John Mundt, Ph.D.
drjohnmundt@hotmail.com
www.drjohnmundt.com

CHALLENGES TO TREATMENT
Cultural / subcultural considerations
MILITARY CULTURE
 Importance of group over individual
 “What happens in the bush, stays in the bush”
 “Machismo”
 Issues re: authority
GENERATIONAL
 Young adults
vs reservists
ETHNICITY/NATIONAL ORIGIN
 Culturally appropriate emotional expression

CHALLENGES TO TREATMENT
Other Mental Health Problems
Pre-existing Trauma
 Common Therapist Error: failure to assess for other trauma
 Can be from many non-military sources: childhood abuse, traumatic loss, correctional system, addiction
 Discrete trauma (rape, natural disaster) vs. prolonged or repeated
 Multi-layered trauma: complex, more difficult to treat

CHALLENGES TO TREATMENT
Other Mental Health Problems
“Personality Disorders”: Problem of diagnosis and nomenclature
 Controversial use of Character Disorder diagnoses by military
 “Cluster B” personality traits: overlap with concept of multiple layers of trauma
 Continuum of trauma-based disorders: PTSD, BPD, DID are all possible responses to stress and trauma
 “Personality Disorder” can both increase and decrease likelihood of “PTSD”

CHALLENGES TO TREATMENT
Other Mental Health Problems
Other Axis I psychiatric illness
 Typical onset age for chronic mental illness coincides with military service
 Diathesis-Stress Model: warzone deployment is the stress
 Risk of assuming PTSD in all OEF/OIF veterans presenting for treatment
 Assess family history of mental illness/psychiatric treatment

“Signature Injury” of this war
• Explosions account for 3 of 4 combat-related injuries 1
• Use of IED’s in Afghanistan and Iraq
• Improvements in warzone trauma treatment decrease fatalities
• Exposure to toxins, other causes of brain injury
1 Zouris,J.M., Walker, G.J., Dye, J. & Galarnewau, M. (2006). Wounding patterns for U.S. Marines and sailors during Operation Iraqi Freedom, major combat phase. Military Medicine, 171(3):246-52.

CHALLENGES TO TREATMENT
ADDICTION and SUBSTANCE ABUSE
 Alcohol, cocaine and methamphetamine were available in Iraq
 Afghanistan is world’s largest producer of opium
 Many medically injured troops are prescribed painkillers
 VA: 10%+ increase in veterans seeking drug treatment since start of war
 Significant impediment to treatment of OEF/OIF veterans with PTSD
 Lessons from Vietnam veterans

ADDICTION and SUBSTANCE ABUSE
Factors leading to substance abuse problems:
 Pre-existing problems
 “Self-medication” of depression, PTSD
 Chronic pain
 Boredom
 Affiliation/ peer pressure: culture

 Anxiety and hypervigilance
 Insomnia
 Depression
 Anger and volatility

 Intractable pain as a chronic stressor
 Physical demands of military deployment: “Battle rattle”
 Headaches: PTSD versus TBI versus other medical basis
 Orthopedic, neurological, psychosomatic
 Medication of “pain”: physical versus emotional

CHALLENGES TO TREATMENT
ADDICTION and SUBSTANCE ABUSE
DAY HOSPITAL PROGRAM approach:
 Detailed assessment
 Psychoeducation: - use vs. abuse vs. dependence
-abuse = impairments in functioning
(emotional, vocational, social, physical)
 Emphasis on honesty over total abstinence
 Lapses are a part of recovery: lapses are not relapses, but may lead to them
 Continued abuse: progressive “tightening of the reins”
(Dual Diagnosis engagement groups for combat veterans)
 Caveats: dangerous use, clear-cut dependence, historical treatment failures

CHALLENGES TO TREATMENT
ADDICTION and SUBSTANCE ABUSE
Dangers of extremes in therapist stance:
TOO PERMISSIVE:
 Failure to benefit from treatment
 Intoxication, self-medicating as end-point of abreaction
 Therapist frustration
TOO RIGID:
 Withdrawal from treatment
 Contraindications of formal addictions programs

