Social Work Clinical Skills used In Assisting Afghanistan and Iraq Combat Veterans: Cultural Considerations for Hispanic Veterans

Course Objectives

1. Be familiarized with diagnostic skills used assisting Hispanic Veterans with Post Traumatic Stress Disorder 2. Learn to identify the PTSD cluster symptoms; Re experiencing, Arousal and Avoidance 3. Be introduced to evidence-based practices currently used in the treatment of combat-related PTSD

Rise in Hispanics in the military; more suffer from PTSD

• • • • • • 2012: 1.2 Million Hispanic veterans; 39% suffer from PTSD 1994 to 2008: Hispanics in the military grew from 6 to 13 % 2004: Hispanics in the Army: 12.1% , Hispanics in the USMC: 40% 2012: Hispanic Females in the military: 7%, Hispanic Males in the military 6% 2012: 24% Hispanics joined the Army, “ for the desire to serve my country.” 2012: Rand Corporation: 88% Hispanics joined the military to obtain a college degree

Proud History of Hispanic Veterans in Service to Our Country

• • • • • • • • World War II: Hispanics served in both the European and Pacific Theatres of War. 400,000 / 12,000,000 or 4.7% were Hispanic, Full integration into military units.

200 th Coast Artillery from New Mexico and the Bataan Death March 65 th Infantry Regiment in France commanded by LTC Juan Cesar Davila relieved the 442 nd RCT Veteran Dr. Hector Garcia started the American GI Forum in 1948 to stop discrimination of Latino veterans Korea: 147,800 Hispanics served in all branches. 9 received the Medal of Honor, 100 received the Distinguished Service Cross and Silver Stars for combat bravery Vietnam: 344, 000 Latinos Served, 23 Hispanic Medal of Honor Winners Iraq War Afghanistan War, 1 Hispanic Medal of Honor Winner

The Cultural Formulation Interview (CFI) of Hispanic Veterans

• • • • • •

Understanding the cultural context of combat trauma for Hispanic Veterans is essential for effective diagnostic assessment and clinical management

Focus are four (4) domains of assessment: 1

. Cultural Definition of the Problem: Focus on the individual’s own way of understanding the problem;

experiences?) ( What are your Idioms of distress, Language used to describe your problems, individual’s ethnic background and developmental 2

. Cultural Perceptions of Cause, Context and Support: Focus is on the meaning of the condition for the individual, and the views of members of the family, friends and community;

(What do you think are the causes of your problems, and what does your family, community think is causing your problem?)

Stressors and Supports: Elicit information on resilience, social supports and also stressful aspects of the individual’s environment i.e. discrimination, difficulties at work, school or relationships

( Are there any kinds of support from family, friends that make your problem better? Are there any kinds of stressors that make your problem worse; such as money or family problems?)

*DSM-5

The Cultural Formulation Interview (CFI) of Hispanic Veterans (Part 2)

• • • • • •

Role of Cultural Identity: Elicit aspects of your cultural identity that make your problem better or worse (

Are there aspects of your cultural identity that make it better or worse for you?)

3. Cultural Factors Affecting Self-Coping and Past Help Seeking: Elicit various sources of self-help; (

What kinds of help were most useful? Not useful?)

Barriers: Ask about social barriers to seeking help; Stigma, discrimination;

( Has anything prevented you from getting help?)

4. Cultural Factors Affecting Current Help Seeking: Clarify the person’s cultural network of support including Religion, Spirituality, Older Adults;

(What kinds of help from your family, community, church would be helpful to you?)

Clinician-Patient Relationship: Elicit concerns about the clinician’s values and cultural background; (

Do you have concerns with the care I am giving you?) *DSM-5

The Hispanic Veteran and the Role of Hispanic Identity

• • • Strong Family Support Religion & Spirituality Language • • Implications for the Therapist:

Ask the veteran which aspects of Hispanic identity make the problem better, or worse?

