NC-PTSD Disaster Mental Health Actvities 37

Time-Limted Group Treatment for PTSD 42

Women and Trauma: A Clinical Forum 47

Family Members of the PTSD Veteran 48

  	

	



National

Center

for

PostTraumatic

Stress

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

Because of recent events and because publication of

this issue of the Clinical Quarterly was delayed, this summary, which was written several months ago, needed to be

updated before we went to press. The National Center has

been very involved in the immediate response to the Sept

11 terrorist attacks on the World Trade Center and Pentagon. Our website <www.ncptsd.org> has won national acclaim for rapidly providing educational materials for clinicians and the general public. A team of National Center staff

from the Education Division in Palo Alto provided immediate consultation, training in disaster mental health, and debriefing for Department of Defense (DoD) personnel and their

families at the Pentagon Family Assistance Center in Crystal

City, Virginia. The National Center is also working with

VA, other Federal, New York State, and New York City officials in planning the next phases of the post-Sept 11 mental

health response. Therefore, I’ll begin this summary with an

historical overview of how we first got into the emergency/

disaster mental health business. I’ll finish by describing our

current activities and plans for the immediate future.

Background

Past Activities

Those of you familiar with the early history of the National Center for PTSD know that we were literally thrust

into the disaster mental health business by the Loma Prieta

earthquake of October 1989. That dramatic cataclysm,

witnessed by millions of Americans watching the televised

World Series game between the San Francisco Giants and

Oakland A’s, shook up the whole Bay Area, destroying (among

many other structures) the main building at the Palo Alto VA

Hospital.

THE NATIONAL CENTER’S

 DISASTER MENTAL HEALTH ACTIVITIES:

PAST, PRESENT, AND FUTURE

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

Four days later a few of us made the hazardous trip from

Palo Alto to Santa Cruz, the locale of the earthquake’s epicenter. There we established a “helping the helper” program, led by Bruce Young, that provided crisis counseling

and other psychological support to Red Cross personnel,

school teachers, mental health workers and other local officials. We maintained that program in Santa Cruz for 18

months. During that time we had our first introduction to

he National Emergency Disaster System and collaborated with

officials from the Federal Emergency Management Agency

(FEMA), the Public Health Service, military emergency

technicians operating out of the Oakland Naval Hospital,

in addition to the Red Cross and local disaster personnel.

These activities were made possible by VA Secretary

Derwinski’s unprecedented decision to permit VA personnel to assist civilian federal and local authorities in the postearthquake restoration of order to the entire Bay Area.

Indeed, the first issue of this newsletter (NCP Clinical Quarterly, Spring 1990) describes these activities in detail, along

with a page 1 photograph of Fred Gusman peering into the

30 foot deep fissure in Santa Cruz where the earthquake

had its origin.

Since that time, disaster mental health has been one

of the National Center’s highest priorities. This is consistent

with VA priorities in which the VA’s fourth mission (after

treatment, education, and research) is to assist in times of

national emergencies and natural disasters. During the past

11 years, our activities in this area have been reported in our

Annual Reports and in this newsletter. Without rehashing

too many details, major accomplishments include collaboration with the DoD in preparation for the Gulf War, development of a disaster mental health manual that has been adopted
 	

		



NATIONAL CENTER FOR PTSD

Executive Director

	

				



 

Education and Clinical Laboratory Division



!"	#		

$$$% &'&

Pacific Islands Division



!"	#		%%("

)$$) *+,'

Behavioral Science Division

-.		

/"""""0,'

Women’s Health Science Division

12
.3		3

/"""""0,'

Clinical Quarterly Staff

  	
 
		 
 		 
	
 
    
!! 
!" #$#$$$ %	&   
 ! '	("
)

*&	

   
'
	
 	
+ ,	
-	 
 - .
	)+ /0  0	
 1	- )	!+ #23 45#667+8 9+-0 $#

FROM THE EDITOR...

