Readjustment
Counseling
Louise A. Weller, Ph.D.
Clinical Psychologist
MST Coordinator,
Chalmers P. Wylie Ambulatory Care Center
Department of Veterans Affairs
Columbus, Ohio
Louise.Weller2@va.gov
Readjustment Issues
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OEF/OIF veterans will present with
subclinical PTSD symptoms.
Criteria arousal symptoms prevalent
Report hypervigilance and hyperarousal
May/may not have reexperiencing or
avoidance issues.
May/may not have sleep issues
Often have some problems with irritability
Readjustment Issues
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Coming home from a war zone is great and it
should be a happy time. But it is not always
easy to make the transition home. Veterans
except to take up their lives as they left them.
They expect to be happy to be home. They
look forward to old hobbies, habits, interests
and being with family and friends. They may
have been told but they often don’t realize
what it will mean to readjust for the war zone
to the cilivian life.
Readjustment Issues
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Being away: life has moved on, other people
pick up responsibilities, make new friends,
develop new patterns. Dealing with this may
cause stress, but usually it is worked out.
Being in a war zone: To survive and
function, veteran may have acquired skills
that were necessary and are behaviorally
powerful, but no longer fit in a civilian setting.
And they don’t just come off with the uniform.
Readjustment Issues
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In a war zone”
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Critically important to be hypervigilant
SM carried a weapon much of the time
Keep senses on high alert to respond to an
emergency quickly and correctly
Take charge of situations and order others
around as needed
SM needs to doubt, question, verify in order
to be safe
Difficult to relax, to sleep
Readjustment Issues
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Being in extremely intense situations:
Events can occur in war zones that have a
powerful effect on a veteran’s beliefs about
the nature of the world and mankind.
War zone skills are over-learned for safety of
self and others.
What is crucially important is to realize that
the rules of the war zone do not
automatically change when soldiers come
home.
Readjustment Issues
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Dr. James Munroe of the Boston VA
developed a program for “Transitioning from
the War Zone: Information for Veterans and
Those Who Care.”
It provides information for the veteran and
the family about the difficulties of readjusting
from life in a war zone, life in a tightly bonded
military unit, back to home, family and the
civilian life.
Readjustment Issues
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It provides modules with questions that the
veteran can work on at home and bring to
the next session. It focuses on areas of
readjustment such as feeling safe, building
trust, dealing with anger, and others.
You can google “Transitioning from the War
Zone” and find the entire handout.
You can email james.munroe@va.gov
Treatment for
Military Sexual
Trauma
Louise A. Weller, Ph.D.
Clinical Psychologist
MST Coordinator,
Chalmers P. Wylie Ambulatory Care Center
Department of Veterans Affairs
Columbus, Ohio
Louise.Weller2@va.gov
So What Do We Do?
An Overarching Framework for Treatment
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Judith Lewis Herman’s Trauma and Recovery:
The fundamental stages of recovery are…
1. Establishing safety
2. Remembering and mourning
3. Reconnection and meaning-making
• Not necessarily a linear progression through
these stages
• Parallels common distinction between skillsbuilding (stabilization) and trauma processing
(exposure) work
How?
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Plain old good clinical skills: Research has
demonstrated the importance of non-specific
factors common to all forms of therapy
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Forming a therapeutic alliance
Demonstrating cultural competence
Using systematic case formulation
Monitoring patient progress and adjusting practices
accordingly
 Effectively attending to these common factors constitutes
evidence-based practice
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Empirically-supported treatment protocols: Can
be a useful supplement to your work (“new
tools for your toolboxes”)
A Loose Categorization of Some
Commonly Used Protocols
Establish
safety
Seeking Safety
Dialectical Behavior Therapy
(DBT)
Cognitive Processing
Therapy (CPT)
Prolonged Exposure (PE)
Acceptance & Commitment
Therapy (ACT)
Remember
and mourn
Reconnect and
make meaning
Across Stages, Across Treatment Approaches…
Top 10 Things I’ve Found Helpful
(in no particular order)
1. Adopt a strengths-based approach
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Likely a novel, validating idea for the veteran; will
help you maintain an empathic, patient stance
2. Empathy goes a long, long way
3. Provide ongoing psychoeducation /
normalization / validation
4. Be transparent and genuine
5. Offer choice, restore control
6. Help the veteran balance the big and little
picture, the long- and short-term perspective
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Hold the hope
Across Stages, Across Treatment Approaches…
Top 10 Things I’ve Found Helpful (cont.)
