Anger and the Veteran - UKPTS · Effects of service life on the veteran and his family: Service provision and the role of Combat Stress ... •No prior intervention •NHS has not

British VeteransEffects of service life on the veteran and his family:

Service provision and the role of Combat Stress

Dr Walter Busuttil

Medical Director & Consultant Psychiatrist

Combat Stress

[email protected]

British Veterans• A veteran is someone who has served at least

one day in the military

• Veterans and combat veterans

• Around 25,000 leave the military each year.

• There are about 5 million Veterans in the UK

and 7.5 million first degree dependents.

British Veterans

• What are the issues?

• What is the need? Numbers? Clinical

need? Welfare need?

• What services are needed?

Why is working with veterans complicated?

Mental health problems can arise from a variety of causes in Veterans:

• Pre service vulnerabilities – many join to escape a difficult lifesituation, poor education levels, IQ?

• Military life itself – instutionalization, alcohol, family issues;bullying, non-operational occupational mental health injury;Operational service – traumatic exposure

• Earlier onset of physical disorders because of military life –mainly orthopaedic including chronic pain / ENT problems

• Leaving the service and adjusting to civilian life:institutionalisation

• Help seeking issues: Issues surrounding being macho,avoidance of seeking help, lack of understanding of and bycivilians, shame, stigma, guilt, you were not there etc

• Combination of the above

Incidence of mental health problems in Veterans

1. No UK Population Studies

2. Need National Vietnam Veterans Readjustment Study (NVVRS) equivalent studies

3. KCL OP Telec (Iraq Invasion and occupation) Studies will help as long as population is followed up as veterans

4. Population Studies being set up in Scotland and Wales

• Depression • Anxiety• PTSD• Alcohol• Drugs• Personality problems

PTSD: CO-MORBIDITY:

(incl NVVRS Study and other studies)

BIO/PSYCHO/SOCIAL

• Depressive illness 50-75%

• Anxiety disorder 20 -40%

• Phobias 15 - 30%

• Panic disorder 5 -37%

• alcohol abuse / dependence 6 - 55%

• drug / abuse / dependence 25%

• Divorce

• Unemployment

• Accidents:

• RTA rates 49% higher in Vietnam vets than non-vets

• Suicide: 65% higher in combat veterans

What is PTSD?

A Dynamic Model for the Interaction

of the Symptom Clusters in Established PTSD.Modified by Busuttil (1995) from Horowitz (1976) Information Processing Model

Stressor

Arousal

Re-experiencing

Avoidance

Aetiology of PTSDMemory: Facts

Feelings

Sensations

Stressor

Triggers

Arousal

Re-experiencing

Personality/

developmental stage/

social support

Avoidance

Depression/isolation/alcohol/illicit drugs/ guilt

Relationship between:

PTSReaction & PTSDisorder

ASD & PTSD

DSM & ICD

ASD ----->Acute PTSD---->Chronic PTSD

fluid state--------------------->fixed state

0___________________1________________________4________Months

time in months

CO-MORBIDITY: BIO/PSYCHO/SOCIAL

• Depressive illness 50-75%

• Anxiety disorder 20 -40%

• Phobias 15 - 30%

• Panic disorder 5 -37%

• alcohol abuse / dependence 6 - 55%

• drug / abuse / dependence 25%

• Divorce

• Unemployment

• Accidents:

• RTA rates 49% higher in Vietnam vets than non-vets

• Suicide: 65% higher in combat veterans

RISK FACTORS:

• Primary: Nature & Dose of Stressor.

• Secondary:Preparedness - perceived ability to counter threat

Support networks during exposure

Dissociation during or after exposure – peri-traumatic

dissociation

?personality deficits

?past psychiatric history

?age

?gender

?education status

?previous PTSR / PTSD.

Classification

DSM-IV

• Acute Stress

Disorder

• Acute PTSD

• Chronic PTSD

• Delayed PTSD

ICD-10

• Acute Stress

Reaction

• PTSD

• Enduring

Personality

Change Following

Catastrophic

Stress

Exposure to Psychological Trauma

Multiple vs Single Trauma

Single Exposure

• Lockerbie Clear-

up operation

Multiple Exposure

• CSA for five years

• Road Traffic

Accident

• Falklands War

• Lockerbie Clear up

operation

Multiple TraumatisationConsiderations:

• Nature and Extent of Trauma

• Age and Developmental Stage

• Reason / Cause / Ideology

• Support - Group vs Isolation

• Sustained - predictable / unpredictable

• Intermittent

Personal

General

KZ SyndromeKonzentrations Lager Syndrome:

Concentration Camp Syndrome

(Herman & Thygersen, 1953)Characterized by 12 severe chronic psychiatric and non-specific

somatic symptoms comprising:

• fatigue

• impaired memory

• dysphoria

• emotional instability

• sleep impairment

• feelings of insufficiency

• loss of initiative

• nervousness

• restlessness & irritability

• vertigo

• vegetative lability

Concentration Camp Syndrome

(Herman & Thygersen, 1953)

Associated symptoms

(Eitinger1961)

• anxiety

• nightmares

• depression

• alcohol abuse

• reduced alcohol

tolerance

Associated symptoms

Friedman, 1949):

• re-experiencing symptoms

• emotional numbing

• apathy

• survivor guilt

• psychosomatic symptoms

• anxiety hyperarousal

Associated symptoms

Chodoff, 1963

• Avoidance symptoms

Cognitive Defect States

• Organic insults infections, vitamin

deficiencies, head injuries

• PTSD

• Depression

Multiple Traumatisation in AdultsStudies of Hostages and POWs (Busuttil, 1992)

• Stress Disorders (incl ASD & PTSD): pre-captivityexperiences; initial captivity experience; torture;solitary & group confinement

• Depressive Disorders: torture, loss events,captivity experience itself

• Cognitive Defect States: weight loss, vitamindeficiencies, CNS infections

• Psychotic States: isolation and confinement

• Personality - Character Changes: captivityexperience itself: coping style and locus ofcontrol (includes enduring personality change)

• Physical Illness - Somatiform & Genuine

Enduring Personality Change after

Catastrophic Stress (ICD-10, 1992)

Prolonged exposure to life threat/s

PTSD may precede the disorder

features seen after exposure to threat:

• a hostile mistrustful attitude towards the

world

• social withdrawal

• feelings of emptiness or hopelessness

• chronic feelings of being on edge or

threatened

• estrangement

Multiple traumatisation in Children and

young people before the age of 26:

Complex PTSD:

Diagnostic framework (Bloom 1999)

Three areas of disturbance -

• Symptoms

• Characterological / personality changes

• Repetition of Harm

Complex PTSD: Disturbance on Three Dimensions(Bloom, 1999)

• Symptoms of : PTSD

Somatic – cf GWS

Affective

Dissociation

(psychotic presentations)

• Characterological Changes of:

Control: Traumatic Bonding

Lens of Fear

Relationships: Lens of extremity-attachment vs

withdrawal

Identity Changes:

Self structures

Internalized images of stress

Malignant sense of self

Fragmentation of the self

• Repetition of Harm

To the self - faulty boundary setting

By others - battery, abuse

Of others - become abusers, aggressors

Deliberate self harm

Delayed Onset PTSD

• Onset in 43% cases within first year of

leaving Military

• Rates twice as high as compared to

civilian population

• (Brewin & Andrews, 2008)

• Onset in old age – effects of retirement

and life events (Busuttil, 2004)

Clinical Services for Veterans in UK

• Third Sector Charities – Combat Stress

• NHS

• Recent Government Initiatives

Combat Stress:

Ex-Servicemen’s Welfare Society established 1919• National Charity

• Only mental health charity of any size for Veterans

• Part funded via War Pensions system Part funded by

Charity

• Offers multidisciplinary community outreach service

including welfare needs and multidisciplinary inpatient

bespoke programmes.

• Clinical Outreach services being expanded.

• Helplines / websites

• Most referrals self referral or through family (46%) or ex-

service charities (31%) - NHS only 3%!

• 1200 new referrals last year

• 3500 active patients – receiving either welfare or clinical

help or both

Typical new referral 2008• Average age 44 year old (youngest aged 20 oldest 93)

• Ex Army

• Childhood trauma, neglect, poor care giving

• Multiple traumatic exposure. Service in many war theatres NI commonest.

• Family Ultimatum – usually second marriage

• History of Multiple house moves, employers, long spells of unemployment or homelessness

• Many children mostly not in touch

• History of domestic violence

• Significant physical illness

• Classically diagnosed with PTSD, Depression; Alcohol misuse

• No prior intervention

• NHS has not helped (for a variety of reasons)

89 Years of Care

• Over 85,000 veterans and their families have been helped

• 3,680 Active cases currently registered with the Society

• 1,160 new referrals year ending 31 March 2008

• Average age of new referrals 43 years

• On average present some 13 years after leaving military

• On average have served for 11 years

Veteran Age Profile

0

20

40

60

80

100

120

140

160

180

200

0

200

400

600

800

1000

1200

20 and Under 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 71 - 80 81 - 90 91 plus