Neuroscience Division

.2"$		

") *,*

Northeast Program Evaluation Center

4"5		

")*,*

6
77%

33 6


68 6


"" 6


""" 6


"39 


/)	:31		#		

"%;	<5		



	!"	#		

6/	$"		

42"/		

/)	:3

 		



 





	

 

	


Bruce H. Young, Editor-in-Chief

Though these are uncertain times, it is certain that after events of Sept11, the field of trauma services, research, and

education will work at speeds greater than ever to improve service delivery to survivors and helpers and to increase the empirical

knowledge about multi-modal interventions designed to mitigate and treat stress reactions. This will be most likely be accomplished

by legislation, the development of interagency agreements, the innovative use of existing assets, new methods and forms of information dissemination, research, development of best practice guidelines and specialized treatment programs, as well as reviews and

modifications of current programs and approaches to service. Much is underway already. In this issue, NC-PTSD Executive Director, Dr. Matthew Friedman gives a summary of how cooperative agreements with other government agencies are shaping the disaster

mental health initiative of the National Center. Over the next year, the Clinical Quarterly will track efforts by key agencies to keep

you informed of important developments.

Prior to the Sept 11th attack, two articles related to the VA/NC-PTSD primary mission of veteran care, were in press for this

issue of the Clinical Quarterly. The first of these articles pertains to group treatment. There are several reasons why group treatment

continues to be one of the most common forms of therapy for PTSD. Group treatment enables clinicians to assemble survivors who

have had similar experiences; it provides a context in which to build a therapeutic community of acceptance and support; it provides

a context enabling survivors to recognize the universality of PTSD symptoms and trauma-related problems; and, group treatment

costs less in time and energy than equal amounts of individual treatment. There are two primary forms of group treatment: trauma

focused exposure-based treatment involving a retelling of the trauma experience; and “here-and-now” focused treatment targeting

current trauma-related problems, e.g., communication skills, anger management, stress management, interpersonal relations, employment, housing, substance abuse, etc. Facing diminishing clinical resources and the challenge to increase staff productivity while

improving the standard of care, Repasky, Uddo, Franklin, and Thompson describe the VA New Orleans Trauma Recovery Program,

an innovative time-limited group treatment model utilizing both trauma narrative and psychosocial management skills.

Another innovative effort to improve the standard of veteran care is described by Lyons and Root who present the work of the VA

South Central MIRECC to meet the needs of families of veterans receiving treatment for PTSD. In addition to highlighting the important

role of the family in the care of veterans, they frankly acknowledge the difficulties encountered engaging families in treatment and share their

strategies to increase families’ attendance and participation, including the use of a phone survey to identify obstacles to seeking

services. Both articles represent VA clinicians’ creative and thoughtful efforts to support and achieve the Department of Veterans

Affairs Strategic Plan For Employees 2001-2006 goals to meet the needs of veterans and their families in the new millennium.
	

		





by VA, DoD, and civilian programs (and which is accessible

on both DoD and National Center websites), participation

in crisis counseling following the Oklahoma City bombing,

joint training with Readjustment Counseling Service of approximately 250 VA professionals in nine separate VISNs in disaster

mental health interventions, and ongoing collaboration with VA’s

Emergency Management Strategic Healthcare Group (EMSHG)

previously headed by General Joe Grey and currently led by Dr.

Kristi Koenig.

Although we have been proud of these accomplishments, often achieved under the leadership of Fred Gusman

and Bruce Young, we have been dissatisfied that such activities represented episodic responses to emerging situations

rather than ongoing programmatic participation in the National Domestic Medical System’s post-disaster mental health

response.

All that changed last year when I was approached by

Beth Nelson, Chief, Emergency Services and Disaster Relief

Branch of the Center for Mental Health Services (CMHS).

CMHS is a component of the Substance Abuse and Mental

Health Services Administration of the Department of Health

and Human Services. Ms. Nelson explained that guidelines

for emergency mental health services, developed in the context of earthquakes, floods, hurricanes, and other natural disasters, did not appear to be appropriate for criminally-perpetrated mass casualty events such as the Columbine school

shooting, Oklahoma City bombing, or the Pan American

Flight #103 plane crash over Lockerbie, Scotland. PTSD

rates are generally much higher following a criminal event

and the duration of psychological distress may last much

longer. (For example, traumatic reminders tend to be

retriggered throughout the post-traumatic period by arrests,

trials, sentencings, executions, and anniversaries, all of which

may take several years to unfold.)

Future activities will include best

practices and training curricula with

specialty modules for a wide array of

audiences, surveys of federal/state

practitioners and administrators, a

consensus conference, disaster site

surveys, program evaluation of the

disaster response system in action,

and empirical research.