7. Figure out what need is being met by a behavior
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Engage in a discussion of the pros and cons of meeting
it in this way versus some other way
8. Don’t assume you know what the worst part of the
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veteran’s experience was (and is)
Attend to parallel process and other dynamics in the
room
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Be present, be a witness, and be a secure base
10.Prioritize self-care, so that you can remain engaged
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Monitor your own reactions
Remind yourself that recovery can be a long-term
process
Seek out support from others
Seeking Safety
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Developed by Lisa Najavits for concurrent
treatment of dually diagnosed individuals
with a substance abuse disorder and PTSD.
A 25-session manualized treatment that
provides a focus every other session on the
basics of treating SA and treating PTSD.
Provides safety skills training
Provides coping strategies.
Dialectical Behavior Therapy (DBT)
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Some individuals with a history of complex
trauma may present for therapy who are not
able to engage in psychotherapy due to:
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Low tolerance for distress
Emotional dysregulation
Poorly developed behavioral management
Chronic suicidality
Interpersonal ineffectiveness
May engage in self-injurious behavior or
chronic substance abuse
Dialectical Behavior Therapy (DBT)
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DBT was developed by Marsha Linehan to
treat individuals with complex trauma,
particularly those with BPD and suicidality.
DBT developed to engage patient in a
combination of group therapy, skills coaching
counseling, and individual psychotherapy.
DBT has been modified to use in private
practice and individual clinical settings.
Dialectical Behavior Therapy (DBT)
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Central aim of DBT: to replace ineffective,
maladaptive, or unskilled behavior with
skillful responses. Steps to skill building:
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acceptance of self
identification of maladaptive behavior
Develop skills to improve distress tolerance,
manage emotional responses, change
behavior, identify and regulate cognitions
Develop mindfulness skills/wise mind
Exposure Therapy
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Research has indicated that exposure
therapy is an effective treatment for the
effects of sexual trauma.
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Foa & Rothbaum, 1998
Research has indicated that Cognitive
Behavioral Therapy is an effective treatment
for the effects of sexual trauma.
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Williams & Poijula, 2005
Exposure Therapy
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Primary therapy protocols presented are
CBT exposure based therapies.
Patients who manage to construct a
coherent narrative of the trauma event during
exposure therapy profit most from treatment.
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Foa, 1995
CBT provides a framework to the patient in
order to manage affect, probe more deeply,
reframe cognitive distortions, and develop
more effective coping strategies.
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Shipherd, Street & Resick, 2006
Exposure Therapy
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Evidence based therapies that utilize
exposure therapy and CBT include:
Cognitive Processing Therapy
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With and without an exposure element
Prolonged Exposure Therapy
EMDR
Narrative Exposure Therapy
Eye Movement Desensitization &
Reprocessing (EMDR)
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An exposure-based therapy that is only
taught in certified EMDR training programs.
EMDR therapy proposes to directly affect the
brain, allowing the individual to resume
normal functioning while no longer reliving
the images, sounds, and feelings associated
with the trauma
Most often accomplished by use of eye
movements, rhythmic tapping, or sounds.
Eye Movement Desensitization &
Reprocessing (EMDR)
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History and treatment planning
Education and Preparation
EMDR Process:
A target - the visual image of a traumatic
memory and the associated emotions and
bodily sensations.
A negative belief about yourself related to
the memory, which you will rate depending
on how true you feel this belief to be
A preferred positive belief about yourself.
Eye Movement Desensitization &
Reprocessing (EMDR)
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Reprocessing and Desensitization - the
therapist asks the client to hold the image
and negative beliefs in mind while EM’s or
other rhythmic processes are utilized to
initiate/continue dual processing.
Installation – the therapist asks the client
what s/he would prefer to believe when this
image or memory is brought to mind.
EMDR proposes that new beliefs about the
self and interpretations of the trauma replace
old beliefs.
Eye Movement Desensitization &
Reprocessing (EMDR)
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Benefits include:
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EMDR does not require the client to go into
detail about the distressing events of the past
There is no need to analyze the trauma for
long periods of time
It is client-centered in that the client sets the
agenda for the session material
Multi-faceted approach – works on mind,
body and emotions together. Emotional pain
can manifest itself as physical pain and by
changing beliefs, experience of pain can be
changed.
Eye Movement Desensitization &
Reprocessing (EMDR)
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Concerns include:
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Training is private and can be quite costly
Some patients are uncomfortable with using
eye movements or any of the EMDR devices,
or with the nearness of the therapist when the
eye movements are used.
Critics claim that the improvements that have
been documented, in dozens of professional
journals, are due to the included elements of
exposure therapy and CBT process.
