Healing the Warrior Within: Utilizing
Dialectical Behavior Therapy to
Restore the Mind, Body, and Spirits of
Our Veterans
Veterans may experience compounding traumas from the military context of their
experience and exacerbation of stress symptoms from military culture that
encourages stoicism and symptom suppression. Dialectical behavior therapy (DBT)
focuses on regulating emotions and tolerating distress. This workshop will illustrate
the usefulness and difficulties of utilizing DBT with veterans.
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Introduction: Learning
Objectives
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OIF/OEF/OND Treatment utilization
Risk of PTSD in the OIF/OEF/OND Population
Compounding factors of the military culture
Empirical evidence for DBT
Why DBT?
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OIF/OEF/OND Veterans
and Treatment Utilization
• As of September 30, 2011 there are 2.6 million
Operation Iraq Freedom (OIF), Operation Enduring
Freedom (OEF) and Operation New Dawn (OND)
Veterans
*12% of the Veteran population
• 38% access Mental Health Services at a VAMC
– -*More than any other era
OIF/OEF/OND Veterans
and Treatment Utilization
• Recent conflict Veterans use of Mental Health Services
has more than doubled since 2006
– 4% to 12%
• Of those that access Mental Health Services over half
access some type of PTSD-related service
• Very unlikely to complete full treatment protocol
– 9.5% complete recommended number of sessions
Why does this matter?
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Higher risk for suicide
Alcohol and drug use
Mental health problems continue to increase
Relationship issues
Family consequences
Isolation from community
Vocational consequences
PTSD Prevalence in
OIF/OEF/OND Population
• 18.5%-50.2% have a PTSD diagnosis
• 14-16% have experienced PTSD symptoms
• Most common diagnostic category: Adjustment reaction
• 88% PTSD
• Twice as likely to have an adjustment disorder reaction
• How can we predict who develops PTSD?
PTSD: Defined
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Post Traumatic Stress Disorder (PTSD) is a maladaptive pattern in the stress
response system.
Preceded by an individual experiencing a traumatic event in which the person
experiences, witnesses or is confronted by an event that involves actual or
perceived threat of death, serious injury or a threat to physical integrity of self or
others.
The traumatic event must meet specific standards and the individual must
experience a number of symptoms from the following areas: intrusion, avoidance,
negative alterations in cognitions and mood and alteration in arousal and reactivity
Symptoms must last a specified length of time, impair functioning and not be in
response to a medical condition or substance abuse issue. A diagnosis of PTSD is
indicated if an appropriate number of symptoms are present in each category (A= 1
required B=1 required; C=1 required; D=2 required, E=2 required), symptoms last
longer than one month, the disturbances creates significant distress or impairment
in social, occupational, or other important areas of functioning and they cannot be
attributed to a medical condition or substance use issue (APA, 2013).
PTSD: Associated Factors
Pre-Trauma
Factors
Trauma
Characteristics
Post-Trauma
Factors
Strong Associations
None
Trauma/combat exposure
severity
Perceived life threat
Combat-related injury
Peritraumatic distress or
disassociation
Lack of social support,
negative homecoming
experience, exposure to
additional life stressors
Intermediate
Associations
Lower education, lower
intelligence, lower military
rank, lower socioeconomic
status, prior trauma, prior
psychiatric history/symptoms,
family psychiatric symptoms,
family psychiatric history,
behavioral problems in
childhood, childhood abuse or
adversity
Exposure to death, Killing
or abusive violence
PTSD Treatments for
Veterans: VAMC
• Evidenced Based Treatment
– Prolonged Exposure
– Cognitive Processing Therapy
– Cognitive Behavioral Therapy
– Medications
Influencing Factors for
Treatment Utilization
Factors
Study
Concerns that treatment will not be kept confidential
Treatment will constrain future job assignments and
military-career advancement
Unpleasant side effects of treatment
Mental health care is not effective OIF/OEF/OND feeling out
of place at a VA facility
Delay or difficulty in scheduling appointments
Tanielian & Jaycox, 2008
Stigma and beliefs about mental health care
United States Government Accountability Office, 2011
Lack of understanding or awareness of mental health care
United States Government Accountability Office, 2011
Logistical challenges to accessing mental health care
United States Government Accountability Office, 2011
Concerns about VA’s health care
United States Government Accountability Office, 2011
Clinic of first mental health diagnosis and distance from VA
facility
Seal et al., 2010
Type and complexity of mental health diagnosis
Seal et al., 2010
Unstable housing, financial distress, unemployment or
underemployment, divorce or separation
Jakupcak & Varra, 2011
Influencing Factors: Military Culture
• Military Culture
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Loyalty, Patriotism, Obedience
Compromised adaptation, flexibility & adjustment skills
Strict roles
Exhibit painful emotions and vulnerability
• Deployments
– Constant separation and reunion
– Lack of community integration
– Concealment of combat related fears
• Postwar
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Reintegrating into the family system and community
Vicarious trauma
Internal dissonance
Biological memory
DBT: Origins
Dialectical Behavior Therapy (DBT), developed by Marsha
Linehan, Ph.D., ABPP, at the University of Washington
In the late 1970s, Marsha M. Linehan (1993) attempted to
apply standard Cognitive Behavior Therapy (CBT) to the
problems of adult women with histories of chronic suicide
attempts, suicidal ideation, urges to self-harm, and selfmutilation.
