According to Larson, Wooten, Adams and Merrick (2012) over two million service members have served in both Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). The cost of mental health services to address posttraumatic stress disorder (PTSD) and other comorbid disorders is estimated to reach over $6 billion dollars in the near future (Rosenthal, Grosswald, Ross, & Rosenthal, 2011). Among veterans, PTSD is the most likely disorder to be diagnosed alongside substance use disorder (SUD) (Possemato, Wade, Andersen & Ouimette, 2010). Skidmore and Roy (2011) report that increased stress that is associated with combat, in conjunction with age and genetic predisposition, place some veterans at an increased risk of substance use disorder (SUD). The rates of alcohol misuse among active duty is documented to be between 11% and 35%, and veterans requesting services through the Veterans Administration (VA) who misuse alcohol range from 26% and 40% (Jakupcak et al., 2010). Studies indicate that veterans and active duty members who have actively participated in, or have been exposed to combat are more likely to self-medicate using alcohol (Jakupcak et al., 2010). Veterans diagnosed with comorbid SUD and PTSD present elevated symptomology, severity, and inadequate treatment outcomes than those who present with a single diagnosis. Increased PTSD symptomology may lead to increased self-medication with substances, as well as increased substance use may lead to increased PTSD symptoms. (VanDam, Vedel, Ehring, & Emmelkamp, 2012).
Co-morbid disorders within the veteran population can often lead to risk of incarceration, and it is estimated that 10% of the nation's incarcerated people have served in the armed forces (Noonan & Mumola, 2007). It is also estimated that Vietnam veterans are incarcerated at almost twice the rate of non-veterans of the same generation (Brown, 2008). Less than a decade after the end of the Vietnam War, the VA ascertained that the more combat exposure a veteran experienced, the higher the likelihood he or she would come into contact with the criminal justice system (Brown, 2008). Presently, Veterans Treatment Court (VTC) is available in over 168 courts in 26 states (Cavanaugh, 2011). These specially designed courts were modeled after both mental health and drug courts, and have assisted veterans since their inception in 2008 (Blue-Howells, Clark, Van den Berk-Clark & McGuire, 2013). Veteran's treatment courts, however, are reserved for non-violent misdemeanor offenses (Blue-Howells, et al., 2013). Veterans who are accused of committing violent or felony offenses often do not qualify for VTC (Blue-Howells, et al., 2013). Of those veterans who are facing the criminal justice system outside of the VTC, mental illness due to combat exposure and time in uniform are often not considered by prosecutors (Blue-Howells, et al., 2013). As the number of incarcerated veterans grows, with the most recent numbers on record over 160,000, the need for veteran specific mental health interventions rises ("The 2012 Statistical Abstract, Section 5," 2012). The current paucity on literature specific to incarcerated veterans with mental health disorders is a clear indication that services are not equally available to all veterans, and many of our men and women are being left behind.
Case Study: The Case of Jeremy
Jeremy is a 24 year old Petroleum Supply Specialist who enlisted into the United States Army in 2008, when he was seventeen years old. Jeremy came to my attention upon his transfer to the veterans' dorm at Santa Rosa Prison. Jeremy was referred to mental health for evaluation as is the protocol for all new arrivals. Upon completion of the prison self-administered questionnaire, Jeremy showed signs of posttraumatic stress disorder and substance use disorder. Jeremy and I met for the first time within 24 hours of the completion of the questionnaire. During the initial assessment, Jeremy and I completed a biopsychosocial history. Jeremy entered the United States Army where he was stationed in Fort Stewart, Georgia. It was in 2009, when he was 19 years old, that Jeremy first deployed to Mosul, Iraq. During his time Jeremy reports he went on countless patrols, coming under heavy enemy fire almost each time he left the FOB. Jeremy shared that it was on May 9, 2010 when the convoy he was traveling in was hit by an IED, causing a roll-over of the Humvee in which he was manning the .50 caliber machine gun. Jeremy also shared that he believes he experienced a blackout immediately after the detonation, but he is unsure of how long he was unconscious. In that attack, Jeremy reports the deaths of his 1st Sergeant Dever, his Staff Sergeant, Beech, and his battle buddy, Specialist Gann. Jeremy reports less than 48 hours later, he was back out on patrol. Upon return from Iraq, Jeremy reported waking in the middle of the night in a cold sweats and screaming from the nightmares he was experiencing, all of which were replays of the IED blast. Jeremy reports consistent symptoms including angry outbursts for seemingly no reason; intense fear; avoidance of the motor-pool area on post; intense and uncontrollable mood swings; inability to maintain relations with others; inability to fall asleep; and self-destructive behavior such as excessive and hazardous drinking. Jeremy shared that immediately upon return from theatre, he began using alcohol to cope with his nightmares, fear and sleep deprivation. Jeremy also reports using alcohol to numb his feelings to the point of consistently blacking out and waking up not knowing how he got home. He shares that he began drinking to dull the flashbacks and that blacking out helped him to temporarily forget about his fallen brothers. He reports that since his alcohol use has increased, he began needing more alcohol to attain the same effects, having terrible withdrawal symptoms that included delirium tremens, and spending most of his paycheck on alcohol. According to Jeremy, almost every area of Jeremy's life was affected by the symptoms of PTSD and SUD. Upon completion of his contract, and two more deployments to both Iraq and Afghanistan, Jeremy received an honorable discharge and returned to his home town.
