Volume 11 (2) 2002

17

NC-PTSD Clinical Quarterly

 Continued on page 19

REDUCING CAREGIVER BURDEN

 AND PSYCHOLOGICAL DISTRESS

IN PARTNERS OF VETERANS WITH PTSD

Patrick S. Calhoun, Ph.D. and Tim Wampler, L.C.S.W.

Inside this issue Reducing Caregiver Burden 17

New Directions 24

Early Intervention: A Clinical Forum 25

Matching Treatment Resources 26

2002 Volume 11 (2) ISSN-105-7168

These difficulties have led some

clinicians and researchers to

conceptualize PTSD as a long-term

disease that places stress on caregiving

partners (11). Indeed, partners of

veterans with PTSD must face a number

of significant stressors associated with

caring for a partner with a chronic

Menlo Park/Palo Alto * Boston * Honolulu * West Haven * White River Junction

CLINICAL Q CLINICAL QUARTERLY

The impact or burden of caring

for persons with chronic illness was first

examined in the 1960s in studies of

family members caring for relatives with

mental illness (1). Since then, caregiver

burden has become an increasingly

recognized and examined construct.

While the majority of research examincrisis management, symptom management, social

isolation, financial problems, strain on the family system,

and adjustment to the course of the disease (12).

There is increasing evidence that PTSD and

associated behavioral problems have a negative impact

on those living with patients with PTSD. In a study

comparing veterans with and without PTSD, high levels

of stress and adjustment problems were found in the

majority of partners of patients with PTSD. Almost

half of these women reported having felt ìon the verge

of a nervous breakdownî (13). In one of the first studies

designed to specifically examine caregiver burden in

partners of patients with PTSD, Beckham and colleagues

documented that PTSD symptom severity was both

cross-sectionally and prospectively related to caregiver

burden and partner psychological distress (1).

 Similarly, more recent research examining the

associations between caregiver burden, PTSD and

associated difficulties (e.g., hostility, depression, health

 ing caregiver burden has focused on

caregivers of older adults and patients with Alzheimerís

dementia, recent research suggests that caring for an

individual with chronic posttraumatic stress disorder

(PTSD) is associated with significant burden and may

have deleterious effects on caregiver psychological

adjustment (2,3). Caregiver burden can be understood

as both the objective burden associated with caring for

an individual with chronic illness (e.g., financial

problems, disruption of family life, strained neighbor

relations) as well as the subjective burden (e.g., caregiver

responses, affective responses) associated with these

demands (4). Caring for a family member with chronic

illness has been associated with both poorer

psychological adjustment and physical health (5).

PTSD is believed to be chronic in approximately

one third of people with a lifetime history of the disorder

(6). There is clear evidence that patients with PTSD

experience both significant intrapersonal and

interpersonal difficulties including problems with

communication, self-disclosure, sexual intimacy, family

cohesion, hostility, aggression and interpersonal violence

(7-10).

Authors note: The views expressed in this paper are those of the authors

and do not necessarily represent the views of the Department of Veterans

Affairs

Patrick Calhoun Tim Wampler disease. These stressors may include
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

18

NATIONAL CENTER FOR PTSD

Executive Director

Matthew J. Friedman, M.D., Ph.D.

VAMC/ROC White River Junction

Vermont 05009

Education and Clinical Laboratory Division

Fred Gusman, M.S.W., Director

VAMC, Palo Alto, California 94304

Pacific Islands Division

Fred Gusman, M.S.W., Chief of Operations

Honolulu, Hawaii 96813

Behavioral Science Division

Terence Keane, Ph.D., Director

VAMC, Boston, Massachusetts 02130

Women’s Health Science Division

Lynda King, Ph.D., Acting Director

VAMC, Boston, Massachusetts 02130

Clinical Quarterly Staff

Please feel free to contact us at the Education Division: FTS 463-2673/2494; commercial number 650-493-5000 ext. 22673/22494; or E-mail: ncptsd@bruceyoung.net

Please address all correspondence to: Editor, National Center for PTSD Clinical Quarterly, VA Palo Alto Health Care System, 795 Willow Rd (352E117), Menlo Park, CA 94025

FROM THE EDITOR...

Neuroscience Division

John Krystal, M.D., Director

VAMC, West Haven, Connecticut 06516

Northeast Program Evaluation Center

Robert Rosenheck, M.D., Director

VAMC, West Haven, Connecticut 06516

Editor-in-Chief

Managing Editor

Executive Editor

Associate Editors

Assistant Editor

 Design & Production

Bruce H. Young, L.C.S.W.

Josef I. Ruzek, Ph.D.

Fred D. Gusman, M.S.W.

Eve B. Carlson, Ph.D., Ilona Pivar, Ph.D., & Robyn Walser, Ph.D.

John Aboytes, B.A.

Bruce H. Young

A primary reason for publishing the Clinical Quarterly is to disseminate innovative ideas that address the challenges

commonly faced by VA and other PTSD treatment providers. The two feature articles of this issue respectively describe new

clinical approaches that VA practitioners are using to increase veteran social support and meet the growing demands for PTSD

treatment services in an era of diminishing resources..

While social support plays a vital role in the quality of life for virtually everyone, for many PTSD diagnosed veterans,

having or developing close supportive relationships is exceedingly difficult, and many such veterans are socially isolated, divorced,

or have severely strained personal relationships (1). Itís probably fair to say that VA PTSD-related treatment that aims to

enhance social support (by improving such skills as communication, anger management, conflict resolution, etc.) is often conducted

within a group of veterans or with the veteran alone. However, new treatment strategies are emerging that involve family

members as another means to help better social support. In previous issues of the Quarterly, Erika Curran (2) presented a

ìfamily approachî to address the affect of a fathersí PTSD related symptoms on their children, and Judy Lyons and Leslie

Root (3) described their strategies to increase family involvement in treatment. In this issue, Pat Calhoun and Tim Wimpler share

the approach they have developed to identifying and addressing persistent family relationship problems in their effort to help

improve the quality of veteransí lives.

The effort to increase the utilization of PTSD screening measures by primary care providers and others is successfully

moving forward (see this issueís New Directions column). However, as PTSD treatment services receive more referrals, the

increase is occurring at a time when such treatment services are losing resources. In our second featured article, Evelyn Sandeen

and Ella Nye describe how their outpatient PTSD clinical program has been restructured to best provide the greatest number

of veterans the right care, at the right time by assessing several domains related to treatment readiness. In sum, both featured

articles describe excellent examples of the types of creative and pragmatic clinical innovation being implemented by VA practitioners

to meet the challenge of providing the highest level of care to our veterans.

