explained by PTSD and TBI

18

Many veterans with PTSD live with profound doubts about the meaning of a life dominated by suffering, guilt, and death. This loss of meaning and purpose has pronounced

effects on all areas of psychosocial functioning (Southwhick, Et. Al, 2006).

18

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


16

17

18


8/24/2019


MORAL INJURY

• In the military, service members were part of something larger than themselves

• Loss of camaraderie and mutual connection can lead to disengagement

• Confusion and anger about the loss of purpose and meaning is not explained by PTSD and TBI

19

Moral Injury can be defined as “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

(Litz, et al., 2009)

19

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


NEEDS FULFILLMENT

• Learning how to fulfill needs in new ways, rather than changing the needs being met

• The “shadow side” of Maslow’s Hierarchy: meeting needs in socially unacceptable ways, such as using force and aggression to meet safety and aesthetic needs

20

Once a veteran has developed a sense of achievement and mastery in the military, they then have to pivot to developing

mastery in an entirely different arena.

20

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


RELATIONSHIPS

• Disrupted relationships

• Cross‐generational combat operations

• Multiple deployments compounding impact on family

• Domestic Violence

21

When military parents fulfill occupational duties during wartime, children and families face multiple challenges, including extended separations, disruptions in family routines, and potentially compromised parenting

related to traumatic exposure and subsequent mental health problems (Paley, Lester, & Mogil, 2013).

21

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


19

20

21


8/24/2019


POLLING QUESTION #3

There is a single intervention that is best at addressing all or most of the aspects of comprehensive SMVF mental health

22


POSTTRAUMATIC STRESS DISORDER INTERVENTIONS

• Cognitive Processing Therapy

• Prolonged Exposure

• Cognitive Behavioral Therapy

2323

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


TRAUMATIC BRAIN INJURY INTERVENTIONS

• Treating co‐morbid psychological disorders: TBI

• Medical interventions: Pain management

• Physical interventions: Balance, Physical rehabilitation

• Cognitive restructuring: Neurofeedback, biofeedback, speech‐language pathology

2424

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


22

23

24


8/24/2019


ADDICTION INTERVENTIONS

• Contingency Management

• Motivational Interviewing


• Relapse Prevention

2525

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


EMOTION DYSREGULATION INTERVENTIONS


• Dialectical Behavior Therapy

• Learned Helplessness (Toxic leadership, unavoidable aversive situations)

2626

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


PURPOSE AND MEANING INTERVENTIONS

• Existentialism: Rollo May, Irvin Yalom, Viktor Frankl

• “Veterans appeared to be particularly attracted to complementary health approaches because these therapies addressed spiritual issues and questions of meaning not inherent in conventional medical approaches” (Schuman, 2016)

2727

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


25

26

27


8/24/2019


MORAL INJURY INTERVENTIONS

• Adaptive Disclosure

• Prolonged Exposure

• Acceptance and Commitment Therapy

2828

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


NEEDS FULFILLMENT INTERVENTIONS

• Maslow’s Hierarchy of Needs

• Community‐based intervention: Homelessness, employment

• Connectedness: peer groups

• Acceptance and Commitment Therapy

2929

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


INTERPERSONAL RELATIONSHIP INTERVENTIONS

• Inter‐generational and Intra‐generational

• Family systems theory

• Marriage and Family Therapy

• Dialectical Behavior Therapy (Interpersonal Relationships)

3030

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


28

29

30


8/24/2019


POLLING QUESTION #4

Comorbid substance use disorders are an exacerbating factor of the other aspects of comprehensive SMVF mental health

31


ADDICTION AND PTSD

• Increase avoidance of traumatic memories

• Impact vivid reexperiencing

• Alterations in mood and cognitions impacted by substance use

3232

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


Individuals with co‐occurring PTSD and substance use may be using substances in an attempt to forget or block out trauma related recollections…several substances including alcohol have been found to impair cognitive

capacities such as memory and thus may serve as a viable means of suppression (Walton, Et

al., 2018).

ADDICTION AND TRAUMATIC BRAIN INJURY

• Increased risk for self‐inflicted death.