Jeremy's encounter with the criminal justice system came as a result of public intoxication, assault on a law enforcement officer with a deadly weapon, and resisting arrest. Due to the fact Jeremy's alleged offense was a felony charge, Jeremy did not qualify for VTC and subsequently was sentenced to three years in a state penitentiary. Jeremy's occupation and personal relations were negatively affected by his PTSD and SUD, as were his finances, social networks and self-esteem and self-worth. Jeremy reports feelings of hopelessness and worthlessness, fatigue, a decrease in appetite and sexual drive, and an overall reduction in everyday functioning that began while he was still deployed.
As a result of the clinically administered PTSD Checklist ' Military Version (PCL-M), a 17 item questionnaire that measures the symptoms and severity of PTSD symptoms, and the Alcohol Severity Index (ASI) to measure all of the dimensions that contributed to his substance use, Jeremy was dually diagnosed with PTSD and Alcohol Use Disorder as defined by the DSM 5 (Boden et. al., 2012; Carter, Capone, & Eaton Short, 2011). Although Jeremy presents with symptoms of depression according the DSM 5, this disorder will be listed as a rule out until such time it can be determined if these symptoms are overlapping the PTSD and SUD diagnoses. The primary diagnoses of PTSD and SUD will be addressed initially.
Upon the gathering of these baseline measurements and the clinical diagnoses, Jeremy was referred to the prisons Seeking Safety for veteran's group therapy program. In this program, Jeremy would be provided the opportunity to gain coping skills for both SUD and PTSD symptoms. It is within this non-trauma focused, cognitive behavioral therapy that that Jeremy will be afforded the opportunity to gain the skills necessary for successful reentry into the community when it came his time to be released.
There is a paucity of literature related to therapeutic interventions within the incarcerated veteran population. Seeking Safety is an evidenced based practice that has been studied within the veteran population and adopted into use by the VA, and is noted as an evidenced based practice for incarcerated women (Zlotnick, Najavits, Rohsenow, & Johnson, 2003; Cook, Walser, Kane, Ruzek, & Woody, 2006). Given the high rate of efficacy of Seeking Safety with both the veteran and incarcerated women population, it is hypothesized that by implementing Seeking Safety within the incarcerated veteran population, combat veterans can increase coping skills, reduce substance use to acceptable levels, and have a better hope for their future.
Formulated by Dr. Lisa Najavits, Seeking safety is cognitive behavioral therapy (CBT) that is an integrated non-trauma focused therapy and concentrates on providing coping skills for both PTSD and SUD (Najavits, 2003; Boden et al., 2011). Seeking Safety is designed to be flexible and has proven effective in both individual and group format. Seeking Safety consists of five areas: Safety being a priority, simultaneous treatment of the comorbid disorders, client ideals; and four areas of content that include behaviors, relationships, thought patterns and required resources, or case management, and finally a focus on the practice of the therapist (Najavits, 2002). Within these five domains and four areas of content, there are 25 topics that address coping skills for both PTSD and SUD within the four areas of content (Najavits, 2009).
Safety, the first stage of treatment, considers substance use and self damaging behaviors. Psychoeducation on PTSD and SUD is primary to assisting the veteran in developing coping skills that increase a sense of self-control over symptoms of PTSD and SUD (van Dam et al., 2012). In the next area of content, simultaneous treatment, helping the veteran to understand the cyclical relationship of PTSD and SUD allows for the integration of simultaneous treatment to be more effective. Awareness of the interrelatedness of PTSD and SUD assists the veteran with motivation to overcome the disorders (Najavits, 2003).
