women in the military, redeployment issues in the family, substance abuse in the military, substance abuse

1. SOWK 640
Case Presentation Unit 8
Substance Abuse in the Military Family
Substance Abuse in the Military Family
Substance Abuse in the Military Family
presented by: Alma Garcia and Laura O’Brien
February 26, 2014

2. brief discussion of role within the agency: social worker
• substance abuse counselor
• provide resources to the family as a described
need by the family members
• provide information unknown to family to help
them achieve harmony & autonomy
• psychoeducation; counseling; referrals; case
management
Kadis & Walls, D. (2006).

3. Introduction: meet “Luisa”
• All sessions begin with a full
biospychosocialspiritual assessment
• Disclosure forms and consent forms have
been signed. Client’s name has been
changed for this presentation.
• Luisa is self-referred at her husband’s
request

4. Bio/Psycho/soc/spiritual
• 38 year old female
• married (10 years), husband: Jack (40)
• 2 children: Sam (4) & Isabel (2)
• American born; first generation“Latina”; Catholic
• no forthcoming information on family history with
the exception of being close to her father
• High-school graduate; pre-deployment, school bus
driver, and at home Mom

5. bio/psych/soc continued
• no physical or psychological problems
before deployment
• hobbies: reading, writing, hiking, running
volunteering at the pre-school, yoga
• attends Catholic church with the family; and
as a youth with her family

6. Military
• Serves in the National Guard Reserves
• Enlisted in 2009
• Deployed 12/2012 to Afghanistan for 12
month tour

7. presenting issues (observed and
disclosed)
• fighting with spouse
• isolation
• lack of sleep
• feeling alienated by family
• hypersensitivity; hypervigilence
• flashbacks and nightmares
• anger
• increase of alcohol and marijuana
• lack of trust; over analyzing
• depressed

8. assessment tests
• Michigan Alcoholism Screening Test (MAST) -- score 19 = high abuse and
dependency
• Drug Abuse Screening Test (DAST) -- score of 10 = high for abuse or
dependency for cannabis.
• PCL-17 and scored very high in posttraumatic stress disorder (PTSD).
• Luisa has no suicidal or homicidal ideation, however, this will be continually
assessed (Cato, 2013).
• According to the DSM-5, Luisa has posttraumatic stress disorder 309.81 (F43.10) with dissociative
symptoms which are not related to substance use (American Psychiatric Association, 2013). Luisa
meets all criterions,A-H. Luisa’s descriptions of:“thinking she’s awake when she’s not”;“feels that life is
a super-imposed nightmare on real life”; and “ life is like walking under water, all funky, not real” qualify
her for the dissociative symptom criteria (Gabriel and Wain, 2007).
• Comorbid diagnoses include alcohol use disorder 303.90 (F10.20) which is considered moderate with
the presence of four to five symptoms (American Psychiatric Association, 2013, pp. 490-491) and
cannabis use disorder 304.30 (F12.20), considered severe, with a presence of six or more symptoms
(American Psychiatric Association, 2013, p. 509-510).

9. Luisa’s strengths
• hope
• love of family
• love from family
• hope for future
• resiliency
• spirituality
• self-sufficient & independent

10. challenges
• diversity: female in military; first generation
Latina; religion (in respect to facility)
• self-sufficient & independent
• birth control
• reintegration with family
• fear of sexual assault

11. GOAL of Treatment
• “Increasing the ability to replace impulsive
reactions with reflective reality-based decisions is
critical to managing both intrusive trauma
memories and the cravings for substances and
automatic behavior patterns that sustain
addiction” (Ford & Russo, 2006, pp. 336 – 337).