Narrative Exposure Therapy (NET)
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In 3rd World settings, trauma victims are often
illiterate, in poverty, and cannot attend long term
traditional psychotherapy.
Victims are unable to tell what happened to find their
own healing or to implicate the perpetrators.
NET developed for work in such locations to enable
a short-term exposure therapy.
Remembering & telling the truth about terrible
events are prerequisites for both the restoration of
the social order and for the healing of individual
victims.
• J. L. Herman (1992)
Narrative Exposure Therapy (NET)
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Victims of trauma may experience “flashes”
of memory that activate the fear structure,
leading to avoidance of the memory.
Victims learn to avoid cues that remind them
of the trauma and PTSD is deepened.
NET guides the individual through a
chronological retelling of the event in the
session with the therapist.
The therapist writes the story as narrated by
the individual.
Narrative Exposure Therapy (NET)
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Initially the therapist establishes the bond with
the individual and provides education about the
process / rationale for NET.
The level of fear may be initially high as the
therapist encourages activation of the painful
memoires. Prevention of avoidance is inhibited
during the session.
Habituation of the emotional response occurs as
the memories are no longer capable of eliciting
the response part of the fear network.
Narrative Exposure Therapy (NET)
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NET weaves hot implicit memories as the
story unfolds with cool declarative memories,
allowing the individual to undergo habituation
of the emotional response to the traumatic
memory, leading to remission of anxiety.
At subsequent sessions, the therapist reads
the account, encourages the fear activation
with additions/changes to the narrative,
within the framework of cognitive behavioral
therapeutic challenges.
Narrative Exposure Therapy (NET)
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NET is helpful with patients who cannot do
exposure therapy work at home or who have
problems completing assignments alone.
NET is a useful tool with individuals who have not
been able to emotionally regulate their fear
activation responses.
NET would be a useful too for trauma work with
children.
The manual was written by:
Schauer, Neuner, & Elbert, 2005
Adjunctive Therapies:
Nightmare Resolution Therapy
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NRT designed to help patients who have
recurrent nightmares with the same content
or the same themes.
Protocol is 6-7 sessions, group or individual
Treatment focus is on reducing nightmare
frequency and intensity.
Patient is taught relaxation techniques and
sleep hygiene principles
Adjunctive Therapies:
Nightmare Resolution Therapy
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First session provides education, with
homework to use sleep logs and dream logs,
and a target nightmare be identified.
Second session , complete target nightmare
negative self-beliefs. Continue with logs.
HW is to write a changed dream.
Third session, modify, as needed, the
changed dream and complete changed
dream positive self-beliefs .
Adjunctive Therapies:
Nightmare Resolution Therapy
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Patient is instructed to utilize relaxation strategies
in combination with reading the changed dream &
beliefs three times everyday.
Session 4-6, check in with progress, modify dream
if needed, check logs.
As incidence of target nightmare decreases, the
focus of therapy may move to another repititious
nightmare.
Some individuals stop the dream within the first
week, others modify it, but it almost always either
decreases or changes.
Adjunctive Therapies:
Stress / Anger Management
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Therapy that targets problems with
managing stress or anger managements can
be done in individual or group sessions.
Stress M provides education about stress,
teaches breathing skills, PMR, imagery
rehearsal, body scans, SIT, and mindfulness.
SM addresses how to use coping strategies,
identifies healthier habits, how to use
positive distractions and positive self-talk.
Adjunctive Therapies:
Stress / Anger Management
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Anger Management incorporates the stress
management skills and also focuses on
education about anger, how to identify when
a person is becoming angry, and strategies
to moderate angry responses.
Both stress management skills training and
anger management skills training are ideal
for group settings.
Adjunctive Therapies:
Sleep Hygiene
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Primary presenting symptoms for trauma
survivors, combat or non-combat, is
problems with falling asleep and staying
asleep.
Sleep Hygiene combines a stress
management approach with specific focus
on sleep hygiene and strategies.
It utilizes a CBT approach to sleep
improvement with the use of sleep logs.
Treatment for MST-related MH Issues
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Basic good clinical skills of developing a
therapeutic bond and providing warmth, empathy,
and acceptance are key.
Improving your own professionalism so that
working with these difficult topics is less stressful
for your patients.
Use peer supervision and be mindful of vicarious
traumatization.
Training, skills, manuals are available by the
internet, through workshops, and from the
professional conferences.
Treatment for MST-related MH
Issues
• Thank you for caring about our
veterans!
• Louise.Weller2@va.gov