Focusing on ideals, the third principal of Seeking Safety assists the veteran in realizing the ideals they held prior to PTSD and SUD. An example of these ideals may be compassion. Utilizing the ideal of compassion allows the veteran the opportunity to cease the negative self-talk, and invites the veteran to realize that by taking a loving stance of themselves will elicit positive changes. In addition to compassion, behavioral changes can be elicited by teaching the veteran about self-care. The veteran is asked to make a commitment to do one thing for their own self-care. The areas of thought patterns, behaviors, case management and interpersonal relations are the fourth principle to be address in Seeking Safety. Utilizing education and techniques from CBT allow for the simultaneous treatment of PTSD and SUD (van Dam et al., 2012). Cognitive Behavioral Therapy has been shown to have high rates of efficacy in treating PTSD and SUD individually. Treating both disorders simultaneously the clinician will apply techniques from each therapeutic intervention (van Dam et al., 2012). By integrating these interventions simultaneously, with the same therapist, therapy is focused on psychoeducation and addressing problems in a time fixed and non-traditional setting (Najavits, 2003). Debilitating cognitions can be overcome by implementing cognitive restructuring (van Dam et al., 2012). Trauma can be addressed in the interpersonal domain by working through feelings of worry, suspicion, and bewilderment (Najavits, 2003).
Case management, the fourth principle of Seeking Safety, will address needs upon release such as monetary requirements through employment, medication, shelter, and others (Najavits, 2003; van Dam et al., 2012). The case management principle can assist the veteran with overcoming the reluctance to seek these resources. The fifth and final principle of Seeking Safety is the effectiveness of the approach used by the therapist (Najavits, 2003). Compassion, support, empathy, feedback, and a full awareness of the veteran's reaction to treatment must all be monitored by the therapist, and the therapist must be careful not to overdo it in any of these areas (Najavits, 2003). The therapist must also be aware of countertransference and transference issues, being cognizant of not over supporting the veteran, and allow him/her to remain in control of the treatment (Najavits, 2003). Requiring veteran accountability while being supportive is the main focus of this area of Seeking Safety treatment (Najavits, 2003).
Seeking Safety does not incorporate focusing on trauma, but rather on building coping skills in order for the veteran to address the symptomology presented by a dual diagnosis of PTSD and SUD (Najavits, 2003). Exposure therapy for addressing trauma is best performed after a solid foundation of skills has been developed (Najavits, 2003). Significant improvements can be made surrounding the symptoms of PTSD and SUD by implementing Seeking Safety, and Seeking Safety is noted as superior to standard care (van Dam et al., 2012).
NORMAN ET AL., 2010 ' Study 1
Norman et al., (2010), conducted a pilot study of Seeking Safety with OEF/OIF veterans who screened positive for PTSD and SUD at the San Diego VA. The study consisted of ten weeks of group therapy, each group session lasting 90 minutes (Norman et al., 2010). Of the 25 topics that Seeking Safety offers, supervisors and therapists selected a combination of twelve topics to incorporate (Norman et al., 2010). Of these twelve, five were cognitive focused, three were behavioral, three were interpersonal and one was a combination of all three areas of change (Norman et al., 2010).
Of the nine participants who completed the study, seven were diagnosed with PTSD and alcohol use disorder (AUD), and two presented with diagnoses of PTSD and Cannabis dependence (Norman et al., 2010). Three instruments were used to measure PTSD, depression, alcohol and marijuana use. The PCL-M, Beck Depression Inventory-II (BDI-II), Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST-10) were used to measure symptomology (Norman et al., 2010). The average baseline result on the PCL-M registered a 59.4 prior to treatment, 49.7 mid study and leveled out at 50 at post-test (Norman et al., 2010). This nearly ten point reduction in average total PCL-M score is statistically significant (Norman et al., 2010). Of the seven participants who scored in the hazardous drinking range on the AUDIT pre-test, five participants reported reducing the number of days drinking, the amount of alcohol consumed or both post-test and two self-reported endorsing sobriety post-test (Norman et al., 2010). Both of the participants who were diagnosed with cannabis dependence reported using cannabis in the thirty days prior to post-test results. No frequency data was collected for these participants (Norman et al., 2010). Those participants who did not complete treatment with higher AUDIT scores suggest that veterans with more alcohol related symptoms may be harder to treat (Norman et al., 2010).