With the support and collaboration of Kathryn

Turman, Director, Office for Victims of Crime (OVC) at the

Department of Justice, Beth Nelson told me that CMHS

had decided to develop best practice guidelines for emergency

mental health interventions following both criminal and natural

disasters. She asked the National Center to take the lead in this

multi-year endeavor. Under the leadership of Patricia Watson,

of the Center’s Executive Division, and funded by an Interagency Agreement between CMHS and the National Center,

we have just completed the first year of this exciting initiative.

There are three extraordinary aspects to this endeavor. The first

is the project itself. The second is how it has affected Center

programmatic involvement in the overall mental health component of the National Disaster Medical System. The third is

how it prepared us to make a significant contribution following

the September 11 terrorist attacks on the World Trade Center

and the Pentagon.

Under Patricia Watson’s leadership, we have reviewed:

(a) all evidence-based research on emergency mental health

interventions; (b) numerous reports on interventions in recent federally declared disasters due to either criminal or natural causes; (c) analyses of how the current Federal Response

Plan does and doesn’t work (with respect to legislative mandates, executive orders, earmarked resources, federal-state collaborative arrangements, etc.), and (d) all the diverse current

training curricula concerning disaster mental health. Future

activities will include best practices and training curricula

with specialty modules for a wide array of audiences, surveys

of federal/state practitioners and administrators, a consensus

conference, disaster site surveys, program evaluation of the

disaster response system in action, and empirical research.

This initiative has brought together professionals from VA,

CMHS, OVC, DoD, National Institute of Mental Health,

state officials and experts from academia. National Center

personnel, besides Patricia Watson, who are playing major

roles in this endeavor are Joe Ruzek, Bruce Young, Fred

Gusman, and myself. Other key players are Beth Nelson,

Seth Hassett, Deborah DeWolfe and Diana Norboe (from

CMHS), Skip Burkle and Paul Bolton (from the Johns

Hopkins School of Medicine and Public Health), and Fran

Norris (from Georgia State University).

As a result of this project, Patricia Watson, Joe Ruzek,

and I have been invited to participate in several focus groups

and meetings with colleagues based in other federal departments charged with different but complementary responsibilities concerning early mental health intervention following mass casualties. I have already mentioned CMHS and

OVC as well as collaborative activities with DoD in my previous column. In addition, we have begun to establish programmatic relationships with FEMA, the American Red Cross,

the National Domestic Preparedness Office, the Department

of Transportation (who must intervene following airplane or

FRIEDMAN DISASTER MENTAL HEALTH ACTIVITIES
 	

		

 	

railroad disasters), and the Department of Education (who

direct the mental health response following school shootings).

Our goal is to develop policies and procedures for effective

coordination and collaboration following national emergencies and mass casualty situations. Finally, we have worked

with Cameron Ritchie, Bob Ursano, Jim Stokes, and many

others to plan a DoD sponsored conference on Early Intervention based on what the empirical literature can and cannot tell us about effective post-disaster mental health responses.

Current Activities

Overview

In other words, when the September 11 attacks occurred,

NCPTSD had acquired substantial collective experience with

hands-on post-disaster interventions, education/training in

post-disaster mental health, and assessment of the evidencebased literature on effective interventions following criminal

or natural mass casualties. Of equal importance, NCPTSD

had become part of the federal post-disaster mental health

response network in which it had begun to establish its own

niche.

Notable NCPTSD activities since the terrorist attacks include: utilizing our website <www.ncptsd.org>;

hands-on consultation and intervention at the Pentagon with

DoD personnel and families; and participation in federal,

state (New York and Connecticut) and city (New York) short

and long-range planning for the mental health response to

this catastrophe, consultation to the New York Fire Department, and participation in a planning process for disaster

research. In addition, Patricia Watson and Paula Schnurr

have played the major role in coordinating NCPTSD initiatives with VA postdisaster activities, under the supervision

of Al Batres, Chief, Readjustment Counseling Service, as

well as VISN 3 leadership consisting of Mike Sabo, Mara

Kushner and Henrietta Fishman. Finally, NCPTSD staff from

all divisions have participated in a large-scale public education effort by providing over sixty interviews with the print

and broadcast media in coordination with VA’s Office of

Public Affairs.

Education

Within hours after the September 11 attacks we mounted

on our website Fact Sheets for the public and for professionals containing information and educational materials that

were disseminated widely. Our website received between 13,000

and 31,000 page requests per day during the days and weeks

following the disaster. Fact sheets for the public addressed issues such as:

• Common Reactions to Trauma

• Helping Survivors in the Wake of Disaster

• Terrorism and Children

• Disaster Rescue and Response Workers

• How Terrorist Acts Affect Veterans

• Self-Care and Self-Help Following Disasters, and other

topics.