References

1. Riggs, D.S., Byrne, C.A., Weathers, F.W., & Litz, B.T. (1998). The quality of the intimate relationships of male Vietnam veterans:

 Problems associated with posttraumatic stress disorder. Journal of Traumatic Stress, 11, 87-101.

2. Curran, E. (1997). Fathers with war-related PTSD. NCPTSD Clinical Quarterly 7, 30-33.

3. Lyons, J.A. & Root, L.P. (2001). Family members of the PTSD veteran: Treatment needs and barriers. NCPTSD Clinical Quarterly, 10, 48-52.

Bruce H. Young, Editor-in-Chief
Volume 11 (2) 2002

19

NC-PTSD Clinical Quarterly

REDUCING CAREGIVER BURDEN

complaints, hostility, interpersonal violence) has shown

that compared to partners of combat veterans without

PTSD, partners with a spouse with PTSD, experience

significantly higher levels of caregiver burden, anxiety

and depression (2).

Relatively little research has examined which

symptoms and behaviors are most strongly related to

caregiver burden among partners of patients with PTSD.

partner reports). Thorough evaluation of violence is

important to both ensure the safety of family members

and to develop a treatment plan aimed at reducing

violence (15). While anger management has been

suggested as a critical component of PTSD treatment,

there is a need for further research investigating its

effectiveness at reducing aggression and the burden

experienced by caregivers.

While we would suggest that ensuring the safety

of family members is a critical first step in efforts at

reducing caregiver burden, there is currently little research

to inform clinicians what other steps should be taken in

order to reduce burden among caregivers of patients with

PTSD. Based largely upon reviews of the caregiver

literature examining interventions aimed at reducing

burden among family members of patients with chronic

medical conditions including dementia (17-18), we

currently apply a five component intervention strategy.

These components are outlined in Table 1 and include

Assessment, Education, Support, Counseling, and Case

Management.

Adequate time must be

allotted for the initial contact

with caregivers, as we have

found many partners are

breaking the silence of the

impact of their spouseís

PTSD symptoms for the first

time.

We have found, however, that the presence and level of

interpersonal violence may be an important factor in

levels of burden and spouse psychological adjustment (2).

Veteran initiated violence may lead to acute crises (e.g.,

increased involvement with law enforcement, loss of

employment, exacerbation of PTSD symptoms, medical

problems) that contribute to increased burden among

caregivers. Partners and family members may actually

become victims of violent assaults. Veterans with PTSD

are at increased risk for the perpetration of domestic abuse

(13). Results from the National Vietnam Veterans

Readjustment Study found that as many as one third of

veterans with PTSD had assaulted their partners in the

past year (14). The rates of domestic violence are likely

to be even higher among treatment seeking veterans with

PTSD (15).

Given high rates of domestic violence and a strong

association between interpersonal violence, burden and

poor psychological adjustment, clinicians must carefully

assess for the perpetration of domestic violence. The

frequency and severity of violence should be assessed

through the use of multiple methods, e.g., clinical

interview and validated self-report instruments such as

the Conflict Tactics Scales (16), and multiple sources (e.g.,

• Assessment

Level of burden

Partner depression, anxiety symptoms

Availability of social support

Level of marital conflict

Communication and problem solving deficits

• Education

PTSD symptoms and course

Associated behavioral difficulties

Signs and symptoms of caregiver burden

• Support

Enlist social support

Support group

• Counseling

Stress management

Couples treatment

• Case Management/Referral

Linkage with community resources

Advocacy

Referral to community mental health resources

Table 1. Components of an Intervention Aimed at

Reducing Burden in Caregivers of Patients with

PTSD
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

20

with chronic PTSD, including confusion, anger and

hostility, shame and guilt, depression, anhedonia, anxiety,

social isolation, and marital distress.

In many cases, caregivers remain active in their

partnerís treatment through periodic joint sessions. Joint

sessions help facilitate open and honest communication

between family members, dispel cognitive distortions, and

allow patients to practice efforts aimed at improving emotional intimacy. Often couples will be referred for formal relationship counseling to target communication and

problem solving deficits.

One potential difficulty in efforts aimed at reducing caregiver burden is related to patient trust. Many

veterans suffering from chronic PTSD are openly distrustful

Assessment

We attempt to invite partners or other family

members to our clinic early in the treatment of clients

with PTSD. The involvement of significant others allows

us to gather important collateral information that aids in

the accurate assessment of the identified patientís PTSD

symptoms and other difficulties, including substance

abuse and interpersonal violence. Partner involvement

also provides an opportunity to assess the level of burden

experienced by the family. In order to assess burden and

levels of anxiety and depression experienced by

caregivers, we use both open-ended interview questions

and standardized, psychometrically sound instruments

such as the Burden Interview (19) and the Beck

Depression Inventory (20). We also assess the level of

relationship distress, communication and problem solving

deficits, and the adequacy of social support available to

caregivers.

Adequate time must be allotted for the initial

contact with caregivers, as we have found many partners

are breaking the silence of the impact of their spouseís

PTSD symptoms for the first time. Similar to many of

our patients who have not openly discussed their traumas

for over 30 years, these initial interviews with caregivers

are often emotionally laden. Often this initial assessment

is therapeutic as caregivers feel a sense of relief after

discussing their own feelings and concerns. After assessing

the caregivers current functioning, we address their

education, support or treatment needs.

Education

We begin to educate caregivers during our initial

contact with them. The primary objective associated with

our educational component is the normalization of

symptoms associated with high levels of trauma exposure.

A general overview of PTSD is provided, which includes

a discussion of the potential impact chronic PTSD

symptoms may have on the family system. Current

treatment options are discussed, as is the possibility that

patients may initially experience increased levels of

distress before seeing treatment gains. It is important

that caregivers understand the course of treatment, as

many uninformed family members overtly sabotage

treatment upon witnessing increases in distress in their

partner. Furthermore, we attempt to normalize the many

reactions caregivers experience while living with someone

Support

The role of additional social support for the

caregiver can be invaluable in relieving the felt burden

experienced by partners of veterans with chronic PTSD.