BODEN ET AL., 2011 ' Study 2
In a study of 49 veterans who screened positive for PTSD and SUD in the VA in Oakland, CA, significant improvement was shown in substance use when measured by the Alcohol Severity Index in those who participated in Seeking Safety group therapy over those who participated in Treatment As Usual group therapy (TAU). (Boden et al.,. 2011). Veterans who participated in the Seeking Safety group showed an overall reduction of 39 % from baseline measurements, while those in the TAU group increased substance use by 12% over the same six month time period (Boden et al., 2011). In order to be eligible for this study, participants must have met male veteran status as defined by the VA, have screened positive for PTSD, either partially during a preliminary screening, or in full using the Clinician Administered PTSD Scale (CAPS) (Boden et al., 2011). In addition, participants must not have had current suicidal ideation, psychosis or mania; must not have been in an inpatient program for mental health and must have received approval by the primary clinician (Boden et al., 2011).
Treatment As Usual groups began with three group sessions that included motivational enhancement therapy and a focus on engaging in treatment. Following the three initial sessions, the concentration of therapy included achieving and maintaining abstinence. Participants attended these groups twice weekly, and were offered support groups such as anger management, fitness, relaxation, and family therapy among others. Participants were also provided with case management and individual therapy as needed (Boden et al., 2011). Forty-nine veterans participated in TAU group therapy, and 49 veterans participated in Seeking Safety group therapy (Boden et al., 2011). Those who participated in TAU showed a .02 reduction in drug use, a .11 reduction in alcohol use which is statistically significant, and a reduction from 47.7 to a 36.5, also statistically significant, in PTSD severity, at the six month follow up (Boden et al., 2011). Veterans who participated in Seeking Safety group therapy reflected a reduction of .04 in drug use, a statistically significant reduction of .12 in alcohol use and exhibited a reduction in PTSD severity from 46.8 to 38.9 on the CAPS at the six month follow up. (Boden et al.., 2011). Participants in the Seeking Safety group had greater attendance in treatment, higher levels of treatment satisfaction and increased active coping skills. It should also be noted that it may be more cost effective to train clinicians in the implementation of Seeking Safety (Boden et al., 2011). Seeking Safety incorporates handouts that can be provided to enhance the cognitive and behavioral areas of veterans, all of which increase the ease of implementation for the clinician and use for the participant.
(Cook, Walser, Kane, Ruzek, & Woody, 2006). ' Study 3
According to Cook, Walser, Kane, Ruzek, & Woody (2006), Seeking Safety showed a significant decrease in PTSD symptomolgy in a group therapy study of 25 outpatient veterans. PTSD Checklist ' Military revealed an average rating of symptoms at 65.54 pre-test, and a decrease of 14.39 points, or 51.15, post-test, a significant reduction (Cook et al., 2006). Study participants reported higher life quality, insight into triggers related to SUD and a decrease in the symptoms of PTSD (Cook et al., 2006). Self-reports of an increase problems solving ability and coping skills were noted along with a decrease in the use of substances through regular urinalysis were noted throughout the study. Handouts to increase coping skills were used and the participants reported that having access to these handouts outside of the therapeutic setting resulted in a better understanding of both disorders and the ability to cope with triggers related to SUD and the symptoms of PTSD (Cook et al., 2006).
Zlotnick, C., Najavits, L. M., Rohsenow, D. J., & Johnson, D. M. (2003).
A study of 17 female inmates who met the criteria for PTSD and SUD was conducted in a minimum security prison using Seeking Safety in a group format (Zlotnick, Najavits, Rohsenow, & Johnson, 2003). All of the participants had histories of trauma in the way of physical and/or sexual abuse and all of the participants reported their abuse began as early as the age of eight. Of those women incarcerated and awaiting trial, PTSD and SUD were the most common disorders. With rates as high as 33.5% for PTSD, the rate for comorbid SUD is 1.4 to 5.5 times higher than for women who do not present with PTSD (Zlotnick et al., 2003). Seeking Safety in a group format was conducted twice per week, 90 minutes per session, over 12 weeks. All participants were required to adhere to TAU in conjunction with Seeking Safety group therapy. Pre-test baseline measurements for PTSD were collected via use of the CAPS-I, and SUD was determined pre-test by using ASI (Zlotnick et al., 2003). Upon completion of the study, nine of the participants post-tested negative for PTSD, at ninety day follow up, 46% remained PTSD free (Zlotnick et al., 2003). Random urinalysis over the 12 week treatment program showed none of the participants were using any substances (Zlotnick et al., 2003). Furthermore, a significant reduction in alcohol and drug use was documented from pre-test to ninety day post-test or follow up. The recidivism rate remained steady at 33%, common of this population (Zlotnick, et al., 2003).
While the current form of Seeking Safety has proven efficacy with both the veteran and incarcerated population, studies must be conducted in the incarcerated veteran population. It is postulated that Seeking Safety, being a non-trauma focused, skills building therapy, would be noted as efficacious in this growing population.
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