Since September 11th, 2001, over two million United States service members have been deployed to Iraq and Afghanistan. Multiple factors related to the conflicts in Iraq and Afghanistan and the Global War on Terror (e.g., multiple deployments, length of deployments, intensity and nature of combat operations) have led to an increase in psychological disturbance among service members following their deployments (Rand Study, 2008). Behavioral health issues such as posttraumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), and substance misuse have been seen at increasing higher rates not only in active-duty service members, but in our veteran population as well. Obviously, these problems do not end when an individual separates from the military, but the onus of responsibility for who is responsible for their care does. This shift in responsibility does not fall solely on the Veterans Administration (VA); it also falls on civilian providers of healthcare in the community. President Obama’s signing of an Executive Order to improve access to mental health services for veterans, service members, and military families on August 31, 2012 highlights how these issues have been recognized at the highest levels of government, and that a change in national strategy is needed to meet the needs of our military that have been identified and continue to be unmet. Part of President Obama’s multi-pronged approach asks for partnerships between the VA and community providers to enhance access to mental health care. President Obama has also called for focused attention on treatment- specifically research on treatments for PTSD and TBI (White House Press Release, August 31, 2012). There is a recognition that both within and outside of the VA it can be difficult to identify treatments that work as well as individuals who are competent to provide such treatments.
Examining these challenges for our service members, veterans, and military families on a more local level, the RAND Corporation conducted A Needs Assessment of New York State Veterans in 2011. Sponsored by the New York State Health Foundation, this study found that, among New York State veterans, a significant proportion of those surveyed (56%) were identified as having a need for mental health services. Despite this need, only about half of those individuals actually sought care in the prior year. Most concerning for the half who sought services is that only half received or completed a “minimally adequate” course of treatment. Regarding preference for where veterans want to go for care, 46% indicated they would prefer to receive mental health services from a civilian provider (as opposed to the VA).
These realities highlight a number of factors that civilian, community providers of mental health services need to consider. First, a provider may choose not to take part, or have the opportunity to take part in, the care of active-duty service members and their families. However, they cannot ignore the fact that veterans and their families live within our communities, and some will be in need of competent treatments for PTSD, depression, substance misuse, and other behavioral health issues. To that end, we call have a civic duty to understand the culture from which our veterans come (i.e., military culture), to learn about the range of mental health issues our veterans and their families may be dealing with, and to either provide sound treatments for them or be part of a service-delivery network where we can refer them to if they come through our doors.
For some service members and veterans, the result of their experiences while serving (e.g., combat trauma) leave them with such acute and severe issues that they require an inpatient level of care to be treated in a safe and focused way. While in an inpatient setting, service members may have the opportunity to not only receive medication that will facilitate the stabilization of mood and behavioral symptoms, but also to receive intensive, trauma-specific therapies that assist in the promotion of recovery from both trauma and substance/alcohol abuse. In our Military Wellness Program at Holliswood Hospital, we have developed an integrative model of inpatient treatment for behavioral health and substance misuse disorders, based on five integrative domains: 1) Integration of trauma treatment and substance/alcohol abuse treatment; 2) integration of developmental trauma theory and acute/situational trauma theory; 3) the integration/ assimilation of traumatic memories into existing memory networks; 4) integrating family members into the fabric of treatment for wounded warriors, focusing on enhancing family resiliency and recovery, and 5) integrating a “traditional” inpatient treatment program with trauma processing treatments (i.e.- exposure therapy), expressive arts therapies, alternative treatment approaches (acupuncture and yoga) and the promotion of peer support. What follows is a brief overview of each domain and the application of such a domain in the treatment of service members.