Social support is provided in varying degrees depending

upon the adequacy of the caregiverís social network and

utilization of immediate resources. For caregivers with

good social networks, we discuss how they might better

mobilize support. For partners who are socially isolated,

we discuss ways to increase their networks. The use of

support groups can be particularly helpful to decrease

social isolation and to normalize difficulties common to

relationships destabilized by chronic PTSD symptoms.

Clinicians need to be attuned to the barriers which

complicate the receipt of adequate social support. We

have found, for example, many caregivers are unable to

attend routine daytime appointments due to work

considerations.

Counseling

 We have found high rates of anxiety and depression among caregivers of veterans with PTSD in our clinics

(2). Many caregivers could benefit from individual treatment and are referred to various local community resources for further help. We currently offer a three session psycho-educational intervention that provides education about PTSD, common reactions to coping with a

loved oneís chronic PTSD symptoms, the negative aspects of prolonged stress, and stress management skills

(including relaxation training).

CALHOUN & WAMPLER
Volume 11 (2) 2002

21

NC-PTSD Clinical Quarterly

References

1. Grad, J. & Sainsbury, P. (1963). Mental illness and

the family. Lancet, I, 544-547.

2. Beckham, J.C., Lytel, B.L., & Feldman, M.E. (1996).

Caregiver burden in partners of Vietnam veterans with posttraumatic stressdisorder. Journal of

Consulting and Clinical Psychology, 64, 1068-

1071.

3. Calhoun, P.S., Bosworth, H.B., & Beckham, J.C.

(2002). Caregiver burden and psychological distress in partners of veterans with chronic posttraumatic stress disorder. Journal of Traumatic

Stress, 15, 205-212.

and may view the involvement of their partner in treatment as a threat. In order to foster an atmosphere of

trust, the clinician must be careful not to alienate the

client while attempting to outreach to his/her caregiver.

Clinicians should discuss the potential benefits of having a caregiver involved in the treatment process.

Case Management

Case Management as we define it, is the process

by which clients and family are linked with valued and

needed services and resources. Some of these resources

include county service officers, local veterans organizations, county and state government agencies, and other

DVA resources. Caregivers are often faced with financial, legal, and other difficulties that stretch their own

coping resources. The clinicianís active involvement as

an advocate and liaison with local organizations can help

reduce the objective burden associated with caring for an

individual with chronic PTSD.

Conclusions

While research examining caregivers of patients

with PTSD is in its infancy, it seems clear that chronic

PTSD symptoms are associated with significant burden

and may have deleterious effects on caregiver psychological adjustment. Clinicians need to understand and

directly address the impact PTSD symptoms and behavioral problems have on families and caregivers. Clearly,

there is a need for further research aimed at identifying

effective interventions that reduce the burden of caring

for patients with posttraumatic stress disorder.

4. Vitaliano, P.P., Young, H.M., & Russo, J. (1991). Burden: A review of measures used among caregivers

of individuals with dementia. Gerontologist, 31,

67-75.

5. Kiecolt-Glaser, J.K., Glaser, R., Shuttleworth, C.,

Dyer, C.S., Ogrocki, P., & Speicher, L.E. (1989).

Chronic stress and immunity in family caregivers

of Alzhiemerís disease victims. Psychosomatic

Medicine, 49, 523-535.

6. Kessler, R.B., Bromet, E., Hughes, M., & Nelson, C.B.

(1995). Posttraumatic stress disorder in the National Comorbidity Study. Archives of General

Psychiatry, 5, 1048-1060.

7. Carroll, E.M., Foy, D.W., Cannon, B.J., & Zwier, G.

(1991). Assessment issues involving the families

of trauma victims. Journal of Traumatic Stress,

4, 25-40.

8. Beckham, J.C., Roodman, A.A., Barefoot, J.C., &

Haney, T.L., Helms, M.J., Fairbank, J.A.,

Hertzberg, M.A., Kudler, H.S. (1996). Interpersonal violence and self-reported hostility among

combat veterans with and without posttraumatic

stress disorder. Journal of Traumatic Stress, 9,

335-342.

9. Roberts, W.R., Penk, W.E., Gearing, M.L., Robinowitz,

R., Dolan, M.P., & Patterson, E.T. (1982). Interpersonal problems of Vietnam combat veterans with

symptoms of posttraumatic stress disorder. Journal

of Abnormal Psychology, 9, 444-450.

10. Riggs, D.S., Byrne, C.A., Weathers, F.W., & Litz, B.T.

(1998). The quality of the intimate relationships

of male Vietnam veterans: problems associated

with posttraumatic stress disorder. Journal of

Traumatic Stress, 11, 87-101.

11. Hankin, C.S., Abueg, F., Gallagher-Thompson, D., &

Murphy, R.T. (1993,Oct). Caregiver stress:

Conceptualizing adaptation of partners of posttraumatic stress disorder combat veterans. Paper

presented at the International Society for Traumatic

Stress Studies, San Antonio, TX.

REDUCING CAREGIVER BURDEN
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

22

12. Biegel, D.E., Sales, E., & Schulz, R. (1991).

Family caregiving in chronic illness. Newbury

Park: Sage Publications.

13. Jordan, B.K., Marmar, C.R., Fairbank, J.A.,

Schlenger, W.E., Kulka, R.A.,Hough, R.L., &

Weiss, D.S. (1992). Problems in families of

male Vietnam veterans with posttraumatic

stress disorder. Journal of Consulting and

Clinical Psychology, 60, 916-926.

14. Kulka, R.A., Schlenger, W.E., Fairbank, J.A.,

Hough, R.L., Jordan, B.K., Marmar, C.R., &

Weiss, D.S. (1990). Trauma and the Vietnam

war generation: Report of findings from the

National Veterans Readjustment Study. New

York: Brunner/Mazel.

15. Byrne, C.A., Riggs, D.S. (1996). The cycle of

trauma: Relationship aggression in male Vietnam veterans with symptoms of posttraumatic

stress disorder. Violence and Victims, 11, 213-

225.

16. Straus, M.A. (1979). Measuring intrafamily conflict and violence: The Conflict Tactics Scales.

Journal of Marriage and the Family, 41, 75-88.

17. Sorensen, S., Pinquart, M., & Duberstein P.

(2002). How effective are interventions with

caregivers? An updated meta-analysis.

 Gerontologist, 42, 356-372.

18. Acton, G.J. & Winter, M.A. (2002). Interventions for family members caring for an elder

with dementia. Annual Review of Nursing

 Research, 20, 149-179.