CHALLENGES TO TREATMENT : SUICIDE
Lessons from Vietnam

CHALLENGES TO TREATMENT : SUICIDE
Literature: Both trauma exposure and specific diagnosis of PTSD are linked with suicidal behavior.
Why?
 Despair
 Impulsivity
 Guilt / Grief
 “Misadventure”

CHALLENGES TO TREATMENT : SUICIDE
High-profile suicides of OEF/OIF veterans have led to changes in VA policy/approach:
• Suicide hotline
(National Suicide Prevention
Lifeline: Call
1-800-273-TALK (8255), and press “1” to be connected to
VA hotline)
• Suicide Prevention Coordinators
• Increased outreach and follow-up

CHALLENGES TO TREATMENT :
ASSESSING RISK: Patterson et al’s “SAD PERSONS” mnenomic:
S ex (male)
A ge (elderly or adolescent)
D epression
P revious suicide attempts (highest risk within 3 months of prior attempt)
E thanol abuse (alcoholics’ rate of suicide is 50x that of non-alcoholics)
R ational thinking loss (psychosis)
S ocial supports lacking (subjective perception of lack)
O rganized plan to commit suicide (specific, lethal)
N o spouse (divorced > widowed > single)
S ickness (physical illness)
Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: the
SAD PERSONS scale. Psychosomatics 1983;24(4):343-9

CHALLENGES TO TREATMENT :
ASSESSING RISK: Suicide warning signs in veterans o o o o o o o o
CHANGE in behavior
Calling friends, particularly vets, to say goodbye
Cleaning weapons
Visiting graveyards
Stopping or hoarding medication, alcohol
Spending sprees, buying gifts
Obsession with media coverage of war
Wearing uniform, combat gear

CHALLENGES TO TREATMENT :
WEAPONS and OEF/OIF veterans
“Don’t leave home without it!”

CHALLENGES TO TREATMENT :
GENERAL CONSIDERATIONS with OEF/OIF veterans
 Efficacy of no-suicide contracts
 Importance of ongoing assessment during trauma therapy
 Crisis Intervention: plan ahead

CHALLENGES TO TREATMENT :
ASSESSMENT: Should be specific
 Impulsive/reactive (in context of hyperarousal?
Dissociation?) AFFECTIVE VIOLENCE
 Planned/deliberate (starting fights? “patrolling”?) PREDATORY VIOLENCE
 Domestic violence
 Intoxication (disinhibition?)
 Related to peer-group
 “Suicide by cop”

CHALLENGES TO TREATMENT :
WEAPONS
PARANOIA STIMULANTS

 Substance abuse (DUI/DWI; intoxication)
 Aggression and violence (DV; workplace; public fights)
 Suicidal behavior
 Driving offenses
 Weapons
 “disorderly”: crowds, authorities

CHALLENGES TO TREATMENT

Should be brief if possible
 Initial experience may determine future compliance in emergency situations
 Acute versus planned (specific programs)

CHALLENGES TO TREATMENT
Confronting AMBIVALENCE

TRAUMA is about loss of power and control
 Psychoeducation should be ongoing: joint perusal of a roadmap
 Flexibility in “closing cases”: “diminishing orbits” concept

CHALLENGES TO TREATMENT
MALINGERING
 Politics of PTSD and disability benefits:
"We have young men and women coming back from Iraq who are having PTSD and getting the message that this is a disorder they can't be treated for, and they will have to be on disability for the rest of their lives. My concern about the policies is that they create perverse incentives to stay ill. It is very tough to get better when you are trying to demonstrate how ill you are.“
 Process of assessment should include questions re: claims, benefits
 Detecting/confronting malingering is at odds with usual therapist stance

CHALLENGES TO TREATMENT
DETECTION of MALINGERING
 Assess for secondary gain (VA claims, lawsuits)
 Psychometric measures (both specific to PTSD, and general like MMPI-2)
 Presentation of client: “every symptom in the book”
 Traumatic material: no distress upon exploration OR total avoidance
 Traumatic material: inconsistent with probable experience
 Benefit of therapy groups