Fact sheets for professionals included the aforementioned topics as well as:

• Risk Factors for Adverse Outcomes

• Psychosocial Resources

• Phases of Traumatic Stress Reactions in a Disaster

• Mental Health Interventions

• Working with Trauma Survivors

• Pharmacologic Treatment of Acute Stress Reactions

• Treating Survivors

• PTSD Screen for Primary Care Settings

• Impact of Disasters on People with Severe Mental Illness

• Casualty and Death Notifications, etc.

In addition, we made our Disaster Mental Health Services:

Guidebook for Clinicians and Administrators easily accessible as well as two videos: Children and Trauma and Hope for

Recovery. Great appreciation has been expressed from many

quarters for the rapidity, comprehensiveness, clinical utility, and

scientific basis for these fact sheets, our disaster manual, and

other materials. Credit for this accomplishment goes to Patricia

Watson, Jessica Hamblen, Eve Carlson, Joe Ruzek, Bruce Young,

Steve Southwick, Fran Norris, Candice Monson, and Kay

Jankowski.

Disaster Relief at the Pentagon

Immediately following the terrorist attacks, Fred

Gusman and five other Palo Alto-based NCPTSD staff (Joe

Ruzek, Sherry Riney, Greg Leskin, Robyn Walser, and Kent

Drescher) obtained clearance and permission from VA and

DoD officials to travel to the Pentagon disaster. Once onsite,

the NCPTSD team worked with DoD leadership, including Lt. Gen. John Van Alstyne and Col. William Huleatt,

to coordinate the mental health disaster response at the Pentagon Family Assistance Center and the US Army Community and Family Support Center. For twenty-five days, the

NCPTSD team worked closely with Col. Huleatt’s SMART

team to provide psychological support, consultation and education to DoD leadership and staff, Casualty Assistance Officers (CAOs), family members, and other disaster services

personnel (e.g., American Red Cross, FEMA, FBI Crime Victims Services, and VA Benefits). The NCPTSD team provided twice daily debriefings to Pentagon staff, as well as

FRIEDMAN DISASTER MENTAL HEALTH ACTIVITIES
	

		

 



psychoeducational presentations on early intervention and

self-care strategies related to the Pentagon attack aftermath.

Specifically, the NCPTSD team trained mental health staff

on psychological first aid/ defusing/debriefings, identifying

pathological reactions or behaviors, and encouraging selfcare and healthy coping. In addition, the NCPTSD team joined

DoD staff to form a collaborative, multidisci-plinary team offering direct mental health services to Pentagon military and

civilian employees, Pentagon families, and families of passengers

killed on American Airlines flight 77. For example, the

NCPTSD team accompanied family members during ceremonial visits to the Pentagon crash site. In addition, the NCPTSD

team worked with Col. Huleatt to develop educational materials and survey instruments. A debriefing training manual was

written to help instruct DoD mental health specialists to continue to facilitate debriefings integrating both the DoD and

NCPTSD intervention strategies. Also, a program evaluation

instrument, referred to as the Casualty Assistance Officers-Survey (CAO-S), was written to monitor the effectiveness of DoD’s

disaster response. The CAO-S measures perceived self-efficacy,

utilization and satisfaction of resources and services, and global

stress levels of CAOs. Results from this survey will be used to

support policy planning for future disaster responses. Preliminary results indicate that CAOs were “very satisfied” with the

VA’s debriefings, as well as VA’s benefit and compensation services. Members of the NCPTSD team continued to provide

services until the conclusion of Phase I of the Pentagon disaster relief operation.

Disaster Relief in New York

Finally, because of NCPTSD’s aforementioned Interagency Agreement with SAMHSA’s Center for Mental

Health Services (which is the lead federal agency for the mental health response on all national disasters), we have participated in planning the overall disaster response for New York

State and City. I visited Ground Zero at the World Trade

Center site and met with federal, state, and city officials on

September 21. Along with Patricia Watson, Joe Ruzek, and

Fran Norris, I have remained involved in developing an overall master plan for the New York clinical response and for

research during the weeks and months ahead.