Strong Family Support; Stressors and Support

• • • • Devotion to the family Source of Material and emotional support Reliance on each other Shame is experienced when roles of proper conduct are not met • • Implication for the therapist:

Are there any kinds of support from your family that makes your problem better, or worse?

Spirituality: Cultural Factors Affecting Self-coping and Past Help-Seeking

• • • • Maintain strong spiritual beliefs Most belong to organized religions Predominantly Catholic Rituals are interwoven in the lifestyle • • • • Implications for the therapist:

Ask if your religion, faith, has been helpful to you?

Include the use of rituals to assist in the intervention For Moral Injury : The concept of seeking forgiveness and making amends

Language, Cultural Definition of the Problem

1.

2.

3.

Spanish language has idioms of distress

: Uncomfortable emotions are expressed somatically- reason for seeking primary care providers Panic Attacks can be expressed as “ nervios”

4.

5.

6.

Tradition of machismo:

Does not allow for complaints Treatment is for others • • • • •

Implications for the Therapist

:

How would you describe your problem?

” Spanish is primary language of use when one wants to convey different emotions To validate the client’s language;“ How would you say that in English,”

Asking for Help: Barriers

• • • • • Proud people have difficulty asking for help, due to: Pride Loyalty Machismo Gender Roles

Treatment Considerations for Hispanic Veterans: Clinician-Patient Relationship

1. Higher respect for authority; will defer to therapist directives 2. Provide psycho-education on rationale for treatment and coping mechanisms; which will improve client decision making and increase self-esteem 3. Directive Interventions; Cognitive Behavioral Therapy using Cognitive Restructuring, Journaling, and homework assignments 4. Provide Couples and Family Therapy; will help re-connect and re-vitalize family relationships 5. Ritualize Treatments; integrate treatment with religious practices and family activities.

Posttraumatic Stress Disorder, DSM- V

A. Exposure to actual or threatened death, serious injury, or sexual violence:

A.

Direct experience B.

Witnessing in person as is occurs to others C. Learning that the traumatic event occurred to a close family member or close friend D. Experiencing repeated or extreme exposure to aversive details of the traumatic event B.

Intrusive, recurrent , involuntary: memories, dreams, dissociative reactions (flashbacks)

, Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble the event, Marked physiological reactions to internal or external cues

Posttraumatic Stress Disorder -continued

C.

Persistent Avoidance of stimuli associated with the traumatic event

: A. Avoidance of memories, thoughts or feelings B. Avoidance of people, places or situations D.

Negative Alterations in Cognitions and mood associated with the traumatic event

A. Persistent and exaggerated negative beliefs or expectations about oneself, others or the world B. Persistent, distorted cognitions about the cause or consequences of the trauma that lead to the individual to blame him/herself C. Persistent negative emotional state ( fear, horror, anger, guilt, shame) D. Markedly diminished interest in significant activities E. Feelings of detachment from others F. Persistent inability to experience happiness, satisfaction or loving feelings

Posttraumatic Stress Disorder -continued

E.

Marked alteration in arousal and reactivity associated with he traumatic event

A. Irritable behavior and angry outbursts B. Reckless and self-destructive behavior C. Hypervigilance D. Exaggerated startle response E. Problems with concentration F. Sleep disturbances F.

Duration of Disturbance in > one (1) month

G.

Significant disturbance or distress in social, occupational or other important areas of functioning

H.

Disturbance is Not related to substance abuse

Types of Stressful Combat Zone or Military Setting Experiences

         

Terrorist Activities Exposure to Improvised Explosive Devices (IED’s) Exposure to Vehicle Based Improvised Explosive Devises (VBIED’s) Surviving attacks from explosive devices Exposure to suicide bombers Ambushes Firefights House-to-house searches Accidentally wounding or killing civilians

         

Being shot at Surviving combat wounding Exposure to the wounding or death of others.