Domain One – Integration of trauma treatment and substance/alcohol abuse treatment: When one develops the knowledge and understanding of the relationship between trauma and substance/alcohol use, the integration of trauma treatment and substance/abuse treatment is truly the only logical model of treatment to follow. Fisher (2000) most succinctly elucidates a coalescence of both trauma and substance/alcohol use- she refers to the use of substances as a “survival strategy” when one is confronted with or exposed to triggers or reminders of the traumatic memory; a way for the individual to allay themselves of overwhelmingly unmanageable and destructive thoughts and dysregulated feelings. Her work, based partly on that of Siegal (1999), refers to each individual’s “Window of Tolerance,” whereas their ability to maintain the self within the window of tolerance allows for manageability and control over thoughts and/or emotions. Once outside this zone of optimal arousal, thoughts and feelings become overwhelming, leaving the traumatized individual at increased risk to self-medicate with either substances and/or alcohol. Persons exposed to overwhelming trauma or suffering from posttraumatic stress disorder show a “bi-phasic” trauma response, vacillating between emotional and behavioral “highs” (e.g., hypervigilance, agitation, obsessional thinking) and lows (extreme dissociative states, lethargy, depression) and have difficulties with emotional regulation. Teaching service members this concept (the relationship between emotional dsyregulation and substance misuse) and teaching them more adaptive ways to regulate their emotional and physiological arousal is a key aspect of treatment.
Domain Two – Integration of developmental trauma theory and acute/situational trauma theory: Integrative inpatient treatment of PTSD and substance misuse disorders requires an intimate understanding of the difference between developmental trauma, (as defined by van der Kolk and colleagues) and what we think of as acute (or adult-onset) trauma; as well as the interface between the two. van der Kolk (2005) defines developmental trauma as a chronic exposure to trauma, typically experienced during childhood (e.g. – childhood physical and/or sexual abuse), and of an interpersonal nature that impedes the development of the child’s ego in such a way that leaves them at increased risk for subsequent trauma (and difficulties managing that trauma) over the lifespan. Furthermore, exposure to trauma of this nature almost always leads to impairments in the following domains of functioning: biological, cognitive, attachment, affect regulation, self-concept, dissociation, and behavioral control (for a more extensive description, please see Cook, Spinazzola, Ford, Lanktree, et al., 2005; van der Kolk et al., 2009). Acute trauma, or what we have come to know of as PTSD, as defined in the DSMIV-TR recognizes that a single event (e.g. car accident) or even sometimes multiple events experienced as an adult impact the psyche in a negative way. However, while exposure to an acute traumatic event may negatively impact the emotional and behavioral functioning of an individual, it does not necessarily alter the developmental trajectory of an individual or present its sequela in as pervasive or diffuse a manner as seen with developmental trauma. For example, the three main criteria for PTSD (re-experiencing, avoidance and numbing, hyperarousal) are much more focal and directly tied in both content and experience to the actual traumatic event when compared with the sequela of developmental, interpersonal trauma experienced during childhood and adolescence. When working with service members who have been exposed to trauma, it is important to inquire not only about combat or deployment-related trauma, but also a history of developmental trauma. Only after one gains a comprehensive overview of the service member’s lived experience can the treatment provider proceed with the appropriate course of treatment that can account for multiple levels of traumatic exposure and their interactions.
Domain Three – Integration of traumatic memories into existing memory networks: A major part of integrative treatments aimed at decreasing the frequency and severity of trauma triggers experienced by service members (and also aimed at decreasing their vulnerability for substance misuse) is to facilitate the integration of split-off traumatic memory traces (e.g., affect states, body sensations, image fragments, etc) back into declarative, narrative memory networks so that they are more in the volitional control of the service member and carry less intensity over time. In addition, the “paired associations” that have been classically conditioned around traumatic experiences must be desensitized to likewise reduce trauma triggering and emotional/physiological reactivity. These associations, as well as paired associations related to substance misuse, are part of what trigger and maintain cravings for substances, and perpetuate cycles of relapse and misuse. Implementing a model of care that can accomplish the above goals is essential to address both the symptoms of PTSD and substance misuse that many service members present with. Evidence-based therapies for PTSD (Exposure Therapy, Cognitive Processing Therapy, Eye Movement Desensitization and Reprocessing), expressive therapies, equine-assisted psychotherapy, and Brainspotting can all play a role towards this end.
