University of Southern CaliforniaSchool of Social Work

SOWK 641

Treating Trauma and Post Traumatic Stress

In Military Social Work and Veterans Services

Spring 2010

Instructor:Valvincent A. Reyes, LCSW, BCD

Office Hrs.Tuesdays from 11:00AM to 12:00PM

Office:Social Work Center, Room 109

Day/Time:Section 60813 / Class meetings are Tuesdays, 4:10PM to 7:00PM

Location:Von Kleinschmidt Center (VKC), Classroom 254

E-mail

Course Description

This course, Treating Trauma and Post-Traumatic Stress in the Military and Veteran Services, builds on previous courses in a number of ways. Previous knowledge and skill regarding life cycle issues, developmental theory, personality theory, and general systems theory will be applied to practice with military service populations. Generic practice skills in working with individuals and their support systems, carried through from the foundation year, will have a new application specifically to military service and veteran clients. Core concepts of relationship, the therapeutic alliance, problem solving, and the phases of treatment are applied to post-traumatic stress disorder, and its co occurring disorders. Within a bio-psycho-social, eco-systemic framework, specific interventions deriving from a variety of theoretical bases, including neurobiological, psychodynamic (i.e. self psychology, object relations, ego-supportive, attachment theory), resiliency, cognitive-behavioral, and behavioral schools are examined for use in treatment of PTSD. Evidence-based and empirically-supported treatments will be emphasized. The student's introductory skills obtained in the first year, regarding work with clients experiencing common presenting problems, will be advanced. Students will learn how to treat clients from diverse military, ethnic, class, gender, sexual orientation and disability groups, especially those seeking treatment in urban settings such as Los Angeles, and San Diego.

Further, the phases of treatment will be applied to intervention for PTSD and trauma work with military populations. The course opens with a unit on Assessment and we will then examine treatment from various theoretical perspectives. The impact of social injustice on those seeking services, and the effects of stigma will be examined within this course. Further, building on first year content, we will address practice implications of work with culturally diverse client groups: ethnic and racial minorities of color, sexual minorities, women, and other gender related issues in clinical practice. Content will be applied to work in military clinical settings. Knowledge of ethical considerations and the value-base of social work practice will be advanced and applied directly to work in military settings. Throughout the course, we will discuss the effects on the social worker of working with highly distressed clients, and the value base of service providers.

Course Objectives:

Within these parameters, objectives are to enable the student to:

1.Become knowledgeable about the nature of trauma and its clinical and sub-clinical presentations, particularly as they relate to combat, military sexual trauma and othermilitary related traumatic experiences.

  1. Apply differential diagnostic skills in assessing: Acute Stress Disorder

(ASD); PosttraumaticStress Disorder (PTSD); Traumatic Bain Injury

(TBI);Adjustment Disorders and Anxiety Spectrum Disorders. And

identify the relevance of these diagnoses in military and veterans social work services.

b.Understand the differences between Simple and Complex PTSD, their etiology and relevance for military social work practice.

  1. Be able to distinguish and diagnose the three symptoms clusters of PTSD: re-experiencing, avoidance, and hyper-arousal.

d.Be able to identify dissociation and understand its risks in clinical

treatment and its role in traumaresilience and recovery.

2.Become knowledgeable about, and be able to apply, best practices and current evidence-based models for dealing with trauma and PTSD.

a. Understand the reciprocal nature of the bio-psycho-social components and how each contributes to, and is affected by, the others in working with trauma.

b. Be able to identify the goals and course of trauma-based treatment.

3.Deepen understanding of the therapeutic relationship and its impact on the treatment process in working with traumatized clients with and without PTSD.

4.Increase knowledge of the neurobiological underpinnings of trauma and PTSD

and how these inform military social work practice.

5.Increase understanding of diversity issues, including gender, race, culture, disability status and sexual orientation, and how they influence symptom presentation and treatment intervention.