New

Refe

rrals

2007

Acti

ve V

ete

ran

s

Active Veterans Age Profile 2000 New Referrals 2007

2000

31.03.2008

Veterans by ServiceVeterans by Service

Army

81.5%

Royal Marines

2.4%

Royal Air Force

7.8%

Royal Navy

7.6%

Merchant Navy

0.7%

1981

635

460

301

246

182

128

126

57

49

30

15

14

11

11

5

4

3

325

351

0 200 400 600 800 1000 1200 1400 1600 1800 2000

Northern Ireland

None

Gulf

Falklands

Balkans

Other

WWII

Iraq

Aden

Cyprus

Malaya

Korea

Afghanistan

Sierra Leone

Kenya

Suez

Palestine

Burma

Rw anda

Borneo

31.03.2008

Theatres of Operation

The pathway into care…new referrals 1160 in past year

1Apr 07 – 31 Mar 08

NHS, social services & military

service discharge boards11%

Incl Approx

3% NHS

Service charities, welfare

organisations, VA, WPWS31%

SELF REFERRAL 46%

OTHER 13%

Community Welfare arm of Combat Stress• Sixteen Community Outreach Officers across UK and

Eire

• Desk officers manage Community Outreach Officer

• Desk officers offer 9-5 telephone advice to veteran

• Community Outreach Officer is ex-military officer whovisits ex-serviceman and engages him

• Community Outreach Officer visits initially and helpswith practical needs as well as writing referral reportfor Treatment centre assessment and startspsychometric data gathering

• Community Outreach Officer liaises with WarPensions and other service charities & retraining forwork

• Community Outreach Officer follows up and stays intouch as long as the patient’s case remains ‘active’: iehelp delivered for Welfare or Clinical needs or both

Helplines / websites• Welfare Desk officers offer 9-5 telephone

advice to veteran

• Nursing station offers out of hours advice to veterans – effectively a 24hour helpline is available

• – bespoke helpline is in process of being set up with Samaritans.

• Combat Stress website is being upgraded.

Three residential treatment centres

• Tyrwhitt House Surrey

• Audley Court Shropshire

• Hollybush House Ayr

• Sensitive to the military culture

• Therapeutic milieu

• Peer support

The needs of Combat Stress Population:

Clinical Audit Data Combat Stress 2007

% New Patients (n=162) % Review patients (n=169)

Significant Physical

illness

59 86

Physical injury during

military service

45 62

Psychiatric illness as a

measure of chronicity

75 95

Multiple exposure to

psychological trauma

95 84

Present and past history

of alcohol and drug

dependence and abuse

69 74

Significant attachment

difficulties in childhood /

adolescence incl CSA

and other abuse.

59 39

Complex Bio-Psychosocial presentations

Psychiatric disorders• VERY High levels of CHRONIC psychiatric disorder

and co-morbidity especially PTSD, Depression, Alcohol related disorders

• PTSD primary diagnosis in 71-81% of patients• Some psychotic presentations• Anxiety, anger, personality difficulties and

dissociative disorders• Very high rates of attachment / abuse problems

related to childhood: • Attachment problems regenerated after leaving

militaryBehavioural Disorders• Aggression, violent behaviour – offending behaviours

including Schedule 1 offences

Source -Combat Stress Clinical Audit data (n=331) & Psychometric Data Analyses (n=480) 2005-2008

Complex Bio-Psychosocial presentations

Physical Disorders

• Chronic physical disabilities / illness especially orthopaedic and chronic pain, ENT disorders

• Very high levels of psychiatric and physical co-morbidity

Social exclusion

• Dysfunctional relationships Marital and family break down

• Unemployment (up to 75% of those of working age)

• High percentage live alone and have accommodation problems

• Isolation – very common problem

Source -Combat Stress Clinical Audit data (n=331) & Psychometric Data Analyses (n=480) 2005-2008

Combat Stress Treatment Strategy (Dec 2007)

Chronic Disease management as per 2005 NICE

Guidelines for treatment of Veterans for PTSD

1. Initial preparation.

2. Stabilisation and safety.

3. Disclosure and working through of the traumatic material and psychotherapy on an individual basis.

4. Rehabilitation and reintegration within society; normalising activities of daily living.

Treatment of PTSD in Veterans: Basic Principles

Multimodal Assessment:

Clinical History & Mental State Examination; Psychometric Tests: subjective and Objective

Stabilise:

• Prepare for therapy: detox alcohol, drugs,

• welfare needs – homelessness, isolation, job skills etc:

• Prescribe appropriate medications SSRI and related antidepressants, Mood stabilisers, anti-impulse, major tranquillizers; medications for pain,

Therapy :

• Outpatient

assessment plus TF-CBT; EMDR – single trauma much easier!!

• Residential specialist services:

initial stabilisation then disclosure / psychotherapy/ then rehabilitation.

• Group Programmes: psychoeducation; cognitive restructuring groups individual TF-CBT; EMDR; psychodynamic incl disclosure work; narrative therapy.