Domain Four – Integrating family members into the fabric of treatment for wounded warriors: When an individual joins the military, their entire family joins as well. The service and sacrifices of our Nation’s military is carried squarely on the backs of our military families, and when a service member is suffering from acute behavioral health issues, the family suffers as well. Many family members of wounded warriors are tired from being in a caretaking role, are confused and do not have a clear understand of what their family members is truly suffering from or dealing with, and are in need to support themselves as they try to keep their families intact. Finding ways to have family members take an active part in the treatment of their service member, and ways to provide education and support to family members so that they and the entire family is more resilient, is truly necessary to maximize inpatient and outpatient treatment gains. An example of a local, creative collaboration to expand inpatient treatment to include the military family is the Family Reintegration Program. Aligning the missions of the Military Wellness Program at Holliswood Hospital and Hope for the Warriors (a national non-for-profit organization dedicated to supporting wounded warriors and their families), the Family Reintegration Program brings family members of warriors in treatment at Holliswood Hospital to New York free of charge to take part in a four-day intensive treatment workshop. Couples/family therapy, education about PTSD and TBI, family support groups, and respite care for family members are all parts of the program week. This integrative approach with regards to the family allows us to treat a service member in context of his/her support system, improving the chances that treatment gains are maintained and maximized within a more resilient and informed family system.
Domain Five – Integration of a traditional inpatient treatment with trauma processing therapies, expressive arts therapies, equine therapy, alternative therapies (acupuncture/yoga) and promotion of peer support: True integrative treatment involves the creative and evidence-based amalgamation of multiple treatment modalities during the inpatient treatment experience. Overhauling a traditional inpatient treatment program in a way that promotes the coalescence of exposure-based therapies with creative arts therapies (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998; Collie, Backos, Malchiodi, & Spiegal, 2006; Johnson L. 2008); and promotes peer support and peer engagement, leads to a higher level of treatment success, as well as a dissolution of the stigma and resistance typically associated with being in an inpatient treatment facility. Ensuring the coordinated application of multiple treatment paradigms across disciplines and clinicians (as opposed to a haphazard, disconnected approach where “more” does not necessary equate with “better) is key to approaching the individual treatment needs and preferences of each service member who comes for care. Understanding how to “layer” and phase treatment across both verbal and non-verbal modalities is also a prime consideration to be guided by an integrated treatment team.
Conclusion
The complex behavioral and emotional difficulties faced by many of our service members and veterans, exacerbated by prolonged exposure to deployment and combat stress, require integrative and adaptive treatment models to address issues related to PTSD, substance misuse, and other mental health needs. The Military Wellness Program at Holliswood Hospital takes an integrative treatment approach across multiple domains to treat service members, and serves as a model for integrated treatment of co-occurring disorders. This model can be adapted for use in an outpatient setting, and indeed one such replication is currently being developed at River Hospital in Alexandria Bay, New York to support soldiers at Fort Drum, New York with an intensive partial hospitalization program.
We all have a civic responsibility to support our service members, veterans, and their families in return for the service and sacrifices they all make on our behalf. Veterans, National Guard members and Reservists, and military families live in our communities and they rely on us to provide them with care. Cultivating an understanding of the unique experiences of those who serve, and learning about how best to support them in their recovery from mental health difficulties, allows one to best be prepared to assist them in an appropriate way if they come to us for care.
Dr. Michael DeFalco is the Program Director of Adult and Military Services at The Holliswood Hospital and Director of their Military Wellness Program. He is also the Education Chair of the Veterans Mental Health Coalition of New York City and sits on their Steering Committee. He received his doctoral degree in clinical psychology from Long Island University/C.W. Post campus, where he specialized in the diagnosis and treatment of persons suffering from serious and persistent mental illness. Dr. DeFalco has worked for over ten years providing treatment and developing treatment programs for children and adults affected by traumatic stress, depression, and other mental health issues. His current area of specialties include the treatment of Posttraumatic Stress Disorder and other disorders related to experiencing traumatic events, as well as geriatric psychiatry and addictions treatment. Dr. DeFalco is active in community education and he maintains an active private practice in Queens and Nassau Counties.
Tara Bulin, LMSW is a founder of The Military Wellness Program at Holliswood Hospital, and a Program Director on Holliswood’s Adult Service. Ms. Bulin has extensive experience working with individuals recovering from the effects of traumatic stress. She is a doctoral candidate at the Adelphi University School of Social Work, and she maintains an active private practice in Nassau and Suffolk counties.
Any inquiries or correspondence regarding this article should be directed to Dr. Michael DeFalco at mdefalco@libertymgt.com.
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