6.Become cognizant of potential ethical dilemmas and ways of resolving them in working with clients with trauma and PTSD given the culture and context of the military milieu, command deployment priorities and the misuse of diagnoses, ie.

personality disorders in military settings and PTSD in veteran services settings..

7.Increase understanding of the interaction of PTSD with co-occurring disorders such as Traumatic Brain Injury (TBI), depressive disorders, substance abuse, other anxiety disorders, and their post deployment manifestations such as domestic violence.

8.Be able to identify risk factors for PTSD and resiliency factors for recovery as

they apply to post deployment and post discharge stressors and family

reintegration.

9.Understand issues of social injustice, and class disadvantages and be able to advocate for adjunctive services to military clients so that they may eventually reintegrate into a complex urban environment.

Course Expectations & Requirements:

  1. Objective mid-term examination (Multiple Choice) 25%

(Objectives 1-5)

  1. Two (2) Final Projects: A. Psychosocial Assessment 25%

This assignment is a psychosocial assessment of a client held in the field. The assessment discuss explanatory theory (from a bio-psycho-social framework) and clinical treatment applying the phases of treatment from engagement through evaluation and follow-up care using the trauma model(s)as discussed in class. (Objectives 1-9)

B. Cognitive Behavioral Therapy (CBT) Thought Record 10%

This assignment is a Thought Record of a client held in the field. The Thought

Record, taken from the “Mind Over Mood” textbook, is an effective CBT-oriented therapeutic tool designed for the clinician to assist the client to understand automatic thoughts, associated feelings and consequential behaviors.

  1. Class Presentation (Research an article on PTSD and present in class) 25%
  1. Weekly Journal (Write 15 journal entries on one (1) concept learned from each class session) 15%

Required Text

Briere, J. and Scott, C. (2006). Principles of Trauma Therapy. Thousand Oaks, CA: Sage Publications.

Recommended Texts

Greenberger, D. and Padesky, C. (1995) Mind Over Mood. Change How You Feel by Changing the Way You Think. New York: The Guilford Press

Herman, J. (1997). Trauma and Recovery. New York: Basic Books

Paulson, D. and Krippner, S. (2007). Haunted by Combat. Westport, CT: Praeger Security International

Course Outline

Unit 1: Introduction

Session 1: Introduction to the topic

  • History of the concept of trauma and PTSD
  • Military-specific events that lead to PTSD
  • Phenomenology of PTSD: what does it look/feel/sound like?

Recommended Reading

Herman:

Chapter 1: A forgotten history

Chapter 2: Terror

Chapter 3: Disconnection

Paulson and Krippner

Chapter 1: An Overview of trauma and the Mind/Body

Chapter 2: History of the dx and tx of PTSD.

Chapter 3: The phenomenology of PTSD

Briere: Chapter 2: Effects of Trauma

Optional Reading

Matsakis, A. (2007). “He’s not the same:” common traumatic reactions –

anxiety disorders, dissociation, depression, and somatization. Back from the Front.Baltimore, MD: Sidran Institute Press. 68-106.

This session addresses objective #1

Session 2: Assessment

  • Differential diagnoses and interactions

Acute Stress Disorder (ASD) and PTSD PTSD: simple vs. complex (DESNOS)

Traumatic Brain Injury (TBI) vs. PTSD

Adjustment Disordersvs. Anxiety Spectrum Disorders

  • Diversity issuesand developmental issues as risk factors and in symptom presentation
  • Assessment: The three prongs of PTSD: re-experiencing, avoidance, hyper-arousal
  • Counter-transference issues in objective and ethical assessment

.

Recommended Reading:

Briere: Chapter 3: Assessing Trauma

Briere: Appendices 1, 2

Wilson, J. (2004). PTSD and Complex PTSD, symptoms, syndromes, and

diagnoses. In Wilson, J. and Keane, T. (eds.) Assessing Psychological

Trauma and PTSD. Chapter 1, 7-44

Bryant, R. (2004). Assessing Acute Stress Disorder. In In Wilson, J. and Keane, T. (eds.) Assessing Psychological Trauma and PTSD. Chapter 2, 45-60,

Bonanno, G. (2004). Loss, trauma, and human resilience. American Psychologist.59(1). 20-28.