• Repeat admissions? Integrated community and inpatient programmes: eg Australian Veterans

Appropriate treatment for co-morbid disorders

Family and spouse interventions – carer’s groups, family and couple therapy

Safety – supports

Current Clinical Intervention

• Initial Community Care Officer assessment –ESSENTIAL PORTAL OF ENTRY INTO CARE

• CPN assessment / clinical outreach

• Five day week admission for assessment -followed by:

• Three two week treatment admissions over one year period as a maximum

• Or Six one week admissions over one year

• Whole person care plan

• Try to plug into NHS care

• Liaison with MOD Pilot treatment sites

Current Rolling Programme• Establish trust and rapport

• Unique therapeutic milieu

• Group Psycho education: incl PTSD, depression groups; anxiety management; anger management, coping skills training / mindfulness etc.

• Stabilisation on Medication

• Individual therapy include arts therapies to engage; solution focussed therapy.

• Trauma Focussed therapies including TF-CBT and EMDR

• Rehabilitation – Occupational Therapy; Social Skills activities centre; retraining schemes

• Families and carers groups

• Liaison and plug in to local CMHTs/ Psychology etc

Combat Stress Clinical Strategy

Upgrade existing services

• Further develop residential MDT teams inclTraining needs

• Bespoke Programmes – intensive & old age.

• Enhance Rolling Programme

Expansion of Services

• Outreach and outpatient community services.

• Work in partnership with other servicecharities and NHS / Other internationalrehabilitation programmes for Veterans

Bespoke Programmes run on the same lines as

Australian Veterans Programmes

(big links with Australian Veterans Service Heidelberg Melbourne)

Time Limited intensive residential ‘course’ ofgroup treatment comprising:

• Psychoeducation

• Trauma focussed therapies

• Cognitive restructuring

• Rehabilitation

• Referral for Work Re-training

• Maintenance in community – follow-ontherapies

• Follow-up ‘top-up’ brief residential reunions

Development of Community Outreach Services

• Three CPNs already in place working with local MOD Pilots

• Builds on Welfare Service

• Integrates with the NHS & MOD pilots & IAPT.

• 16 Community Outreach Officers leading CommunityOutreach Teams comprising: CPNs; Systemic Therapists forfamily work; Carer’s and adolescent groups; (currently 3CPNs in post and building liaison with MOD Pilots)

• Regional Outpatient Psychiatry and Psychology assessmentand follow-up clinics

• Outpatient Psychotherapy

• Family and Carers Groups (several already running)

• Liaison with local alcohol and drug detoxification treatments– facilitate entry immediately after detox into TC care forunderlying disorders

Maintenance

• Maintenance is an essential part ofchronic disease model for those whoseillness is ongoing.

• The Community Outreach Service must bein place for the bespoke treatmentprogrammes to work well

Care Pathways

• Community Assessment & Management

• Inpatient bespoke intensive ‘course’ of

treatment

• Follow-up and plug-in, into NHS

community services

• Reunion admission for brief periods

• Maintenance and recovery model of

care

Combat Stress: Three streams

1. Community outreach & Welfare

2. Rolling programmes

3. Bespoke programmes

PLUS:

Liaison & Joint Working with local NHS & other services & including:

• NHS CMHTs

• IAPT

• MOD Pilot Sites

• Military Charities

• War Pensions – Benefits Trap: WPs should not be counterproductive to treatment and therapy

• other services

NHS

• Services patchy

• Lack of expertise in assessment and management of psychological trauma cases and PTSD generally

• Lack of expertise in Military psychiatry / psychology

• Lack of appropriate prescribing of medications for complex / chronic PTSD

Major challenges for NHS and Combat Stress

• Complex Trauma Presentations (Complex PTSD)

• Acute alcohol / drug Detox – seamless plug into trauma work

• Schedule 1 Sex Offenders

• Forensic cases – imminent violence, severe behavioural disturbance

• Veterans with mental ill health in the prison population

• Increasing population of Old Age Veterans in the general population – hidden psychiatric morbidity plus locked in chronic PTSD

• Growing number of in service families with psychological and mental health problems

Recent Government Initiatives

• MOD/NHS mental health pilots – six so far

assessed / signposted 180 patients.

• Advice to NHS about priority treatment

• Command Paper – promise of help to

veterans

• Assessment services UK MAP, Chillwell.

• Advice about IAPT (Improving access into

Psychological Therapies)

Service Life effects on

Marriage and the Family

We will talk about:

• Service life

• The effects of cyclical separation on the

family: Exercise and Operations

• Traumatic Exposure – pre-service;

attachments, operational service,

bullying

• Living with Anger / PTSD

Marriage can be

• Pre-service

• In-service

• Post-service

Systems Theory

• Family in a balance of Homeostasis

• Maturity of relationship important

consideration

• Pre-trauma relationship vs post

trauma relationship

Demands of Military Life• 24/7

• Determines where you live

• Married quarters; married patch.