12. treatment plan
Inpatient therapy (remember: she is self-referred. She does NOT want toInpatient therapy (remember: she is self-referred. She does NOT want to
involve the VA. Wants to be anonymous. Wants to re-deploy)involve the VA. Wants to be anonymous. Wants to re-deploy)
first 30-days of treatment = (lock down) for Luisafirst 30-days of treatment = (lock down) for Luisa
6 month duration total6 month duration total
family enter treatment after 30-daysfamily enter treatment after 30-days
MI/PST/CBT for substance abuseMI/PST/CBT for substance abuse
(other services: MFT, spiritual, anger management, D&A classes, grief and(other services: MFT, spiritual, anger management, D&A classes, grief and
loss classes, relapse prevention, 1:1 weekly counseling, AA/NA)loss classes, relapse prevention, 1:1 weekly counseling, AA/NA)
reconnection with familyreconnection with family
be better mother/wifebe better mother/wife
help her lack of sleephelp her lack of sleep
normalization of her lifenormalization of her life
reduce angerreduce anger

13. Trauma Focused CBT for PTSD & Substance Abuse
• The goal of psychotherapy is for the PTSD &
SA interventions to compliment each other.
• Hyperarousal can lead to self-medication to relieve
anxiety.
• Hypervigilance can lead to drug use that increases
the ability to remain alert.
• The goal is for the intervention to work on affect
regulation skills and improve or develop social
problem solving skills.

14. TTrauma Focused Cognitive Behavioral
Therapy basis is Cognitive Behavioral Theory
• A Cognitive Behavioral Therapy (CBT) approach emphasizes correcting
maladaptive cognitive distortions that have been acquired. These
maladaptive thoughts are restructured in order to reduce intrusive
symptoms of emotional numbing, hyperarousal, hypervigilance, and re-
experiencing.
• CBT focuses on helping identify trauma-related triggers and manage the
reactions. The goal is to replace the maladaptive coping skills, in this case
substance abuse, with adaptive one.

15. Challenges of CBT
• Much of the research on CBT for clients with PTSD has
not included those with comorbid substance abuse
disorders.
• Clients with both disorders have a more severe profile
than those with just one disorder as it affects course &
outcome.
• These patients have a higher chance of meeting criteria
for additional disorders such as anxiety and major
depression disorders.

16. various models researched
• EMDR--Eye movement desensitization and reprocessing is nontraditional type of
psychotherapy for treating post-traumatic stress disorder. PTSD often occurs after
experiences such as military combat, physical assault, rape, or car accidents. The
Department of Veterans Affairs and the Department of Defense have jointly issued clinical
practice guidelines. These guidelines "strongly recommended" EDMR for the treatment of
PTSD in both military and non-military populations. (Department ofVeterans Affairs, 2013)
• Prolonged exposure used such as a 16 – week intervention combining with cognitive
restructuring.
• Seeking Safety agency for specific care that integrates treatment for PTSD and substance
abuse (Najavits, 2002; 2007; and 2009). Many of the same educational areas such as
relationships, setting boundaries, and substance abuse overlap but, the focus on attending
sessions will carry into other areas concerning military life and specific concerns not
addressed at the ARC. The ARC’s primary concern is substance abuse, so Seeking Safety will
provide necessary treatment focused on the comorbidity of SUD and PTSD (Bowden,
Bowmen, Carney, Jacob-Lentz, Kimerling, Trafton, Walser, & Weaver, 2011).
• A 12 week partial hospital group CBT intervention that included 6 & 12 month follow-ups.
• An Assisted Recovery Trauma & Substances model include a 20 week intervention. The first
11 sessions of CBT focused on substance abstinence were one-on-one therapy. Then 29
sessions of individualized and paced CBT for PTSD.