19. Zarit, S.H., Reever, K.E., & Bach-Peterson, J.

(1980). Relatives of the impaired elderly: Correlates of feelings. Gerontologist, 20, 649-655.

Patrick S. Calhoun, Ph.D. is a staff psychologist and

Co-Director of the Psychology Training Program at

the Durham VA Medical Center. He is an Assistant

Clinical Professor of Psychiatry and Behavioral

Sciences at Duke University Medical Center and a

Research Associate at the VA Center for Excellence

in Health Services Research in Primary Care. His

current research interests include the relationship

between PTSD and health and the development of

effective interventions aimed at reducing aggression

in patients with chronic PTSD.

Timothy P. Wampler, M.S.W. is a licensed clinical

social worker and Mental Health Disaster Services

Coordinator at the Durham VA Medical Center. He

has served on the VA National Social Work Program

and Evaluation Committee and is the former

chairman of the POW Advisory Committee at the

Durham VAMC. His clinical specialty and practice

focuses on the assessment and treatment of anger,

aggression and family discord among veterans with

chronic, combat-related PTSD.

CALHOUN & WAMPLER

20. Beck, A.T., & Steer, R.A. (1987). Beck Depression Inventory manual. San Antonio: The Psychological Corporation.
Volume 11 (2) 2002

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NC-PTSD Clinical Quarterly

NATIONAL CHILD TRAUMATIC STRESS NETWORK

NATIONAL CENTER

FOR CHILD TRAUMATIC STRESS

Treatment centers from all over the United States have come together

to form a new coalition, the National Child Traumatic Stress Network

(NCTSN). The Network, which is currently comprised of 36 centers, is

being funded by the Center for Mental health Services, Substance

Abuse and Mental Health Services Administration, and the U.S.

Department of Health and Human Services through a Congressional

initiative. This Congressional initiative recognizes the profound,

destructive, and widespread impact of trauma on American childrenís

lives. Its purpose is to improve the quality, effectiveness, provision,

and availability of therapeutic services delivered to all children and

adolescents experiencing traumatic events.

The National Center for PTSD has consulted with NCTSN in two general areas: 1) providing advice on organizational structure and function; and 2) collaborative possibilities with respect to research, education, and consultative activities. With regard to future collaboration, discussions include integration with the PTSD Resource Center,

common research protocols promoting longitudinal research on PTSD

across the lifespan, and a collaborative educational and consultative

approach to early intervention, as well as developing practice guidelines for adults, children and families for long-term treatment of PTSD.

AND

 THE NATIONAL CENTER FOR PTSD
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

24

Matthew J. Friedman, M.D., Ph.D.

Executive Director, NC-PTSD

NEW DIRECTIONS NEW DIRECTIONS

On October 7-8, the National Center held its third National Primary Care/Mental Health Conference in Washington,

DC. This conference is the most visible component of our primary care initiative which has been a major priority of the

National Center for the past five years. It exemplifies our emphasis on the rapid translation of science into practice and practice

into science.

Greg Leskin, with the support of Fred Gusman and Joe Ruzek at the National Centerís Education Division in Palo Alto

deserves the major credit for the success of this conference. As a result of Gregís persistence and dedication, VA primary care

and mental health practitioners have had the opportunity to consider integrated clinical approaches through which to improve

overall treatment for veterans with PTSD. It is also notable that Greg was able to obtain funding entirely from private donors

for this as well, as for both of the National Centerís previous PTSD/primary care conferences.

Conference highlights included a keynote address by Dr. Robert Roswell, VAís Under Secretary for Health. Dr. Roswellís

interest in integrated primary/mental health care dates back to when he served as Chief of Staff at the Birmingham VA Medical

Center, where he oversaw one of the first integrated efforts to attend to the psychological as well as medical needs of Gulf War

veterans.. Another notable participant in this conference was the U.S. Surgeon General, Dr. Richard Carmona, himself a Vietnam

veteran. Dr. Mark Stanton, who directs VAís Primary Care program, was a very active conference participant along with Kirk

Strosahl and Patricia Robinson who have been leading the field in the development and implementation of such integrated

approaches. Finally, Scott Murray, Mary Scholen, and Catherine Vernon presented the very successful results of their integrated

primary and mental health treatment program in VISN 2.

National Center activities in this area began almost ten years ago with scientific findings suggesting that people with

PTSD are at a greater risk to develop medical illnesses than those not affected by this disorder. Paula Schnurrís work with

veterans from the Normative Aging Study stands out as an exemplar of such research, having shown that veterans with PTSD

are more likely to develop peripheral vascular disease and other medical problems than veterans without this disorder. Subsequent research on both veterans and civilian cohorts has confirmed such findings and drawn increased attention to the physical

health problems and higher medical clinic utilization rates of veterans and civilians with PTSD.

Indeed, medical utilization data within both VA and civilian health care systems indicates that individuals with PTSD are

much more likely to seek treatment from primary/specialty medical practitioners than from mental health professionals for

PTSD-related and other physical complaints. Research by Terry Keane and Eva Deykin at the National Centerís Behavioral

Science Division in Boston, has shown that veterans with PTSD are much more likely to rank among the highest utilizers of

medical services.

The obvious implication of such findings is the need to establish integrated primary/mental health care for veterans with

PTSD and othe psychiatric disorders. Two successful examples of such approaches have been developed by the National

Centerís Womenís Health Science and Evaluation Divisions. The integrated model for female veterans, originally developed by

Jessica Wolfe and currently under the direction of Eve Davison, Erica Sharkansky and Lauren Dever at the Boston VAMC, was

one of the first successful programs of that kind within VA. The demonstration of superior clinical care outcomes shown by

Benjamin Druss, Bob Rosenheck, and others at the West Haven VAMC, was one of the first published clinical trials in this area.

The Education Division at Palo Alto has accepted major responsibility for advancing the National Centerís agenda to

promote integrated care. Recent accomplishments include the construction of a reliable 4-item screening questionnaire for

primary care settings by Annabel Prins, Rachel Kimerling, and others, and recent publication of a PTSD/primary care self study

program, the ìVeterans Health Initiative,î under the direction of Joe Ruzek and Patricia Watson (from the Executive Division).

The most exciting new development is the establishment of an integrated clinic at Palo Alto that will permit us to test screening

procedures as well as clinical outcomes from this delivery model. In addition, protocols will be tested for assessing resource and

staffing needs so that VA administrators will be able to make accurate projections for supporting such integrated programs.