• Segregation men and officers

• Own medical services, rules, laws, schools,

regimental system.

• Husband / men ordered away at a moment’s

notice.

• Institutionalising

Traditional Expectations of men and women

Wife• Dependent

• Passive

• Non-competitive

• Interpersonally oriented

• Sensitive

• Subjective

• Nurturing

• Unable to risk

• Emotionally Labile

Husband (Male soldier)• Independent

• Aggressive

• Competative

• Task oriented

• Self disciplined

• Objective

• Courageous

• Unsentimental

• Rational

• Confident & in control of emotions

If wife asserts herself in Military /

system

• Difficult

• Uncooperative

• Rocks the boat

• Bad for husband’s career

• A ‘good’ service wife ? – Husband’s ‘last

three’

- leads to lower self esteem and self worth

Peace time cyclical

separations:

Intermittent Husband Syndrome

• Anxiety,

• Depression

• Sexual difficulties

in wife

Operational and war time separations:

• Psychological effects on families subjected to

enforced and prolonged separations under life

threatening situations

• – DIRECT TRAUMATISATION OF THE FAMILY

• A spectrum of disturbance: depends on the

nature and duration of separation.

Traumatisation Process of the Family

• Direct Exposure

• Indirect Exposure

• Additive: Direct + Indirect

Direct TraumatisationPsychological effects on families subjected to

enforced and prolonged separations enforced under

Spectrum of psychologicasl thrests:

a spectrum of disturbance

Separation type I:

cyclical

separation and reunion:

frequent cycles of

partings and reunion

Separation type II:

separations enforced

under

threat of death

Separation type III:

indefinitely prolonged

separations

enforced under

life threatening

situations

Detachments Going to warPOW

MIA

All conditions of separation cause:• Initial shock, despair, detachment.

• Grief reaction – Anticipatory Grief

• If AG completes – this causes problems for relationship – marriage at risk

• If not: will not cope during separation but marriage OK long term

• Symptoms of: anxiety, PTS, psychosomatic, alcohol / drugs, social indiscretions and financial problems –

• (symptoms also reflected in children).

Concept: Anticipatory Grief & Completed

Grieving

Lindermann 1944; Eliot 1946

• Anticipatory Grief (AG) The wife is so

concerned with her adjustment after the

potential death of her husband that she

goes through all the stages of grief

• Advantage: she becomes independent and

copes well with separation

• Disadvantage: when he comes back

grieving is complete and therefore

husband is not reintegrated properly

within the relationship / family.

Reunion

Considerations:

• Time from release - front to transfer

home

• Venue - private - public

• Husband - experiences and illness

• Wife and family - experiences and

illness

Re-Integration(Hill, 1949)

• ‘the process of opening of family ranks to include

the father,

• realigning of power and authority,

• re-working division of labour and responsibility,

• sharing home and family activities with father,

• renewing husband - wife intimacies and

confidences,

• reappraising mother- child ties, and bringing a

balance between husband, wife, mother child and

father-child relationships.’

Direct Traumatisation

Psychological effects on families subjected to enforced and

prolonged separations enforced under life threatening situations

• A spectrum of disturbance: depends on the nature and duration of the separation

• Coping of the family members left behind determines the outcome for the family in terms of reunion and reintegration

• Treatment of psychological disturbance (may include psychosomatic, PTS and social disturbances) during separations may interfere with reunion and reintegration and longer term relationships.

Family Violence:

Clinical Audit Combat Stress

successive new patients assessed in

psychiatric clinic (n=61) (2007/08).

• Male=60 Female=1

• Mean age 43;

• n=14: 23% severe domestic violence histories

Family issues

• Usually wife or Woman brings veteran into care

• Direct and indirect traumatisation of the family

• Direct exposure to service life, husband’s operation experiences

• Emotional contamination – ripple effect on Family members if these are still around.

• Usually multiple relationships and divorces , partners, children.

DV group more likely to have been married (1.3 vs 0.98)

and have had partner (0.93 vs 0.49) than non-DV group.

Domestic violence group

N=14

Non-domestic violence

group N=47

Number of

marriage/

partners

marriage partners marriage partners

0 1 8 10 31

1 9 3 27 10

2 3 2 9 5

3 1 1 1 1

Indirect Traumatisation : Living with the

veteran suffering from PTSD:

Characteristics of Impaired Veteran Families

Research into Families of PTSD Sufferers

•Generally Sketchy

•Bulk American and Vietnam war era.