• TBI and associated psychiatric and substance use disorders are 21 times more likely to attempt suicide (Brenner, Homaifar, Adler, Wolfman, & Kemp, 2009)

3333

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


31

32

33


8/24/2019


ADDICTION AND EMOTIONAL DYSREGULATION

• Lack of awareness, understanding, and acceptance of emotions

• Difficulties controlling behaviors when experiencing emotional distress

• Lack of access to adaptive strategies for modulating the duration and/or intensity of aversive emotional experiences

• An unwillingness to experience emotional distress as part of pursuing meaningful activities in life

3434

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury

EmotionDysregulation “Overall emotion dysregulation…fully

mediated the relation between negative affect and urges to engage in risky

behaviors, whereas lack of emotional awareness partially mediated this

association” (Weiss, Williams, & Connolly, 2015)

ADDICTION AND PURPOSE AND MEANING

• Addiction may become a purpose substitute, satisfying the need for purpose and meaning in an unsatisfied life (Keshen, 2006)

• Substance Abuse

• Pathologic Gambling

• Overeating

• Pathologic Shopping

3535

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


ADDICTION AND MORAL INJURY

• According to Carmona‐Perera Et al. (2012), Substance use indicates

• defective decoding of moral emotions like anger or disgust

• reduced reactivity to emotionally competent stimuli

• poor affective‐based decision making

3636

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


34

35

36


8/24/2019


ADDICTION AND NEEDS FULFILLMENT

• Rates of medical, psychiatric, and substance disorders are substantial among homeless people (Bakhtiar Et al., 1995)

• The unemployed are more likely to consume excessive amounts of alcohol, and to use illicit and prescription drugs. They are more likely to smoke and develop dependence on alcohol and illicit drugs (Henkel, 2011).

• difficulties in achieving positive lasting social relationships because of ongoing struggles with substance abuse recovery (Padgett, Henwood, Abrans, & Drake, 2008)

3737

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


ADDICTION AND RELATIONSHIPS

• High levels of PTSD severity combined with substance use / abuse indicated higher levels of nonphysical aggression (Hellmuth, 2012)

• Alcohol use likely exacerbates PTSD symptoms, such as difficulty tolerating and regulating strong negative emotions and heightened sense of threat perception (Steppenbeck, Hellmuth, Simpson, & Jakupcak, 2014)

• Aggression is directly related to PTSD re‐experiencing symptoms and alcohol misuse

3838

Purpose and

Meaning

Addiction TBI

PTSD

Relationships

Needs Fulfillment

Moral Injury


THERE IS A MYTH THAT VETERANS ARE BROKEN. THAT WAR HAS SOMEHOW DESTROYED THE MIND, BODY, AND SOUL. THE IDEA THAT WE AS VETERANSARE DYSFUNCTIONAL AND CANNOT REINTEGRATE BACK INTO SOCIETY IS ABSOLUTE

GARBAGE. MANY OF US DO IT TO OURSELVES, THOUGH NOT ON PURPOSE. SOCIETY HAS THIS STIGMA ABOUT WARRIORS, THAT WHAT WE DO SOMEHOW RIPS APART OUR HUMANITY AND DAMAGES US BEYOND REPAIR. SOME WILL STATE THE SUICIDE EPIDEMIC THAT PLAGUES THE VETERAN COMMUNITY ASEVIDENCE THAT WE ARE BROKEN. WE RESPECTFULLY DISAGREE, IT IS, BUT A

SYMPTOM.

‐ JOHN FANNIN, AMERICAN GRIT

37

38

39


8/24/2019


40

• Brenner, L. A., Homaifar, B. Y., Adler, L. E., Wolfman, J. H., & Kemp, J. (2009). Suicidality and veterans with a history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies. Rehabilitation Psychology, 54(4), 390.

• Carmona‐Perera, M., Verdejo‐García, A., Young, L., Molina‐Fernández, A., & Pérez‐García, M. (2012). Moral decision‐making in polysubstance dependent individuals. Drug and alcohol dependence, 126(3), 389‐392.

• Glasner‐Edwards, S., & Rawson, R. (2010). Evidence‐based practices in addiction treatment: Review and recommendations for public policy. Health policy, 97(2‐3), 93‐104.

• Hall, L. K. (2016). Counseling military families: What mental health professionals need to know. Routledge.

• Henkel, D. (2011). Unemployment and substance use: a review of the literature (1990‐2010). Current drug abuse reviews, 4(1), 4‐27.

• Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., ... & Foa, E. B. (2010). Dissemination of evidence‐based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of traumatic stress, 23(6), 663‐673.

• Keshen, A. (2006). A new look at existential psychotherapy. American Journal of Psychotherapy, 60(3), 285‐298.

• Hellmuth, J. C., Stappenbeck, C. A., Hoerster, K. D., & Jakupcak, M. (2012). Modeling PTSD symptom clusters, alcohol misuse, anger, and depression as they relate to aggression and suicidality in returning US veterans. Journal of traumatic stress, 25(5), 527‐534.