To summarize, I wish to commend Greg Leskin and other National Center staff who made our third conference on

this theme such a success. They have all made a significant contribution to our growing momentum in this very important area.

Hopefully, these efforts will lead to improved treatment for veterans throughout the VA system.
Volume 11 (2) 2002

25

NC-PTSD Clinical Quarterly

A CLINICAL FORUM

EARLY INTER Y INTERVENTION: VENTION: VENTION: Josef I. Ruzek, Ph.D.

Associate Director of Education

NCPTSD A CLINIC A CLINICAL FORUM

Early intervention to prevent development of PTSD: Importance of post-trauma beliefs

One of the goals of early intervention is to ensure that trauma survivors are making sense of their experience and its

implications in ways that are adaptive, stress-containing or reducing, balanced, and consistent with our knowledge of traumatic

stress. In fact, much of existing practice in response to trauma survivors involves, in delivery contexts from rape crisis counseling

to disaster mental health, the informal shaping of trauma-related beliefs, interpretations, and judgments. Education about

trauma and its impact, the challenging of rape ìmythsî, the ìnormalizationî of acute stress reactions, and the instillation of

hope for the future that feature in these settings all involve the belief system of the survivor and its impact on recovery.

This focus on beliefs is in fact consistent with much current thinking about traumatic stress. Many existing theories and

therapies for PTSD attend to the role of trauma-related cognitive content in precipitating or maintaining trauma-related distress.

For example, the cognitive model of PTSD proposed by Ehlers and Clark (1) posits that continuing negative appraisals of the

trauma and its effects contribute to the persistence of PTSD by helping maintain a sense of ongoing threat.

Challenges in tackling trauma-related beliefs include the facts that such beliefs are specific to the individual and that

there are many types of potentially important cognitions. For example, a given individual may be troubled by thoughts of

personal guilt or shame, perceptions of a variety of negative future implications of the trauma, low perceived selfefficacy, distressing views of self (e.g., unworthy, weak, damaged, evil), and exaggeratedly negative judgments about

other people or other aspects of the environment (e.g., others canít be trusted, dangerousness of the world). Cognitions

about stress reactions themselves may also be important. The construct of anxiety sensitivity may be especially useful in

this regard (2). Individuals who view their anxiety sensations as dangerous or otherwise harmful may respond poorly to

the common post-trauma experiences of heightened arousal or panic.

One task of the helper is to assess for distressing thoughts and help the survivor rethink such thoughts in ways that

correct mistaken understandings, place the situation in perspective, or simply soothe. However, relatively little is known

about the best ways of identifying and challenging such beliefs in the contexts of early intervention. Several paper-andpencil inventories are available to help assess trauma-related cognition, of which the Posttraumatic Cognitions Inventory

(3) is perhaps the most comprehensive. Such inventories may be useful for identifying significant areas of cognitive

content in the early aftermath of traumatization. In terms of intervention, while cognitive-processing therapy represents

perhaps the most systematic and best validated approach to the restructuring of distressing trauma-related beliefs in those

with PTSD (and has the virtue of being available in treatment manual format (4)), it has not been evaluated as an early

intervention. As currently formulated, it is too intensive an intervention; preventive services will need to be deliverable in

brief, cost-effective formats.

Many post-trauma efforts to influence interpretations of acute stress reactions, personal experience of trauma, and

expectancies of the future are attempted via simple survivor education. The informal discussions that take place between

trauma survivors and emergency mental health workers often address such content when it comes to light in conversation.

Little is currently known about the utility of such helping conversations, or of the more formal didactic educational

presentations that sometimes address these issues. Similarly, while the pamphlets and self-help materials available to

survivors often directly or indirectly affect distressing beliefs, formal bibliotherapeutic interventions for trauma survivors

have yet to be evaluated. The formal cognitive restructuring treatments (e.g., 5-7), while perhaps too time-consuming for

most early intervention purposes, can probably be redesigned as moderate intensity (e.g., 2-5 session) interventions without

a precipitous loss of impact. The relatively brief cognitive-behavioral ìpackageî early intervention used successfully used

to treat accident and assault survivors with acute stress disorder by Bryant and his colleagues ( 8), includes a significant

cognitive restructuring component. It is likely that research will soon enable us to evaluate the relative impact of the

cognitive restructuring component of such care.

At the current time, it is important that providers of early interventions attempt to identify distressing thoughts

experienced by survivors and make them a focus of therapeutic efforts, whether through brief helping discussions,

education, or more systematic multi-session efforts. Ways of doing this are likely to receive increasing attention in the coming years.

CONTINUED ON PAGE 29
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

26

MATCHING TREATMENT RESOURCES TO PATIENT

READINESS IN AN OUTPATIENT VA PTSD CLINIC

EVELYN SANDEEN, PH.D. & ELLA C. NYE, PH.D.

Evelyn Sandeen Ella C. Nye

are either not the highest treatment

priority or are not best described by

a PTSD diagnosis. Addressing primary diagnoses takes priority. An important related point is that having a

trauma history does not imply that a

veteranís difficulties are best conceptualized as PTSD, or that the veteran

will benefit from services in a PTSD

At the New Mexico Veterans

Health Care System (NMVHCS), our

Trauma Clinic, like many others within

the VA system, has been overwhelmed

with the numbers of veterans being

referred for services. At the same time,

our staff has had the clear perception

that some veterans are more ready for

and able to make use of treatment than

are others. We have therefore felt the need

for a rational triage system based

intervention. In developing a model for a triage system, we

have attempted

to identify conceptual categories that may

predict ability

to benefit

from treatment. We have

looked to the

research literature on readiness for treat-

 trauma clinics need a

rational triage system to

manage precious resources

 by identifying those

 characteristics that make trauma

patients able to benefit from

 intensive staff time.

not on acuity as much as on patientsí ability to benefit from

VA

1. Comorbidity Issues PTSD in general, and combat-related

PTSD in particular, is often comorbid with multiple Axis I and

Axis II disorders (2). It is important for patients to meet full

DSM IV criteria for PTSD in order to benefit from traumafocused interventions. There are many patients who have indeed survived trauma but for whom the post-trauma effects

trauma, for instance, have been recognized to be frequently

distinct from PTSD per se (3). Personality disordered veterans

who have a trauma history but do not have PTSD, in our experience, are not helped significantly by the types of treatment we offer in our clinic.