•On female spouses only

•As a general rule findings in spouses reflected in

children

•Cultural and social changes of past thirty years

need to be accounted for

•Cultural ?Applies to older veterans more

Families of Veterans

• In pre-war marriages: Direct traumatisation of family-and separation and reintegration issues – followed by indirect traumatision issues

• In post-war marriages: Indirect traumatisation leading to ‘Ripple Effect’

• Most marriages of Vets are post-war:

• Living with traumatised veteran

• Children, spouse, parents

• Extended families vs one parent families

• Female veterans – little known

• US Vietnam Veterans – 38% marriages broke up within six months of return from SEA (current problems in UK)

• Divorce rates and loss of partner relationships much higher in Veterans

Research demonstrates that the most

powerful predictors of ongoing PTSD in

combat veterans are:

• Dose / exposure to trauma / combat / time in front line

• Impaired family functioning – more powerful than personality and developmental issues.

• Very strong correlation between PTSD severity and family dysfunction.

• Veterans who do well in treatment are those who are in supportive relationship with a female – usually wife – marital support crucial to adjustment in veterans (Egendorlf)

Indirect Traumatisation : Living with the veteran suffering from

PTSD:

Characteristics of Impaired Veteran Families

• Veteran viewed as ‘Identified Patient’.

• PTSD Symptoms: Alienation, depression, emotional numbing,

avoided intimacy, isolation –get hurt if get close to others including

spouse.

• Substance abuse / addiction: alcohol / drugs, family stability &

financial problems.

• Violence / rage / ‘beserking’: 1 in 3 of 600 Vietnam vets admitted to

striking partner or children;

• 21% British Veterans accessing Combat Stress serious domestic

violence situations.

• Inappropriate responses to illness and loss: unable to empathise,

instead becomes hostile and distant.

• Unspoken rules: will not talk about experiences: you were not there, a

long time ago, avoidance – repressed memories: see themselves as

different / special unable to integrate within society.

Indirect Traumatisation : Living with the veteran suffering from

PTSD: Characteristics of Impaired Veteran Families (contd)

• Children of Veteran: act out family pathology.

• Children of Veteran: vet may become over demanding or overprotective of children; occasionally may be affectionate towards children but not to spouse.

• Mate selection: both inadequate – needy: marry for the wrong reasons – resentment.

• Isolation, Mobility, Alienation: uneasy living in same town –move frequently, jealous of wife do not want her to have social ties – reinforces isolation.

• Women as a mainstay: responsible for finances, emotional support, etc.

Spouse:

‘Compassion Trap’ (Adams, 71)

versus

‘Walking the TightRope’ (Jens 79)

• Angry

• Poor self-esteem, low self identity –depression common

• Nurturing, caring, supportive.

• Caring, over caring, being ‘selfish’.

• May think vet’s problem and behaviour are her fault.

Treatment of PTSD: Basic Principles

(big problems with stigma, macho image, rapport with non-

veteran organisations

Multimodal Assessment: Clinical History & Mental State Examination; Psychometric Tests: subjective and Objective

Therapy :

• Outpatient TF-CBT; EMDR

• Inpatient: bespoke veterans programmes incorporating

• individual TF-CBT; EMDR; psychodynamic incldisclosure work; narrative therapy. Group psychoeducation groups; cognitive restructuring groups.

• Repeat admissions? Integrated OPD and inpatient programmes: eg Combat Stress; Australian Veterans

Medication: SSRI and related antidepressants, Mood stabilisers, anti-impulse, major tranquillizers

Respite care: Safety – supports

Appropriate treatment for co-morbid disorders

Treatment of the Family of a

Veteran Suffering from PTSD

Strategies:

• Remove veteran from identified patient

role

• Manage rage episodes

• Deal with war experiences

• Educate family

• Create communication skills

• Clarify roles and values

Treatment of the Family of a

Veteran Suffering from PTSD

Strategies:

• Remove veteran from identified patient

role

• Manage rage episodes

• Deal with war experiences

• Educate family

• Create communication skills

• Clarify roles and values

Spouse (women’s) Carer’s Groups

Therapist Led:

• Enhance trust, group cohesion,

support.

• Educate on PTSD and other mental

disorders

• Problem solving, positive

behavioural change orientation,

reinforce assertive behaviours.

Multimodal Therapy: Integrating family

therapy into other modalities of

treatment:

• Individual therapy for husband and wife first; then group therapy for husbands and wives – groups tend to relieve pressure on relationship.