Recommended Reading:

Briere, J. and Spinazzola, J. (2005). Phenomenology and psychological assessment of complex posttraumatic states. Journal of Traumatic Stress.

18(5). 401-412.

This session addresses objectives #1 a-c; #5.

Unit 2: Explanatory theories that inform trauma work

Understanding “triggers” and “flashbacks”

Session 3: Neurobiology and information processing

  • Psychobiology of trauma

How the brain and body are affected by trauma

  • Interactional relationships among neurobiological, psychological and social factors
  • Neurobiological differences between people with and without PTSD
  • The Co-morbidity of Traumatic Brain Injury and PTSD

Recommended Reading

Briere: Chapter 11: Biology and Psychopharmacology of Trauma. 185- 191.

Vasterling, J., Bremner, D.J, (2006) The impact of the 1991 Gulf War on

the mind and brain: findings from neuropsychological and neuroimaging

research, The Royal Society:

Optional Reading

Van der Kolk, B. (2003). Posttraumatic stress disorder and the nature of trauma. In (eds.) Solomon, M. and Siegel, D. Healing Trauma. 168-196.

Vasterling, J. and Brewin, C. (eds.) (2005). Neuropsychology of PTSD: biological, cognitive, and clinical perspectives.New York: Guilford Press.

(particularly chapter 6: Encoding and retrieval of traumatic memories.)

This session addresses objective #4 and indirectly addresses objective #2a.

Session 4: Explanatory Theories of PTSD Treatment

  • Behavior theory
  • Cognitive theory
  • Psychodynamic theory: ego psychology, object relations, self psychology
  • Existential Theory
  • Goals of treatment (By symptom cluster):

Symptom management, harm reduction or cure?

Acceptance and forgiveness

Defensive functioning vs. coping

Recommended Reading

Paulson and Krippner: Chapter 8: Treatment Approaches

Tick, E. (2005). Inside PTSD: Identity and Soul Wound. War and the Soul.Wheaton, Ill: Quest Books. 97-118.

Optional

Paulson and Krippner, Chapter 9: Keys to treating trauma

This session addresses objectives #2a, 2b, and #5.

Unit 3: Beginning Phase: From “unpredictable danger to safety”

Session 5: Phase 1: The therapeutic relationship and “the holding environment”

  • Transference and Counter-transference issues
  • “Compassion Fatigue” and “Vicarious Traumatization”
  • Using cultural values in relationship building
  • Stages of Trauma Work

Judith Herman’s model: Dialectic of Trauma

Recommended Reading

Herman, Chapter 7: A healing relationship

Herman, Chapter 8: Safety

Briere, Chapter 4: Central issues in trauma treatment

Vogt, D; Pless, A; King, L., and King, D. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War 1 veterans. Journal of Traumatic Stress.18(2). 115-127.

This session addresses objectives #2a, #2b, #3, and #5.

Unit 4: Middle Phase: The “working thru” phase

Session 6: Remembrance and Mourning

  • Dissociation and Repression
  • Identification with the aggressor
  • Atrocities and mass casualties
  • Grieving the losses: survivor guilt

Recommended Reading

Herman, Chapter 4: Captivity

Herman, Chapter 9: Remembrance and Mourning

Dewey, L. (2004).War and Redemption. London: Ashgate.

Chapter 6: “It helps to tell the story.” 116-122.

Chapter 7:Grief and Grieving. 123-127.

Van der Hart; Nijenhuis, E. an Steele, K. (2005). Dissociation: an

insufficiently recognized major feature of complex PTSD. Journal of Traumatic Stress.18(5). 413-423.

Optional Reading

Wilson, J. and Keane T. (2004). Systematic assessment of PTSD: the structured interview for dissociative disorders. 122-143.