• Kulka, R. A. (1990). The national Vietnam veterans readjustment study: Tables of findings and technical appendices. Brunner/Mazel Publisher.

• Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical psychology review, 29(8), 695‐706.

• Padgett, D. K., Henwood, B., Abrams, C., & Drake, R. E. (2008). Social relationships among persons who have experienced serious mental illness, substance abuse, and homelessness: Implications for recovery. American journal of orthopsychiatry, 78(3), 333‐339.

• Paley, B., Lester, P., & Mogil, C. (2013). Family systems and ecological perspectives on the impact of deployment on military families. Clinical child and family psychology review, 16(3), 245‐265.

• Scholten, J., Vasterling, J. J., & Grimes, J. B. (2017). Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference. Brain injury, 31(9), 1246‐1251.

REFERENCES

41

• Schuman, D. (2016). Veterans' experiences using complementary and alternative medicine for posttraumatic stress: A qualitative interpretive meta‐synthesis. Social work in public health, 31(2), 83‐97.

• Southwick, S. M., Gilmartin, R., Mcdonough, P., & Morrissey, P. (2006). Logotherapy as an adjunctive treatment for chronic combat‐related PTSD: A meaning‐based intervention. American Journal of Psychotherapy, 60(2), 161.

• Stappenbeck, C. A., Hellmuth, J. C., Simpson, T., & Jakupcak, M. (2014). The effects of alcohol problems, PTSD, and combat exposure on nonphysical and physical aggression among Iraq and Afghanistan war veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 6(1), 65.

• Walton, J. L., Raines, A. M., Cuccurullo, L. A. J., Vidaurri, D. N., Villarosa‐Hurlocker, M. C., & Franklin, C. L. (2018). The relationship between DSM‐5 PTSD symptom clusters and alcohol misuse among military veterans. The American journal on addictions, 27(1), 23‐28.

• Weiss, N. H., Williams, D. C., & Connolly, K. M. (2015). A preliminary examination of negative affect, emotion dysregulation, and risky behaviors among military veterans in residential substance abuse treatment. Military behavioral health, 3(4), 212‐218.

• Wenzel, S. L., Bakhtiar, L., Caskey, N. H., Hardie, E., Redford, C., Sadler, N., & Gelberg, L. (1995). Homeless veterans' utilization of medical, psychiatric, and substance abuse services. Medical Care.

REFERENCES

42

40

41

42


8/24/2019


[email protected]

WWW.VETERANMENTALHEALTH.COM

THANK YOU!

CE CERTIFICATE

44

CE HOURS AVAILABLE:1.5 CE

REGISTRATION TO ATTEND:

$25

CE CERTIFICATE:INCLUDED

To obtain a CE Certificate for the time you spent watching this webinar:

1. Watch and listen to this entire webinar.

2. Pass the online CE quiz, which is posted at: www.naadac.org/supporting‐those‐who‐served‐webinar

3. Maintain records of your invoice/receipt of payment and any CE certificate received from this series.

4. Email [email protected] if you experience any difficulty with this process.

45

Over 145 CEs of free educational webinars are available. Education credits are FREE for NAADAC members.

WEBINAR SERIES

In each issue of Advances in Addiction & Recovery, NAADAC's magazine, one article is eligible for CEs.

MAGAZINE ARTICLES

NAADAC offers face-to-face seminars of varying lengths in the U.S. and abroad.

FACE-TO-FACE SEMINARS

Earn CEs at home and at your own pace (includes study guide and online examination).

INDEPENDENT STUDY COURSES

NAADAC Annual Conference, September 28 – October 2, 2019Orlando, Floridawww.naadac.org/2019annualconference

CONFERENCES

Demonstrate advanced education in diverse topics with the NAADAC Certificate Programs:

• Recovery to Practice

• Conflict Resolution in Recovery

• National Certificate in Tobacco Treatment Practice

CERTIFICATE PROGRAMS

www.naadac.org/education

43

44

45


8/24/2019


Thank you for joining!

NAADAC44 Canal Center Plaza, Suite 301Alexandria, VA 22314

phone: 703.741.7686 / 800.548.0497 fax: 703.741.7698 / 800.377.1136

[email protected]

46

Date post:	04-Oct-2020
Category:	Documents
Upload:	others
View:	3 times
Download:	0 times

SUPPORTING THOSE WHO SERVED: SUBSTANCE USE AND ... · Moral Injury can be defined as...

Documents