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An Integrative Approach to Recovery POTENTIAL FOR RECOVERY AND HEALING WITHIN A VETERAN’S FAMILY DANIELLE CENTOFRANCHI, MA, LCSW JUNE 14, 2016 Learning Objectives 1. Clinicians will be able to identify the five roles family members or loved ones adopt when there are issues of substance abuse in the family & how to identify which type of communication is necessary to address these roles in order to assist clients with restoring balance. 2. Clinicians will integrate Cognitive Behavioral Therapy, Motivational Interviewing and Seeking Safety to organize the family or client’s difficulty with providing a healthy and supportive environment for the Veteran trying to remain sober and thus, resolve the family dynamic. Physiological & Psychological Effects All branches are trained to be aware of and pay attention to every single detail causing a state of consistent hypervigilance Military service is difficult, demanding, and dangerous The insurgency warfare and guerilla tactics characteristic of post 9/11 war zones are unprecedented and produce significant consequences Over 75% of post 9/11 injuries are results of explosions from improvised explosive devices (IEDs), car bombs, and suicide bombs TBI is the most common physical injury Moral injuries include exposure to traumatic events, multiple deployments, and unpredicted deployment length Invisible injuries present cognitive, behavioral, and interpersonal challenges Consequences of Deployment Frequent relocations and an ever-present concern for the service members well-being during deployment Military families move every 2-3 years, hindering a partner’s ability to maintain a social network and achieve educational or career goals, including any long term plans Emotional impact on partner and children, who report being lonely, anxious and depressed 78% of OEF/OIF veterans reported at least one family issue 25% report that their children are afraid of them 40% felt like a guest in their own home Impact of Deployment on a Family Service member’s children demonstrate more behavioral problems in school and when with peers versus civilian children Partners experience increased psychological stress and decreased psychological functioning Increased rates of child abuse, maltreatment, and neglect Higher divorce rates (statistically observed in the Army) The reorganization of roles within a family can be ambiguous and anxiety-producing for children Injuries that cause prolonged hospitalization and rehabilitation limit a parent's ability to effectively interact with his/her child(ren) The three most common deployment injuries include: TBI, PTSD, and depression Homecoming & Reintegration Service members must adjust to a drastically different environment, daily schedule, and set of relationships that illicit new or different emotions Struggle with the positive and negative stress of incorporating the service member back in to the family Mourning the loss of who the service member was before deployment and acclimating to who the service member is now If physically injured, can result in impairments in parenting and family function Exposure to parental irritability, aggression, and hostility can increase poor child adjustment leading to family disequilibrium Re-conditioning self back to a civilian and civilian way of life Substance Misuse OEF/OIF veterans are facing an estimated co-occurrence rate of between 25 and 50% In 1980 a study found that 74% of Vietnam Veterans with PTSD had comorbid Substance Abuse Disorder (SUD) Alcohol misuse, hazardous drinking, binge drinking, and abusing or misusing prescription medications are common among OEF/OIF veterans Common causes of substance misuse/abuse include using it as a way to self-medicate, to feel numb, to forget about the difficult feelings and to erase the memories related to their experiences Substances are used as an aid to cope with stressful or traumatic events and to subdue mental health problems (sleep, anxiety, depression) Reduces pain, lessens fatigue and help to cope with boredom or panic that accompany battle How to Support Veteran with SUD Family members should be mindful of behaviors by making nonjudgmental statements, not reacting negatively to situations, and by reducing the capacity for trauma-related triggers Understanding of psychological flexibility: the ability to fully experience the present moment while engaging in behavior that is consistent with chosen values even when the present moment includes difficult emotions or thoughts Acceptance has been posited to be particularly appropriate for service members and their partners because of the rigidity and avoidance that typify PTSD Observe behavioral changes within family roles 6 Common Roles in Family with SUD Dependent or the alcoholic, substance user Enabler Hero Scapegoat Lost Child Mascot Substance User/Dependent Experiencing emotional and/or physical pain, shame, and denial Loneliness Uses defenses to hide shame and guilt by acting irrationally angry, charming, rigid, grandiose, perfect, socially withdrawn, hostile or depressed Enabler/Co-dependent/Caretaker Usually the spouse or significant other Will do anything and everything possible to make behaviors stop (except what works) Rarely will they confront the dependent or leave the relationship Enabling is anything that protects the dependent from the consequences of their actions, and this becomes habitual Tends to everyone’s needs in the family Loses sense of self in tasks of domestic nature Purpose is to maintain an appropriate appearance to the outside world Hero This is the person in the family who sees and hears what is happening and takes responsibility for the family by becoming successful and popular Often the oldest child Forms alliance with sober members of family Source of stability and dependability May compensate for dependent’s behaviors through over achievement Feeling of responsibility to fix family’s pain Inner needs are rarely met because only receiving attention for achievements Purpose is to raise family’s esteem Scapegoat Goes against rules, acts out to take focus off dependent Feels hurt and guilt because of behavior Direct message is that they are responsible for the family’s chaos Child has issues with authority figures May show self-pity, strong identification with peer values, defiance and hostility Inside they feel lonely, angry, and guilty Allows other a pretense of control, without it family would dismantle Purpose is to put the focus off the dependent, thereby allowing them to continue using substances Lost Child No connection to the family, difficulty learning communication and relationship skills Much in common with scapegoat Observes more than is said Does not participate in activity of family Loners Isolated physically and psychologically Purpose is to prevent added demands on the family due to their low maintenance Mascot Usually the youngest in the family Conversations are usually superficial as deep meaningful conversations can trigger pain and shame Make light of situation in order to relieve tension and gain parental attention Immature Laughter prevents healing