clinic. The sequelae of childhood

A significant proportion of the dually diagnosed VA

trauma patient population has substance use disorders

in addition to PTSD. Both current literature (4), and

our own experience suggest that substance use disorders must be addressed as a first priority in PTSD treatment. At the NMVAHS, we have established a close

working relationship with the Substance Use Disorder

(SUD) team, developing joint programs for veterans

with both substance problems and PTSD. However,

ment and treatment outcome. We have also identified some

some categories which highlight differences between VA trauma

patients and civilian populations who have been traumatized,

based on our assumption that there are some VA patients who

are more like the non-VA patients who populate much of the

effective trauma treatment literature (1). Identifying patients

who can benefit from intensive treatment is critical, given the

shortage of VA resources in the face of demand. Following

are the categories that we investigate as part of an ongoing

assessment designed to match patients to appropriate treatments:

there is a point at which, if the veteran is not working toward

sobriety, we make the decision that he is not appropriate for

further PTSD treatment. Patients who continue to abuse drugs

or alcohol while in treatment for PTSD do not, in our experience, make lasting gains. Alcohol or drug abuse is an active

avoidance strategy which is in direct contradiction to the treatment philosophy of most PTSD clinics. Additionally, failing to

work on oneís substance problem is a very good behavioral

indicator of overall treatment motivation.

2. Stability Issues Combat veterans often live chaotic, potentially traumatic lifestyles, with high rates of homelessness,

poverty, unemployment and violence (5). In our experience it

is rarely core PTSD symptoms alone that bring patients to our

emergency room or prompt them to call their provider in crisis, but rather factors such as substance use, chaotic relationships, violent behavior, or financial and housing difficulties.

Veterans who present in crisis need crisis-oriented interventions
Volume 11 (2) 2002

27

NC-PTSD Clinical Quarterly

MATCHING TREATMENT RESOURCES

aimed at identifying and addressing the immediate causes of

the crisis situation. These patients are clearly not ready to benefit from intensive trauma-focused therapies.

3. Logistical Issues Within the New Mexico VA system, we

have many veterans who must travel great geographic distances to reach our clinic. We are beginning to work more

closely with VA Community-Based Outpatient Clinics

(CBOCís) and Vet Centers to provide better care to these

veterans. It is important to be practical when undertaking

treatment planning for such patients and define achievable

treatment goals.

4. Motivational Issues VA trauma patients may have ambivalence toward improvement that is not present in nonVA populations. VA patients who are service-connected or

are seeking service connection for their PTSD are in an inherent double-bind situation. There is legitimate fear that if

they improve significantly their service-connected benefits

will not be awarded or will be eliminated or reduced. Research suggests that accurate reporting of symptom levels is

hurt by this situation (6). We suspect that improvement

itself is negatively impacted as well. The reality of conflicting motivations for improvement is explored in an open

and matter-of-fact way throughout treatment. While concern

with service-connection is not seen as a rule-out for treatment,

if motivation for symptom reduction is absent, no treatment

gains are likely.

5. Chronic Overt Anger Higher levels of anger among

veterans have been well documented (7). Because of the

sometimes indefensible past treatment veterans have received from the military and/or from the VA, they understandably transfer some negative feelings onto current VA

treatment providers. We find that working through some

of this anger may be necessary to the early stages of the

treatment process. However, high levels of anger continually expressed toward providers (rather than anger discussed

with providers) hinders the effectiveness of treatment and

bodes poorly for treatment progress (8).

6. Patterns of Attachment PTSD, like most psychiatric

disorders, is often associated with insecure attachment styles

(9). Patterns of attachment are central to an individualís

ability to makes use of forms of treatment which depend

upon group process or the therapeutic relationship. We

believe that much of our ìclinical intuitionî regarding a

veteranís ability to benefit from these types of treatment is

based on observations during the clinical interview that illuminate patterns of attachment. A veteran with PTSD who

8. Readiness for Change We attempt to utilize the stages of

change model (10) and gently push patients to identify whether

they are ready to work and make changes in their lives. One

practical way of doing this is to require homework from patients. Those who do not complete homework, and who are

dismissive of the whole concept, are probably pre-contemplative and are not ready for change. These patients may benefit

from interventions encouraging contemplation of change, but

they are not good candidates for receiving intensive psychotherapeutic resources.

demonstrates a secure pattern of attachment is able to express

a clear valuing of relationships and interpersonal experiences

while also being able to demonstrate apparent objectivity in the

description and evaluations of particular relationships. Individuals vary in their ability to consistently demonstrate secure

attachment, but those veterans unable to do so are unlikely to

benefit from a therapy process that requires the ability to relate

to others in non-rigid ways. These veterans may tolerate psychoeducational groups, but will probably not benefit from resourcerich process groups or short-term individual psychotherapies.

7. Identity Issues Unlike most rape victims or accident survivors, veterans who have been traumatized during their military service may present with a complex set of identity concerns around the role that produced their trauma. In addition

to giving them lasting post-trauma symptoms, wartime experiences have given many veterans some of the most exciting and

meaningful moments in their lives, as well as some of their

most intense relationships with others. The veteranís ambivalence toward his military history sometimes makes him hostile

to treatment interventions perceived as attempts to invalidate

his experience. Given that the average age of a Vietnam combat soldier was 19, developmental identity issues were negatively impacted for many who participated in that conflict.

Young soldiers severely traumatized before adult identity had

fully formed may have been at increased risk of taking on

dysfunctional identities such as ìwounded PTSD Vetî to defend against other identities such as ìkillerî, or the loss of identity. Some veterans have, as a result of their PTSD syndrome,

led chaotic and/or substance-involved lives since their discharge

from the military and have constructed an identity around that

kind of lifestyle. They may be attached to seeing themselves as

ìrebelsî or even ìlosers.î All such dysfunctional identities may

be threatened by active participation in treatment. We have

found that group psycho-education can help some of these

veterans begin to explore new identities. However, if resistance toward treatment remains high, such dysfunctionally-identified veterans will not be offered further psychotherapy within

our system.
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

28

SANDEEN & NYE

These approaches vary both in the intensity of resources they

represent as well as in their ultimate potential for efficacy in

treating PTSD. Psycho-education and support are relatively

inexpensive interventions if kept time-limited, from which nearly

every patient can benefit. Psychiatric management is moderately to highly effective for most of our patients, and represents a moderately expensive intervention. We have found skillstraining to be helpful for patients who have completed some

other form of intervention and have begun to enjoy some

improvements in their lives as a result of treatment. Skillstraining is relatively inexpensive, but only patients who have

shown readiness for change are appropriate for this type of

intervention. We see exposure-based and cognitive therapies

as both the most expensive and the potentially most effective

for those patients who are not ready or able to benefit from

them for the reasons cited above. To achieve both efficiency

and effectiveness, our clinic must utilize ongoing assessment to

match patients to appropriate treatments.