Encountering human remains Surviving a vehicle accident Difficult living and working environments Poor leadership Concerns about relationship, family and life disruptions Sexual Assault or harassment Perceived exposure to chemical, biological or nuclear weapons

Treatment Focus with Hispanic Veterans

• • • PTSD – Military Related Complex PTSD Moral Injury

Moral Injury, Definition

•

Moral injury; a construct that describes extreme and traumatic life experiences, where events are morally injurious if they "transgress deeply held moral beliefs and expectations"

•

The lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations *Moral Injury and Moral Repair Brett Litz, PhD

•

www.ncptsd.va.gov

• • • •

Moral injury is present when: (1) there has been a betrayal of what’s morally correct (2) by someone who holds legitimate authority (3) in a high stakes situation Jonathan Shay MD, PHD Wkipedia.com

Combat Trauma and the Soldier

• • • • • • After the trauma, SM is preoccupied with the event Intrusive memories as a response to horrific experiences Replay the upsetting memories to modify their feelings and to tolerate the memories If unable to integrate the memories, they avoid and become hyper-aroused Failure of time to “heal the wounds.” Memories are not accepted as part of the past

Changes in Belief Systems (STICS)



Self-esteem

. Difficulty believing that life is meaningful , the assumption that one is a worthy person. 

Trust

. Difficulty trusting in one’s own decisions, others, leaders or governments.



Intimacy

. Questions the belief that people are capable of love and worth relating to.



Control and Competency

vulnerability.

. Distorted beliefs that events are no longer orderly, predictable, fair and controllable. Feelings of 

Safety

. A persons sense of safety and security is compromised. The world is a more dangerous place.

RAA Cluster Symptoms of PTSD

•

REEXPERIENCING THE TRAUMA : Intrusive memories, nightmares, flashbacks

•

AROUSAL: Irritability and anger, sleep problems, hyper vigilance, exaggerated startle responses, difficulty concentrating

•

AVOIDANCE: Avoiding one’s feelings, avoiding relationships, losing interest/avoiding activities, being overly detached.

Intrapsychic Factors contributing to PTSD

 Worsening of stress-related symptoms,   new onset of dangerousness to self or others maladaptive coping to stress,  exacerbation of co-morbid psychiatric conditions,  deterioration in psychosocial functioning  new onset stressors

Co-occurring and Psychosocial Issues related to adapting back to family/installation/community living

         

Recognizing co-occurring disorders resulting from combat trauma

Suicide ideations Alcohol and Substance Abuse Anger, Aggression Grief Reactions Physical Health problems Chronic Pain Sleep Problems, insomnia, nightmares Anxiety Depression • • • • • • • •

Recognizing psychosocial issues resulting from combat trauma

Marital conflict and divorce Parent-child relationship problems Domestic violence Employment problems Issues in school or education Financial strain Homelessness

Primary Life Areas of Functioning for the Returning Combat Veteran

• • • • • • • • • Marital, Partner and Family Relationships Employment Higher Education, Vocational Training Peer support and friendships Housing Legal Financial Community and church involvement Recreational

Evidence based practices and non-traditional healing practices for PTSD

• • • • • • • Cognitive Processing Therapy (CPT) Evidence-Based Practice Prolonged Exposure ( PE)Evidence Based Practice Eye Movement Rapid Desensitization (EMDR) Evidence Based Practice Family Therapy (FOCUS) Couples Therapy Specialized Inpatient PTSD Programs Partial Hospitalization Programs    Complimentary and Alternative Medicine (CAM) Animal Assisted Therapy (AAT) Innovative Outdoor Adventure Therapy Programs Resiliency Skills Training • • • •  Pharmacotherapy Anger Management therapy Fitness Training Stress Inoculation Training

Theoretical Basis for Understanding PTSD

• • • • • • 1

. Pre-Trauma Belief Systems

of “Self” and “The World” 2.