Shay, J. (1994). Guilt and wrongful substitution. Achilles in Vietnam.

New York: Scribner. 69-76.

This session addresses objectives #1d, #2a, #2b, and #4.

Sessions 7-9: Individual and group techniques for working through trauma

  • Acute (immediate) and Longer term interventions
  • Establishing a safe place trough “therapeutic rapport”
  • Dealing with “triggers” and “flashbacks”
  • Behavioral techniques

Hierarchical Desensitization

Imaginal Exposure

Working with nightmares

EMDR and Mindfulness based therapies

  • Cognitive techniques

Meaning making

Narratives

Cognitive Processing Therapy

  • Affect regulation and anger management skills ( meditation, prayer, exercise, self talk, affirmation)

Recommended Reading

Zayfert, C. and Becker, C.B. (2007). Cognitive-Behavioral Therapy for PTSD. New York: Guilford Press.

Chapter 5: Introducing Exposure Therapy

Chapter 7: Imaginal exposure

Chapter 8: Cognitive Restructuring

Briere: Chapter 6, Distress Reduction and Affect Regulation

Chapter 7: Cognitive Interventions

Chapter 8: Emotional Processing

Chapter 10: Treating the effects of acute trauma

Appendix 3: Breath Training Protocol

Bradley, R., Greene, J. Russ, E. Dutra, L. Westen, D. (2005)A Multidimensional Meta-Analysis of Psychotherapy for PTSD, Am J Psychiatry 162:214-227

Raphael, B. and Dobson, M. (2001). Acute posttraumatic

interventions. In Wilson, J; Friedman, M; and Lindy, J. (eds.)

Treating Psychological Trauma and PTSD.New York: Guilford Press.

Paulson and Krippner: Chapter 10: Alternative approaches to treating trauma

Davis, J. and Wright, D. (2006). Exposure, relaxation, and rescripting

Treatment for trauma-related nightmares. Journal of Trauma and Dissociation. 5-18.

Rizzo, A; Rothbaum, B; and Graap, K. (2007). Virtual reality applications

for the treatment of combat-related PTSD. In Figley, C. and Nash, W. (eds.) Combat Stress Injury.New York: Routledge. 183-204.

Optional Reading

Monson, C. M., Price, J. L., & Ranslow, E. (2005, October). Treating combat PTSD throughcognitive processing therapy. Federal Practitioner, 75–83.

Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S.P. (2006). Cognitive processing therapy for veterans with military-relatedposttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74,898–907.

These sessions address objectives #2a, #2b, #4, and #5.

Unit 5: Ending Phase: Reconnection

Session 10: From isolation to reconnection

  • Reconnecting with self and others
  • Reintegration in post deployment life in a complex urban environments
  • Psychoeducation
  • Family involvement and intimacy

Recommended Reading

Herman, Chapter 10: Reconnection

Briere: Chapter 9: Increasing Identity and Relational Functioning

Dunn, N, Rehm, et. al (2007). A randomized trial of self-management and psychoeducational group therapies for comorbid chronic PTSD and depressive disorders. Journal of Traumatic Stress. 20(3). 221-237.

Dewey, L. (2004). “Keeping the demons at bay:” sharing and support and “working through” in group therapy. War and Redemption. London: Ashgate. 137-147.

Optional Reading

Fontana, A. and Rosenheck, R. (2005). The role of loss of meaning in the pursuit of treatment for PTSD. Journal of Traumatic Stress. 18(2). 133- 136.

This session addresses objectives #2a, #2b, #3, #5, #8, and #9.

Unit 6: Other Issues

Session 11: A focus on diversity

  • Cultural variations in trauma presentations
  • Factors affecting treatment
  • Race and culture
  • Gender
  • Sexual orientation
  • Disability

Recommended Reading

Paulson and Krippner, Chapter 11: Remembrance

Loo, C. (2007). Ethnic-related stressors in the war zone: case studies of Asian American Vietnam Veterans. Military Medicine.172(9).968-971.