In conclusion, we make the case that VA trauma clinics need

a rational triage system to manage precious resources by

identifying those characteristics that make trauma patients

able to benefit from intensive staff time. We have identified several factors that contribute to the difficulties of a

veteran with PTSD, only some of which are effectively addressed with research-validated trauma interventions such

as exposure therapies and skills training. Individualized assessment and treatment planning are essential both for

proper resource utilization and for truly helping patients.

Finally, we believe that allocating the majority of staff time

to those patients who are most able and ready to benefit is

a key to preventing staff burnout.

References

1. Rothbaum, B.O. & Foa, E.B. (1996). Cognitive-behavioral therapy for posttraumatic stress disorder. In

B.A. van der Kolk, A.C. McFarlane, & L. Weisaeth

(Eds.), Traumatic Stress: The Effects of Overwhelming

Experience on Mind, Body and Society, (pp. 491-509).

New York: The Guildford Press.

2. Keane, T.M. & Wolfe, J. (1990). Comorbidity in posttraumatic stress disorder: An analysis of community

and clinical studies. Journal of Applied Social Psychology,

20, 1776-1788.

3. Herman, J.L. (1992). Complex PTSD: A syndrome in

survivors of prolonged and repeated trauma. Journal of

Traumatic Stress, 5, 377-391

.

New Mexico Veterans Health Care System Trauma Clinic:

Matching Patients To Appropriate Resource Intensity

We have attempted to provide resource-rich therapies to patients who can make full use of them by having a graduated

treatment model in which the first steps of treatment are relatively resource-efficient, such as orientation or psycho-educational classes. Ongoing assessment is based on the patientís

response to early treatment interventions, including interest and

engagement in the process, ability to self-disclose, ability to interact with others in ways that are not rigidly defensive, and

....having a trauma history

does not imply that a

 veteran will benefit from

 services in a PTSD clinic.

ability to express emotions other than anger. Patients who demonstrate these behavioral markers of treatment readiness will

be offered further, more resource-rich therapies such as exposure-based trauma processing. We have tried to eliminate treatment modes within our program that demand intensive staff

time but require no work on the part of patients. We no longer

offer drop-in ìrap groupsî because we found that such groups

were a magnet for patients who wanted to access support, but

were obviously pre-contemplative in regard to readiness for

change. Patients who value support and a sense of belonging

but are unable to participate in treatment are referred to veterans support groups in the community. We try to match the

level of therapist involvement with the level of patient involvement.

Our program rests on the twin pillars of efficiency and effectiveness. Efficiency represents seeing as many patients as we

can ethically and effectively treat, and treating patients for the

minimum amount of time which will produce effective results.

Efficiency also means management of personnel resources to

achieve maximum payoff in terms of patient benefit. Effectiveness represents our commitment to treating patients using

the best-researched and most powerful interventions we have.

In addition to the research literature on treatment of PTSD, we

also include our own program development data and clinical

evaluations of what is effective in making choices about what

interventions to use. As a result of this process, our clinic has

focused on four main approaches to the treatment of trauma:

psycho-education and support, psychiatric management, skills

training, and exposure and cognitive therapies.
Volume 11 (2) 2002

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NC-PTSD Clinical Quarterly

4. Ruzek, J.I., Polusny, M.A., & Abueg, F.R. (1998). Assessment

and treatment of concurrent posttraumatic stress disorder

and substance abuse. In V.M. Follette, J.I. Ruzek &

 F.R. Abueg (Eds.), Cognitive-Behavioral Therapies for

Trauma, (pp. 226-255). New York: The Guilford Press.

5. Shalev, A.Y. (1997). Discussion: Treatment of prolonged

posttraumatic stress disorder - learning from experience. Journal of Traumatic Stress, 10, 415-423.

6. Frueh, B.C., Gold, P.B., & de Arellano, M.A. (1997). Symptom overreporting in combat veterans evaluated for

PTSD: Differentiation on the basis of compensation

seeking status. Journal of Personality Assessment, 68,

369-384.

7. Novaco, R.W., & Chemtob, C.M. (1998). Anger and trauma.

In V.M. Follette, J.I. Ruzek & F.R. Abueg (Eds.),

Cognitive-Behavioral Therapies for Trauma, (pp. 162-

190). New York: The Guilford Press.

8. Chemtob, C.M., Novaco, R.W., Hamada, R.S., & Gross, D.M.

(1997). Cognitive-behavioral treatment for severe anger

in posttraumatic stress disorder. Journal of Consulting

and Clinical Psychology, 65, 184-189.

9. Dozier, M., Stovall, K.C., & Albus, K.E. (1999). Attachment

and psychopathology in adulthood. In J. Cassidy & P.R.

Shaver (Eds.), Handbook of Attachment, (pp. 497-519).

New York: The Guildford Press.

10. Prochaska, J.O. & DiClemente, C.C. (1992). The transtheoretical

approach. In J.C. Norcross & M.R. Goldfried (Eds.),

Handbook of Psychotherapy Integration, (pp. 300-334).

New York: Basic Books.

MATCHING TREATMENT RESOURCES

References

1. Ehlers, A., & Clark, D.M. (2000). A cognitive model of

posttraumatic stress disorder. Behaviour Research and

Therapy, 38, 319-345.

2. Reiss, S. (1991). Expectancy model of fear, anxiety, and panic.

Clinical Psychology Review, 11, 141-153.

3. Foa, E.B., Ehlers, A., Clark, D.M., Tolin, D.F., & Orsillo, S.M.

(1999). The Posttraumatic Cognitions Inventory (PTCI):

Development and validation. Psychological Assessment,

11, 303-314.

4. Resick, P.A., & Schnicke, M.K. (1993). Cognitive processing

therapy for rape victims: A treatment manual. Newbury

Park, California, Sage Publications.

5. Marks, I., Lovell, K., Noshirvani, H., Livanou, M., & Thrasher,

S. (1998). Treatment of posttraumatic stress disorder by

exposure and/or cognitive restructuring. Archives of

General Psychiatry, 55, 317-325.