DBT: Origins
• Clients receiving CBT found the unrelenting focus on
change inherent to CBT invalidating
• Clients unintentionally positively reinforced their
therapists for ineffective treatment while punishing their
therapists for effective therapy
• The sheer volume and severity of problems presented
by clients made it impossible to use the standard CBT
format
Definition: DBT
• Cognitive behavioral treatment program developed to
treat suicidal clients meeting criteria for Borderline
Personality Disorder (BPD)
• Directly targets: suicidal behavior, behaviors that
interfere with treatment delivery and other dangerous,
severe or destabilizing behaviors
• Linehan developed DBT from: restructuring CBT
strategies to incorporate acceptance and change with
dialectical strategies
DBT: Underlying TheoryTheory
• Behavioral principles and techniques (CBT), attitude of
acceptance embodied in validation, empathy and radical
acceptance with relentless focus on problem solving
• Biosocial Theory regarding BPD
• Central Problem: emotional dysregulation
• Emotional regulation is seen as having originated in and as
being maintained by a lifelong mutually shaping transaction
between a vulnerable temperament and an invalidating
environment which leads to deficient emotion modulation
skills and motivational problems
DBT: Major Characteristics
• A behavioral, problem-solving focus blended with
acceptance-based strategies
• Emphasis on behaviorally explicit targets and treatment
strategy groups
• Emphasis on dialectical processes
DBT: Addresses 5 functions
1. Increase behavioral capabilities
2. Improve motivation for skillful behavior (through
contingency management and reduction of interfering emotions
and cognitions)
3. Assuring generalization of gains to natural
environment
4. Structure the treatment environment so that it
reinforces functional rather than dysfunctional
behaviors
5. Enhance therapist capabilities and motivation to treat
patients effectively
DBT: Protocol
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Weekly individual psychotherapy (1hr/wk)
Group skills training (2.5 hrs/wk)
Telephone consultation
Weekly therapist consultation team meetings (to
enhance therapist motivation and skills to provide therapy for the
therapists)
5. 1st four sessions are orientation
6. Full protocol is two 6-month rounds of group therapy
skills training
DBT: Stages
• Stage I: decreasing life threatening behaviors, behaviors that
interfere with therapy, quality of life threatening behaviors
and increasing skills that will replace ineffective coping
behaviors.
• Stage II: addresses the client’s inhibited emotional
experiencing. It is thought that the client’s behavior is now
under control but the client is suffering “in silence”
• Stage III: focuses on problems in living, with the goal being
that the client has a life of ordinary happiness and
unhappiness
• Stage IV: the goal of is for the client to move from a sense of
incompleteness towards a life that involves an ongoing
capacity for experiences of joy and freedom.
DBT: Group Skills Training
• Core Mindfulness Skills: Skills to help one experience
more fully the present moment
• Distress Tolerance: Cope better with painful events by
building up resiliency and using new ways to soften the
effects of upsetting circumstances
• Emotion Regulation Skills: Help one recognize more
clearly what they feel and then to observe each emotion
without getting overwhelmed by it
• Interpersonal effectiveness: New tools to express
beliefs and needs, set limits and negotiate solutions to
problems
• Crisis Planning
Why DBT?
• Effective in treating suicidal ideations and attempts,
self-injurious behaviors, compliance with treatment and
problems in daily living activities
• Associated with better treatment outcomes than
treatment as usual
• Less likely to drop out, require less hospitalization for si,
lower medical risk, fewer psychiatric hospitalizations
and psychiatric emergency department visits
Why DBT with PTSD treatment?
• DBT with PE has been found to reduce severe and
chronic PTSD symptoms
• DBT may protect against attrition
• Promotes coping skills for symptoms of trauma
treatment (i.e. anxiety, fear, shame, anger, etc.)
• Promotes safety plan development and problem solving
for flooding
Why DBT for Veterans with PTSD?
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Structures mindfulness practice
Addresses internal dissonance
Radical acceptance
Distress tolerance
Emotion regulation
DBT with Veterans: Challenges
• Failed to demonstrate superiority when compared to
other treatments
• Evidenced based practice?
• Not validated as a supplement for PTSD treatment
• Abstract concept of mindfulness
– Resistance to expression
Integrating DBT with PE
• Becker and Zayfert (2001)
1. Skills training is integrated with individual therapy
2. Duration is 5-16 weeks
3. Not participating in the larger DBT program
• Purpose is to prepare an individual to cope with any
flooding issues prior to implementing the therapy
• Integration can occur at any point during therapy
– Serve to regulate emotions, tolerate distress and manage any
suicidal impulses
References
Available Upon Request:
elizmorgan33@yahoo.com