Activities in Connecticut

The Clinical Neurosciences Division, NCPTSD,

VAMC, West Haven, CT has been working very closely with

the Connecticut Department of Mental Health and Addiction Services in its response to the World Trade Center disaster and in its plans for responding to future disasters. A team

of experts from the National Center for PTSD, the Yale

Department of Psychiatry, the Yale Child Study Center and

the University of Connecticut Department of Psychiatry

aremeeting on a regular basis with officials from the State of

Connecticut to provide consultation and training in disasterrelated activities.

New York Fire Department and Boston’s Logan Airport

John Greene, PhD of the Behavioral Science Division,

VAMC, Boston, MA has provided clinical services to

firefighters and families of the NYFD in Manhattan. This

activity has paved the way for research opportunities (see

below). In addition, James Munroe, Rose Zimering, Suzy

Gulliver, Chris Makary, and Barbara Niles have worked with

families, airline employees and airport staff at Boston’s Logan Airport, the point from which flights of two hijacked

planes originated.

Research

Terry Keane, Paula Schnurr, and I have also participated

in NIMH discussions chaired by Farris Tuma and Dennis

Charney to establish research priorities and to create new

(fast track) mechanisms for funding research protocols concerning New York City, the Pentagon and other relevant sites.

Terry Keane and Joe Ruzek have met with the New York Fire

Department to plan research opportunities in that arena.

Finally, I have been meeting with federal (New York) state

and city officials to develop a coherent and efficient process

for evaluating, implementing and monitoring New York-based

research activities. It is clear that any research must complement and be well-integrated into ongoing community and

clinical interventions.

 It is also clear that NCPTSD will continue to play a

major consultative/educational/research role in the post-disaster

response for the next few years. I will keep you informed of

these activities as they develop.

FRIEDMAN DISASTER MENTAL HEALTH ACTIVITIES
 	

		

 


TIME-LIMITED OUTPATIENT

GROUP PTSD TREATMENT

STEPHANIE A. REPASKY, PSY.D., MADELINE UDDO, PH.D.,

C. LAUREL FRANKLIN, PH.D., & KARIN E. THOMPSON, PH.D.

Group therapy is recommended as a potentially effective treatment for PTSD (1-3) and is associated with positive treatment outcomes across a variety of difficulties (1,3,4).

Group treatment offers patients support, encouragement, and

cohesion (1,4,5) and can be particularly therapeutic for combat veterans who may feel ostracized from society, misjudged,

and/or blamed for their difficulties (6). The main goals of

cognitive-behavioral group treatments for PTSD are to reduce the frequency and intensity of symptoms, enhance management of chronic symptoms, and improve quality of life

(1).This treatment modality also offers a mechanism for providing effective, efficient treatment to a large number of veterans with modest demands on clinical staff (2).

The New Orleans VAMC PTSD Outpatient Clinic

recently developed a time-limited, cognitive-behavioral group

Trauma Recovery Program (TRP) to address the high demand

for clinical services with limited resources. The TRP,

conceptually divided into five-phases of treatment, is a twoyear group treatment program for PTSD veterans. Veterans

presenting to the PTSD program for treatment are assessed

with a clinical interview and battery of self-report

instruments. Veterans who report symptomatology consistent

with PTSD, have no active substance abuse or psychosis,

and are stable enough for, and interested in, group treatment

are referred to the TRP. Veterans may also be followed by a

PTSD staff psychiatrist for medication management. While

not all veterans are appropriate, interested, or able to enter

this program, over the past year, approximately 60% of all

PTSD intakes have been referred to the TRP. Current

participants number 118, 56% of whom are AfricanAmerican, with an average age of 51. The majority served

during the Vietnam era (68.3%), with an average of 11

months in combat. Each month, a cohort of approximately

15 male veterans begin the program. Each cohort is

comprised of intakes from the previous month deemed

appropriate for the TRP. Twelve one-month modules are

conducted continuously, and every month, each cohort moves

from one group to the next in sequence. That is, each month

as one cohort moves out of a particular group, a new cohort

moves into that group. In order to foster a time-limited,

rehabilitative model, contact with the program gradually

decreases from weekly to biweekly and finally, monthly sessions (See Table 1). Although the program is designed for

veterans to progress through groups sequentially, individualized treatment plans allow for veterans to repeat groups or

proceed in a different order, if necessary. During the initial

month, each veteran is assigned a case manager who meets

with the cohort monthly to develop group cohesion and provide present-centered group treatment. Case managers are

also available for crisis intervention as well as individual,

marital, or family counseling, as necessary, and provide referrals to trauma focused treatment, as appropriate.