The Traumatic Event

: Trauma memories of : A .Stimulus Elements (Auditory, Visual, tactile triggers) B. Response Elements ( Fight or Flight) C. Meaning Elements (“Dangerous” “Incompetent”) 3

. Post-Trauma Experiences

(Persistent Symptoms, Disruptions in daily life, negative reactions from others) • •

Two negative schemas that underlie chronic psychopathology

: “ The world is completely dangerous and, the self is totally inept” • Foa and Kozak (1985)

Core Clinical Assumptions

• • • • •

Suffering from PTSD for the Hispanic veteran can involve betrayal of/ by

spiritual, moral, cultural and family values

Healing from PTSD requires understanding what belief systems have been compromised; the Cognitive Dissonance Clinicians can assist the veteran to emotionally process guilt, shame, sorrow, and re-evaluate his/her sense of responsibility related to the trauma There is the need for Making Amends, Forgiveness or Restorative Justice in order to reattach back to one’s family and community Spiritual, community, cultural, and family acceptance matters a great deal

• Brett Litz, Moral Injury and Moral Repair

Mechanisms of change for Trauma-Focused psychotherapies

             

Trauma-focused psychotherapies

include: exposure techniques that involve repetitive review of traumatic memories and trauma related situations, cognitive techniques that focus on identification and modification of trauma-related beliefs and meanings, and/or stress reduction techniques designed to alleviate PTSD symptoms and assist patients in gaining control and mastery over the physiological reactivity

SIT protocols

include components of cognitive restructuring or in-vivo exposure, breathing retraining relaxation

The core components

involve combinations of: exposure (particularly in-vivo and imaginal/oral narrative), cognitive restructuring, relaxation/stress modulation techniques, and psychoeducation.

P117 Guidelines

Treating symptoms using Cognitive Behavioral Therapy; for arousal, avoidance and re-experiencing

  

For increased arousal,

the goal of treatment is to help the person learn skills that will reduce overall arousal . relaxation, self-hypnosis, and physical exercises that discharge tension

.

• For

behavior,

the goal of treatment is to review a person's most frequent ways of behaving under perceived threat or stress and help him or her to expand the possible responses. time-out; writing thoughts down when angry; communicating in more verbal, assertive ways; and changing the pattern "act first, think later" to "think first, act later." • For

thoughts/beliefs,

positive thoughts. individuals are given assistance in logging, monitoring, and becoming more aware of their own thoughts prior to becoming emotionally upset. Give alternative, more positive replacement thoughts for their negative ideas (e.g., "Even if I am out of control, I won't be threatened in this situation." . Individuals often role-play so they can practice recognizing their emotionally-arousing thoughts and apply more

Engagement: Initiating trust with the Hispanic Veterans; Five “Icebreaker” questions

1. Ask : What was the client’s branch of the military? Army / Navy / Marine Corps / Air Force / Coast Guard?

2. What was service member’s rank? ie SGT/Chief Petty Officer 3. What unit was the service member assigned to? ie 1 st Marine Division 4. Where did he/she serve? Iraq/Afghanistan/ USS Enterprise/ Fort McNair 5. What was the service member’s Military Occupational Specialty (military career)? ie 11B Infantry

Establishing a Therapeutic Alliance with a Hispanic Service member or veteran

• • • • • • • •

Compassion

, that the military is an honorable but hazardous occupation

Empathy;

understanding that combat creates the most intense feelings of grief, fear, anxiety

Trustworthiness

; “ Do what you say you are going to do”

Acknowledgement

of the client’s service to the country,

Understanding of the military sub-culture Provide realistic hope

; that the client will learn to live more comfortably with uncomfortable feelings

Be open-minded

and

non-judgmenta

l Watch a military documentary or movie

PTSD Screening Tools

• PTSD Checklist (PCL-M) • Beck Depression Inventory • Novaco Anger Scale • Assessment for Suicide

PTSD Checklist (PCL): The PCL has been used extensively in military and civilian populations, and there are numerous validation studies, including studies in military populations (Terhakopian et al., 2008).

Research supports the utility of brief screening tools for identifying undiagnosed cases of PTSD

Questions and Discussion

Gracias, Thank you, for your participation