Jones, L; Brazel, D; Peskind, E; Morelli, T; and Raskind, M. (2000). Group therapy programs for African-American veterans with PTSD.

Psychiatric Services: Brief Reports. 1177-1179.

Rosenheck, R. and Fontana, A. (2008). Black and Hispanic veterans in intensive VA treatment programs for PTSD. Medical Care.40(1).

Optional Reading

Marsella, A.J.,Friedman, M.J.Gerrity, E.T. and Scurfield, R. (1996)

Ethnocultural Aspects of PTSD: Issues Research and Clinical Applications, American Psychological Association

This session directly addresses objective #5 and indirectly addresses objectives #1, #2, #3, #6, and #9.

Session 12: Post-traumatic Growth and Resiliency factors

  • What is “successful” treatment
  • Help seeking skills
  • Relapse prevention planning
  • Bio-Psycho-Social and Spiritual Growth and Resilience
  • Dealing with reactivations, abreactions, anniversary reactions, avoidance characteristics and flight into health. (avoidance vs. healthy repression)

Recommended Reading

Dewey, L. (2004). The cure of love: what the world’s best copers tell us about living well. War and Redemption. London: Ashgate. 229-239.

Carver, C. (1998). Conceptual considerations and scope in the study of thriving: resilience and thriving: issues, models, and linkages. Journal of Social Issues.54(2). 245-266.

Littleton, H; Horsley, S, John, S; and Nelson, D. (2007). Trauma coping strategies and psychological distress: a meta-analysis. Journal of Traumatic Stress.20(6). 977-988.

Optional Reading

Paulson and Krippner, Chapter 12: Gold along the path.141-149.

Dresher, K; Smith, M; and Foy, D. (2007). Spirituality and readjustment

following war-zone experience. In Figley, C. and Nash, W. (eds.) Combat

Stress Injury.295-310.

This session directly addresses objectives #1c, #8, #9, and indirectly addresses objectives #2a and #2b.

Session 13: Adjunctive Therapies

  • 12-Step and other support groups
  • Couples and family therapy: Dealing with intimacy and other trauma-related issues
  • Psycho-education
  • Residential vs. Outpatient Treatment
  • Telemental health
  • Cultural based healing

Recommended Reading

Herman, Chapter 11: Commonality

Briere, Chapter 11: Biology and psychopharmacology. P. 192-232.

Paulson: ch. 10, Alternative approaches to treating PTSD.

Dekel, R. and Solomon, Z. (2007). Secondary traumatization among wives of war veterans with PTSD. In Figley, C. and Nash, W. (eds.) Combat stress injury: theory research, andmanagement.New York:

Routledge.

Lyons, J. (2007). The returning warrior: advice for families and friends.

In Figley, C. and Nash, W. (eds.) Combat stress injury: theory research, andmanagement.New York: Routledge. 311-324.

Optional Reading

Guay, S; Billete, V; and Marchand, A. (2006). Exploring the links between PTSD and social support: processes and potential research avenues. Journal of Traumatic Stress.19(3). 327-338.

This session addresses objectives #7 and #9.

Session 14: Co-occurring disorders and self-destructive behaviors: correlates of PTSD

  • Substance abuse
  • Domestic and other violence
  • Suicidality
  • Sexual dysfunction
  • TBI
  • Depression
  • Vocational
  • Homelessness

Recommended Reading

Alim, T; Charney, D; and Mellman, T. (2006). An overview of PTSD in

African Americans. Journal of Clinical Psychology. 62(7). 801-813.

Coleman, P. (2006). Suicide in the aftermath of Vietnam. Flashback.

Boston, MA: Beacon Press. 129-147.

Zayfert, C. and Becker, C.B. (2007). Supplemental tools. Cognitive-Behavioral Therapy for PTSD. New York: Guilford Press. Chapter 9,

202-213.