• Then couple therapy

• Multiple Couple Groups

• Family and Marital Counselling

• Community education / outreach

Anger and the Veteran

Veterans and Anger

When leave Military:

• Loss of career

• Loss of safety and leadership

• Loss of status and rank

• Loss of friends

• Alienation from society

• Loss of ability to trust

• Loss of support structures

• Perceived maltreatment / bullying by the Military Service

• PTSD - Loss of ability to have intimate relations

• Psychological Trauma – guilt, shame, blame, grief, embarrassment

• PTSD – Impulsivity internalised losses; externalised losses

• ?Expressed anger – acted on; not acted on

• Violence; Impulsivity; Domestic; Road rage

• Random – provoked / unprovoked assaults Beserking - Vietnam veterans

• Verbal – Nonverbal aggression

• Exacerbated / disinhibited by alcohol, drugs, inappropriate medications

• Enduring Personality Change Following Catastrophe

• Sociopathic Personality (Type II Personality Disorder spectrum incl Borderline PD)

• Psychopathic Personality

Anger Treatment and PTSD

• Very little research

• Treatment outcome studies have not

looked at anger as an outcome

• Few Controlled studiesHawaii Study

Chentomb et al, 1997 in Vietnam Vets an exception

Treatment of Anger • Medications: anti PTSD / anti

depressants, Mood stabilisers, anxiolytics

beware disinhibition

• CBT Anger management – a treatment

adjunct to routine psychological

intervention in the treatment of Combat

and Veteran related PTSD

Anger Management

General PointsForbes and Creamer (2003)

• Anger very common among chronic PTSD veteran population

Important have skills to control anger before TF work is done.

• Psych ed – enables them to understand what is happening

• Anxiety mgt – not in isolation – physical, cognitive, behavioural

aspects

• Controlled breathing

• Progressive musc relaxation

• Reduce stimulants caffeine, nicotine

• Thought stopping for intrusive mems / phenomena.

• Use of coping self statements / guided self dialogue

(Meichenbaum 1985)

• Non-specific Behavioural interventions for isolation, insomnia,

incl activity scheduling, communication skills, assertiveness

Cognitive Behavioural approach

to anger treatment (12 Sessions)

Chentomb et al, 1997 in Vietnam Vets (Hawaii study)

1. Client education about anger, stress & aggression

2. Self monitoring of anger frequency, intensity and situational triggers

3. Construction of a personal anger provocation hierarchy created from the self monitoring data and used for the practice and testing of coping skills

4. Arousal reduction techniques of progressive muscular relaxation, breathing focussed relaxation ands guided imagery training

5. Cognitive restructuring by altering attentional focus, modifying appraisals and using self instruction

6. Training in behavioural coping and respectful assertiveness as modelled and rehearsed with the therapist

7. Practicing the cognitive, arousal regulatory and behavioural coping skills while visualising and role playing progressively more intense anger arousing scenes from the personal hierarchies.

8. Imaginal provocation

9. Graded exposure

10. Stress inoculation techniques

DO NOT FORGET

Dangerousness

Don’t forget to refer!! Forensic assessment

• Do you carry a weapon?

• Have you a weapon in the house, under the

bed?

• Do you go out on patrol to check your

neighbourhood before you retire for the

night?

Some insights into anger and

aggression in Veterans

• 8400 in poison – reflection of

aggression?

• Problems relating to women

Many Vets have problems with women: example Vietnam Vets:

• Intimacy problems – because of PTSD:- anger from within –

• To make soldiers kill dehumanise the enemy: evoke enough emotion to make them kill – tell them their girlfriends and wives have been having a good time while they are putting their lives at risk (US Army wife is at home having an affair with ‘JODY’ – JODY is nickname of the man who did not sign up to fight in Vietnam and who stayed at home to have a good time).

• Many in Vietnam received ‘DEAR JOHN’ letters – 38% of those who fought in Vietnam divorced within 6 months of return – see also recent King’s study about operational deployments causing family problems.

• Many went to prostitutes in Vietnam – no warmth, no intimacy, sex a physical lust – myth of masculinity: ‘fighting and f**king’. US Military fosters this myth and the young men believed it.

Some insights into anger and

aggression in Veterans

• Some comments from therapy

Vets may have problems with

Empathic understanding

• Formation of self protective mode – formidable barrier to role taking (empathic) perspective that is essential to anger regulation

• Leads to self absorption, defensiveness, preoccupation with threat

• Cannot display empathic understanding of others’ perspectives

• When faced with adversity instead of feeling disappointment, feel anger provocation instead.

Cognitive restructuring must be grounded in trust and safety of therapeutic relationship

Comments from therapy with Male Veterans:

The male Veteran working with a non-veteran

non-military female therapist

Vet brings this myth home he becomes:

• Very possessive and jealous

• Does not let partner go out alone

• She becomes prisoner in her own home

• Wife / partner either has rest of life destroyed or gets out of

relationship.