17. • American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th Ed. Arlington, VA: American Psychiatric
Association
• Barlow, D., and McHugh, R. (2010).The dissemination and implementation of evidence-based psychotherapy treatments: Review of current
efforts. American Psychologist, 65(2), 73-8
• Bowden, M., Bowmen, D., Carney, D., Jacob-Lentz, J., Kimerling, R.,Trafton, J.,Walser, R.,Weaver, C. (2011). Seeking safety treatment for male
veternans with a substance use disorder and post-traumatic stress disorder symptomatology. Addiction. doi: 10.1111/j.1360-
0443.2011.03658.x. Retrieved from: http://www.seekingsafety.org/7-11-03%20arts/2012%20boden%20ss%20study.pdf
• Briere, J., and Scott, C. (2012).Assessing trauma and posttraumatic outcomes. In Principles of trauma therapy:A guide to symptoms, evaluation and
treatment, 2nd Edition (chap. 3, pp. 49-78).Thousand Oaks, CA:The Guilford Press.
• Bryant, R. (2011). Post-traumatic stress disorder vs traumatic brain injury. Dialogues in Clinical Neuroscience.Vol. 13(3): 251-262. Retrieved from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182010/
• Cato, C. (2013). Suicide in the Military. In Rubin,A.,Weiss, E. & Coll, J. (Eds.). Handbook of Military SocialWork (pp. 225-244), Hoboken, New
Jersey: John Wiley & Sons, IncColl, J., Metal, M., and Weiss, E. (2013). Military culture and diversity. In Rubin,A.,Weiss, E. & Coll, J. (Eds.).
Handbook of Military SocialWork (pp. 21-36), Hoboken, New Jersey: John Wiley & Sons.
• Department ofVeterans Affairs. (2004).Veteran's Health Initiative:Traumatic brain injury Independent study course.Washington, DC:―
Department ofVeterans Affairs
• Ford, J. D., & Russo, E. (2006). Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment
for posttraumatic stress and addiction: trauma adaptive recovery group education and therapy (TARGET). American Journal
of Psychotherapy, 60(4).
References

18. References continued
References continued
• Gabriel, G. and Wain, H. (2007). Psychodynamic concepts inherent in a biopsychosocial model of care of traumatic injuries. Journal of the American Academy of
Psychoanalysis and Dynamic Psychiatry, 35(4), 555-573.
• Greenberger, D., and Padesky, C. (1995). Mind over mood. NewYork: Guilford Press.
• Kadis, J., and Walls, D. (2006). Military facts for non-military social workers. Washington, DC:Veterans Health Association Handbook.
• Leach, S and Nidiffer, F. (2010).To hell and back: Evolution of combat-related post-traumatic stress disorder. Developments in Mental Health Law,Vol. 29(1), 1-22.
• Martin, J. (2000).Afterword:The changing nature of military service and military family life. In J.A. Martin, L. N. Rosen, & L. R. Sparacino (Eds.), The military family:A
practice guide for human service providers (pp. 257-270).Westport, CT: Praeger.
• Najavits, L (2002). Seeking Safety:A treatment manual for PTSD and substance abuse. NY: Guilford Press
• Najavits, L. (2007). Seeking Safety:An evidence-based model for substance abuse and trauma/PTSD. In: KA Witkiewitz & GA Marlatt (Eds.), Therapists' Guide to
Evidence-Based Relapse Prevention: Practical Resources for the Mental Health Professional, pages 141-167. San Diego: Elsevier Press
• Najavits, L. (2009). Seeking Safety:An implementation guide. In A. Rubin & DW Springer (Eds). The Clinician's Guide to Evidence-Based Practice. Hoboken, NJ: John Wiley.
• Pardini, D., Plante,T., Sherman,A, and Stump, J. (2000). Religious faith and spirituality in substance abuse recovery: Determining the mental health benefits. National
Library of Medicine. Vol. 19 (4): 347-54. Retrieved from: http://www.ncbi.nlm.nih.gov/ pubmed/ 11166499
• Safer, M., andVan Winkle, E. (2011). Killing versus witnessing in combat trauma and reports of PTSD symptoms and domestic violence. Journal ofTraumatic Stress, 24(1).
107-110.
• Schäfer, I., & Najavits, L. M. (2007). Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse. Current
Opinion in Psychiatry, 20(6), 614-618.
• Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M.T., Chow, B. K., ... & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in
women: a randomized controlled trial. Jama, 297(8), 820-830.

19. Thank you.