6. Tarrier, N., Sommerfield, C., Pilgrim, H., & Humphreys, L.

(1999). Cognitive therapy or imaginal exposure in the

treatment of post-traumatic stress disorder: Twelvemonth follow-up. British Journal of Psychiatry, 175, 571-

575.

7. Resick, P.A., Nishith, P., Weaver, T.L., Astin, M.C., & Feuer,

C.A. (2002). A comparison of Cognitive-Processing

Therapy with prolonged exposure and a waiting

condition for the treatment of chronic posttraumatic stress

disorder in female rape victims. Journal of Consulting

and Clinical Psychology, 70, 867-879.

8. Bryant, R.A., Sackville, T., Dang, S. T., Moulds, M., &

Guthrie, R. (1999). Treating acute stress disorder: An

evaluation of cognitive behavior therapy and supportive counseling techniques. American Journal of Psychiatry,

156, 1780-1786.

EARLY INTERVENTION: A CLINICAL FORUM

CONTINUED FROM PAGE 25

Evelyn Sandeen received her doctorate in clinical psychology from

the State University of New York at Stony Brook in 1985. Since

1989 she has worked in the VA system, and is currently assistant

director of the New Mexico VA Healthcare system PTSD Clinic

in Albuquerque. Dr. Sandeen is the co-author of two books,

Conceptualization in Psychotherapy (Lawrence Erlbaum, 1985)

and Depression in Marriage (Guilford Press, 1987).

Ella C. Nye received her doctorate in clinical psychology from

the University of New Mexico in 2000. She is currently a staff

psychologist in the New Mexico VA Healthcare system PTSD

Clinic where she provides clinical services and conducts research

on attachment and PTSD. Dr. Nye has also published research

on alcohol problem recognition in the Journal of Studies on

Alcohol, 1999.
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

30

The NC-PTSD Clinical Quarterly is available for free to

readers employed by the Department of Veterans

Affairs. Non-VA employees can receive the Clinical

Quarterly at nominal cost by using the Superintendent

of Documents form below. Selected articles are also

available for free to any interested reader from our

website: www.ncptsd.org .ncptsd.org

SUBSCRIPTION INFORMATION
Volume 11 (2) 2002

31

NC-PTSD Clinical Quarterly

PTSD Assessment Library

Available upon request are selected instruments from our library of assessment and program evaluation tools (with

accompanying articles), together with templates describing over 100 trauma-related measures courtesy of Beth

Stamm, Ph.D., and Sidran Press. Telephone (650) 493-5000 ext. 22477.

PTSD Article Library

A helpful set of key articles on aspects of PTSD is available to VA or Vet Center clinicians free of charge.

Telephone (650) 493-5000 ext. 22673.

PTSD Video Library

The Menlo Park Education Team maintains a small videotape lending library exploring topics related to

PTSD diagnosis, evaluation, and treatment. Videotapes may be borrowed free of charge. Telephone (650)

493-5000 ext. 22673.

PTSD Program Liaison and Consultation

The Menlo Park Education Team can help VA health care professionals locate needed resources. Services may include

assistance in locating relevant articles, locating resource persons, or problem-solving. Staff are available to consult in

the areas of PTSD Diagnosis and Treatment, Program Development and Design, Women and Trauma, Relapse

Prevention, and with other PTSD-related concerns. Telephone (650) 493-5000 ext. 22977.

National Center for PTSD Web Page

The NC-PTSD Home Page provides a description of activities of the National Center for PTSD and other trauma

related information. The world wide web address is: http://www.ncptsd.org

PILOTS Database

PILOTS, the only electronic index focused exclusively on the worldís literature on PTSD and other mental

health consequences of exposure to traumatic events, provides clinicians and researchers with the ability to

conduct literature searches on all topics relevant to PTSD. http://www.ncptsd.org/PILOTS.html

NC-PTSD Research Quarterly

The Research Quarterly reviews recent scientific PTSD literature. Telephone (802) 296-5132 for subscription

information.

Disaster Mental Health Training and Consultation

Education staff provide training and consultation in disaster mental health services. Training topics include key

concepts, interfacing with other agencies, pre-, within-, and post-disaster risk factors, psychological first aid,

screening for adverse mental health outcomes, early intervention, guidelines for working in large group settings,

support for bereavement, working with special populations, disaster worker stress, referral, self-care before,

during, and after an assignment, and other related topics. Telephone (650) 493-5000 ext. 22494 or email:

ncptsd@bruceyoung.net

Conferences and Training Events

The Menlo Park Education Team provides consultative support for the development of training in PTSD. Services

include assistance in finding faculty and designing program content. Telephone (650) 493-5000 ext. 22673.

NATIONAL CENTER FOR PTSD

EDUCATION, TRAINING, & SUPPORT SERVICES
NC-PTSD Clinical Quarterly Volume 11 (2) 2002

32

The Education and Clinical Laboratory Division for the National Center for Post Traumatic

Stress Disorder at the Palo Alto CA VAMC, in collaboration with the VA Employee

Education System, offers a Clinical Training Program (CTP). The training program is

approved for 30 Category 1 CEUs for physicians, psychologists, social workers, and nurses.

Each year we welcome many mental health professionals from across the United States

and from around the world. Most clinicians who enroll in the program have a working

knowledge about treating the effects of trauma and PTSD and are looking to upgrade

their clinical skills. The CTP offers a broad range of educational activities, including:

* Lectures

* Clinical consultation

* Clinical observation of group treatment

* Group discussions facilitated by staff

Specific training topics include warzone trauma group treatment, treatment of women

veterans, treatment of sexual assault related PTSD, relapse prevention, cross cultural

treatment issues, assessment and treatment of families, disaster mental health services,

cognition and PTSD, assessment of PTSD, and psychiatric assessment.

Training programs are scheduled for a minimum of one week, though longer programs

are available if the applicant can justify an extended stay. Programs are scheduled nine

times per year, on the second or third week of the month.

Funding for attendance is not available from the National Center. There is no fee for the training

program itself, but participants are responsible for providing their own transportation, lodging, and

meals. Interested applicants are encouraged to explore funding options through their local medical

centers or VA Employee Education System.

For more information, or to request an application, please email:

Josef.Ruzek@med.va.gov

or telephone FTS 700-463-2673; commercial number 650-493-5000, ext. 22673.

Refe

NATIONAL CENTER FOR PTSD

CLINICAL TRAINING PROGRAM