NB: veteran does NOT understand what he is doing he merely

assumes he is showing he is caring for her wheras he is

constantly pushing her away with his mistrust.

The male Veteran working with a non-veteran

non-military female therapist

• Difficulty trusting outsiders

• Resentment as became political pawns

• Feelings built up over many years leading to:

1. Anger

2. Rage

3. Depression

4. Cynicism

5. Mistrust

The male Veteran working with a non-veteran

non-military female therapist

But you were not there – How do you know?:

Do’s and Don’ts

• NEVER say you understand – say that other

people – vets- have said the same things.

• Say you cannot imagine how terrible that was.

• Encourage them NOT to force others to

uinderstand how they feel- Rather:

• Get them to accept no-one can possibly

understand how they feel because they did not go

through the same experience.

ReferencesBrewin. C & Andrews B.(2008) Delayed onset PTSD: New research on an Old Controversy.24TH ISTSS Annual Meeting Terror and its Aftermath. Abstract 196022: The Palmer HouseHilton. Chicago. USA

Busuttil, W. (2004) Post Traumatic Stress Disorder and the Elderly: A need for investigationInternational Journal of Geriatric Psychiatry, 19, 429-439.

Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When theBody Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56,(eds M Nasser, Kbaistow & J Treasure). Routledge: London.

Busuttil W (2008) Psychometric Data Analyses and Clinical Audit Data for Combat Stress2005-2008. Leatherhead Internal Publication.

Busuttil, W. (2008) Prolonged Incarceration: Effects on Hostages of Terrorism. Journal ofthe Royal Army Medical College. 154(2) 128-135.

Creamer, M., Morris, P., Biddle, D., & Elliott, P. (1999). Treatment outcome in Australianveterans with combat-related posttraumatic stress disorder: A cause for cautiousoptimism? Journal of Traumatic Stress, 12, 545–558.

Kearney GE, Creamer M, Marshall R, Goyne A (2003) Military Stress and Performance: The Australian Defence Force Experience. Paul & Co Pub Consortium: Defence Science and Technology Organisation. Canberra.

References

• Busuttil, W. & Busuttil, A. M. C. (2001) Psychological effects on families subjected to enforced and prolonged separations

generated under life threatening situations. Sexual and Relationship Therapy, (Special Psychological Trauma Edition) 16: 3; pp

207-228.

• Busuttil, W. & Busuttil, A. M. C. (2003) Psychological effects on families subjected to enforced and prolonged separations

generated under life threatening situations: A summary. DART Website. www.dart.org

• Chentomb, C.M., Novaco, R. W., Hamada, R. S., Gross, D.M. (1997) Cognitive behavioural treatment for severe anger in Post

Traumatic Stress Disorder. Journal of Consulting and Clinical Psychology, 65, 184-189.

• Forbes & Creamer M, (2003) The Treatment of Chronic Post Traumatic Stress Disorder. In: Military Stress and Performance: The

Australian Defence Force Experience (eds G E Kearney, M Creamer, R Marshall, A Goyne) pp206-218, Paul & Co Pub

Consortium: Defence Science and Technology Organisation. Canberra.

• MacFarlane, A C., Bookless, C. (2001) Effect of PTSD on interpersonal relationships: Issues for emergency service workers.

Sexual and Relationship Therapy, (Special Psychological Trauma Edition) 16: 3; pp 261-268.

• Murphy P. J., Turnbull, G T., & Busuttil, W. (2003) Providing Support to Long-Term Hostage Incidents. A CARE Australia Case

Study. In: Military Stress and Performance: The Australian Defence Force Experience (eds G E Kearney, M Creamer, R Marshall, A

Goyne) pp125-138, Paul & Co Pub Consortium: Defence Science and Technology Organisation. Canberra.

• Novaco R W, (1996) Anger treatment and its special challenges. Clinical Quarterly 6, 3; Summer issue. National Center for Post

Traumatic Stress Disorder. Palo Alto.

• Novaco R W & Chentomb, C.M., (1998) Anger and Trauma. In Cognitive behaviour therapies for Trauma. Eds V M Folette, J I

Ruzek & F R Aburg. Guilford Press New York

• Williams, T (1987) Post Traumatic Stress Disorders: A handbook for clinician's. Disabled American Veterans Ohio.

Recommended reading• Effective treatments for PTSD. ISTSS Practice

Guidelines (2009) eds Foa, E Keane & Friedman,

M J. Guilford Press: New York.

• Psychological Trauma. A Developmental

Approach (1997) eds Black, D., Newman M, Harris

Hendriks J., Mezey, G. Gaskill: London

• Traumatic Stress: The Effects of Overwhelming

Experience on Mind Body and Society (1997) eds

van Der Kolk B A, McFarlane A, C., Weisaeth, L.

Guilford Press: New York.