COMMON THERAPIST ERRORS
1) Premature focus on trauma processing
2) Avoidance of trauma processing
3) Projection of therapist’s beliefs and values about military experience
4) Projection of therapist’s assumptions about what is and what is not traumatic
5) Inadequate assessment of trauma history

COMMON THERAPIST ERRORS
1) Premature focus on trauma processing: “Get it all out”
Can lead to:
• Frightening dissociation
• Suicidal or violent behavior
• Withdrawal from treatment
• Abreaction

ABREACTION: Intense reliving of the trauma
• Freud (1892) used hypnosis to facilitate
• Long considered an important part of trauma therapy
• Technique or adverse effect?
copyright Mundt 2012

ABREACTION as a goal of therapy:
• “Lancing a boil”
• Bennett Braun’s BASK theory:
• Dissociative client needs to re-experience b ehavior, a ffect, s ensation, k nowledge
• (Braun, B.G. (1988) BASK Model of
Dissociation, Part I. Dissociation, 1:1, 4-23)

ABREACTION as an adverse effect:
• Painful and intense: somatic memories
• Dangerous behavior during dissociation
• Persists beyond session

ABREACTION:
“The abreaction of intense affect is not a goal of psychotherapy; it is an inevitable concomitant experience in the therapy of persons with post-traumatic histories, physical and/or sexual abuse, neglect, and related innate experiences.”
Chefetz, R.A. Abreaction: Baby or Bathwater. Dissociation
Vol.X, No.4, 12/97

Managing ABREACTION:
•
•
•
•
Maintain a calm demeanor
Consider your tolerance for extremity and for strong affect
Safety considerations
Consider both timing and pacing of sessions

COMMON THERAPIST ERRORS
2) Avoidance of trauma processing can lead to:
• Worsening of symptoms and related behavior
• Increased subjective pressure to “self-medicate”
• Entrenching maladaptive coping responses
• Withdrawal from treatment

COMMON THERAPIST ERRORS
3) Projection of therapist’s beliefs and values about military experience
• Do a “self-assessment” as to your own views of the war, your assumptions about the military, about soldiers
• Consider the source of your beliefs and assumptions

COMMON THERAPIST ERRORS
4) Projection of therapist’s assumptions about what is and what is not traumatic
• Importance of assessment not just of experiences, but of client’s PERCEPTION of those experiences
• Avoid “loaded” words like traumatic : Ask “what was hardest for you?”
• Maintain awareness of triggers/stressors unique to
OEF/OIF experience (i.e., Arab-appearing clinicians/staff)
• Be alert for vicarious traumatization
(“PTSD by proxy”)

COMMON THERAPIST ERRORS
5) Failure to assess for “layers” of trauma
• Assessment should include childhood and other noncombat trauma
• Consider possible causes of failure to disclose
(subjectively “unsafe”, security clearances, classified
“black ops”)

10 things to do in
#1: PRAISE the client
#2: VALIDATE their experience
#3: EDUCATE about pacing and timing
#4: PREDICT the course of treatment
#5: ACCEPT the inappropriate
#6: EXPLAIN parameters of sessions
#7: WARN about worsening of symptoms
#8: EMPLOY analogies liberally
#9: OFFER human touch
#10: GIVE something to read

10 things to do in
-
Reinforce their decision to start this process
-Acknowledge the difficulty in this, the stigma, the risk
-Express optimism

10 things to do in Session #1 !

10 things to do in Session #1 !
#3: EDUCATE about timing & Pacing

10 things to do in Session #1 !
#4: PREDICT the course of therapy

10 things to do in Session #1 !
#5: ACCEPT the inappropriate
-”Gallows” humor
-Extreme views, statements
-Prejudices, profanity

10 things to do in Session #1 !

10 things to do in Session #1 !

10 things to do in Session #1 !
-Process of turning an 18-wheeler around
-Hurricane reporters
-veterans: basic training drills
-bowel/bladder analogies

10 things to do in Session #1 !

10 things to do in Session #1 !

drjohnmundt@hotmail.com
www.drjohnmundt.com