rather than produces it Purpose is to provide levity to the family and relieve stress and tension by distracting everyone Difference between Enabling & Supporting Enabling looks like: Putting your own needs aside to care for the substance user Feeling resentful for taking on more than your share of responsibilities Lying to others, especially yourself, about unacceptable behavior Spending a lot of time focusing on fixing the substance user Bailing the substance user out of disasters they created Difference between Enabling & Supporting Supporting looks like: Establishing clear and consistent boundaries with what behaviors are and are not acceptable from the substance user Utilizing appropriate consequences for negative or dangerous behaviors Providing and encouraging substance user to obtain services for their substance use Exploring options for self-care and self-help, including meetings Evidenced Based Therapies Cognitive Processing Therapy Cognitive Behavioral Therapy Prolonged Exposure Therapy Eye Movement Desensitization and Reprocessing (EMDR) Motivational Interviewing Seeking Safety Cognitive Processing Therapy CPT is a manualized 12-session, specific form of Cognitive Behavioral Therapy (CBT) for PTSD that has a primary focus on cognitive interventions Initial session of CPT is psychoeducational Clients are taught to identify the connection between events, thoughts, and feelings and to practice this throughout assigned homework Includes exposure to traumatic memory through writing and reading accounts, with a focus on feelings, beliefs, and thoughts that emanated from the traumatic event Overgeneralized beliefs are challenged as they relate to self and others Cognitive Behavioral Therapy CBT is goal directed and semi-structured therapy that involves a partnership between the client and the therapist CBT focuses on exploring relationships among a person’s thoughts, feelings, or behaviors Therapist works to uncover unhealthy patterns of thought and how they may be causing self-destructive behaviors and beliefs Therapist works with client to develop constructive ways of thinking that will produce healthier behaviors and beliefs Core principles are identifying negative or false beliefs and restructuring them through use of homework in between sessions Prolonged Exposure Therapy PE is an evidenced based, manualized protocol effective for the treatment of PTSD PE is based in Emotional Processing Theory, which posits that PTSD symptoms arise as a result of cognitive and behavioral avoidance of trauma-related thoughts, reminders, activities and situations. PE helps the client interrupt and reverse the process by blocking cognitive and behavioral avoidance, introducing corrective information, and facilitating organization and processing of the trauma memory and associated thoughts and beliefs EMDR Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy approach that has been proven effective for the treatment of trauma Set of standardized protocols that incorporates elements from many different treatment approaches; however, is a non traditional form of therapy EMDR is an 8 phase treatment Involves attention to three time periods: past, present, and future The therapist moves his finger back and forth in front of your face and asks you to follow these motions with your eyes while asking you to recall a disturbing event, then gradually will guide you to shift your thoughts to more pleasant ones Motivational Interviewing MI works on facilitating and engaging intrinsic motivation within the client in order to change negative behavior Goal oriented and client centered counseling Non-judgmental, non-confrontational, and non-adversarial Increases the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the change behavior Main goals are to engage clients, elicit change talk, and evoke motivation to make positive changes from the client Seeking Safety Seeking Safety is evidenced-based, present-focused counseling modeled to help people attain safety from trauma and/or substance abuse Directly addresses trauma/abuse without requiring clients to delve into the trauma narrative 25-week curriculum therapy, styled similar to Cognitive Behavioral Therapy Focuses on grounding techniques, coping skills, and inner-self talk/dialogue Focusing on CBT, MI, and Seeking Safety Interventions are statistically proven to reduce negative symptoms of PTSD and SUD Encourage open-lines of communication with family members and peers Explore use of self-talk and inner dialogue Promote effective and assertive communication skills Includes homework, handouts, and psychoeducational material Limit recount of trauma narrative Increase coping skills Importance of Psychoeducation Psychoeducation is education offered to individuals or families with a mental health condition to help empower them and deal appropriately with their condition, yielding optimal results Patient training courses, family training courses, and parent training courses are examples of psychoeducation The goal with psychoeducation is for the consumers to understand the diagnosis and ways to effectively manage the situation Resources and coping skills are strengthened and used to contribute to the family’s emotional health and well-being, in addition to the client’s Different Types of Communication Passive Aggressive Passive-Aggressive Assertive Importance of Communicating Assertively Allows the expression of clearly stated opinions and feelings Allows the advocacy of their rights and needs without violating the rights of others Encourages high-self esteem Stems from emotional intelligence Promotes healthy boundaries Fundamental for positive mental health and healthy relationships How MI, CBT, and Seeking Safety Reinforce Assertive Communication MI teaches the client to feel comfortable with confrontation, feel safe setting appropriate boundaries and limits, establishes credibility, and encourages the use of appropriate self-disclosure CBT reinforces positive self-esteem, appropriate self-talk/internal dialogue, and promotes healthy boundaries Seeking Safety teaches positive coping skills, effective grounding techniques, and closure to traumatic events or experiences while promoting safety Why Include the Family into Treatment? Post-deployment reintegration strengthens family relationships through a shared sense of purpose Positive family reintegration is an important determinant of longterm psychological well-being Physical reunion does not always guarantee emotional reconnection Gearing sessions to focus on shared meaning, committing to mutual collaboration, and using open expression and assertive communication helps to build resiliency and facilitate positive growth Clinicians should focus on prevention, psychoeducation, behavioral management and communication style Resources Where to go when loved one is using substances? Where to go when you are using substances? Importance of appropriately trained staff aware of how to address the military culture Credible and current provider list Point of contact at nearest VA Hospital Contact Information Danielle Centofranchi, MA, LCSW [email protected] Hopeforachange.org (516) 987-7139