Phase I is directed at educating the veteran about

PTSD and helping him to identify appropriate treatment

goals. During PTSD Education, veterans receive a) education about PTSD symptoms and how these are addressed in

treatment; b) instruction in sleep hygiene; and c) information on the impact of PTSD on family systems (7). Written

educational materials are provided, which veterans are encouraged to share with significant others. Veterans then attend a motivation enhancement Problem Area Review Group.

The aim of this group is to increase their awareness of problem areas for the focus of their treatment, thereby enhancing

treatment planning and reducing the likelihood of relapse (8).

Phase II is organized around psychoeducational skillsbased groups delivered over a period of four months. Anger

Management Group focuses on identifying personal warning signs of increasing irritability, employing a time-out technique, and training in assertive behavior (9). Veterans also

examine the origins and costs of aggressive behavior. Training in cognitive restructuring addresses the impact of common cognitive errors and provides techniques for developing

more rational responses (10). Stress Management Group

provides an introduction to a variety of relaxation skills and

In order to foster a time-limited,

rehabilitative model, contact with

the program gradually decreases

from weekly to biweekly and

finally, monthly sessions
	

		

 



	
			

Topic # of Sessions Session Duration

Phase I: Orientation/Education (2 months)

1. PTSD Education 4 1 hour

· PTSD symptoms

· Sleep hygiene

· Impact of PTSD on family systems

2. Problem Area Review 4 1.5 hours

· Identification of potential problems

· Decision making to determine if it is a problem or not

· Examines pro’s and con’s of behavior

· Assists veteran with comparing own behavior to an “average guy”

Phase II: Coping Skills (4 months)

1. Anger Management 4 1 hour

· Identify personal warning signs of increasing irritability

· Use of time-out to manage irritability

· Examine benefits of changing behavior patterns

2. Cognitive Restructuring 4 1 hour

· Identification of automatic thoughts

· Identification of common cognitive errors

· Development of more accurate, rational responses

3. Stress Management 4 1 hour

· Introduction to various relaxation exercises

· Emphasizes daily management of stress

4. Relationship Skills/Social Support 4 1 hour

· Development of trust

· Communication skills

· Assertion versus aggression

Phase III: Developmental Perspective – Putting the Trauma in a Life History (3 months)

1. Pre-military Autobiography 4 1 hour

· Identification of Pre-military notions of topics such as relationships, trust,

 authority, emotional expression

2. Military Autobiography 4 1 hour

· Identification of how military experiences influenced pre-military notions

 and continues to impact on current functioning.

3. Three-way Mirror 4 1 hour

· Combines new insight on current behavior with coping skills previously

 discussed to encourage continued growth in one’s recovery

· Uses cognitive restructuring to re-examine current cognitions identified

 in Military Autobiography Group

Phase IV: Consolidation – Putting It All Together (3 months)

1. Relapse Prevention 2 1.5 hours

· Identification of personal triggers and warning signs of relapse

· Development of relapse prevention plan

2. Wellness 2 1.5 hours

· Emphasizes overall well-being

· Exercise, medication management, nutrition

3. Transition 2 1.5 hours

· Emphasizes long-term management of PTSD

· Development of personal treatment contract

GRADUATION

Phase V: Alumni (1 year) monthly 1 hour

· Continued support for recovery

TME-LIMITED OUPATIENT GROUP PTSD

TREATMENT

REPASKY, UDDO, FRANKLIN, & THOMPSON
 	

		

 

emphasizes the importance of acquiring new coping skills

(7). Finally, Relationship Skills Group targets issues of trust

and communication, with an emphasis on assertive communication skills (11).

Phase III, “Developmental Perspective,” aims to help

veterans identify, examine, and understand how relationships, experiences, and trauma over their life impact current functioning (12).

Veterans spend the first month reviewing their pre-military histories, with a focus on identifying values, beliefs, and salient

experiences prior to entering the military. Veterans then examine the impact of military trauma on their beliefs and cognitions associated with critical issues such as trust, intimacy, and

authority. During the third month, the three-way mirror technique (pre-military, military, and post-military life review) assists veterans with understanding symptom development over

the life span and to use new coping skills, combined with newly

identified cognitions, to effect positive changes in current functioning (12).

Although the program is

designed for veterans to

progress through groups

sequentially, individualized

treatment plans allow for

veterans to repeat groups

or proceed in a different

order, if necessary.










 !

"!


#$#
" 
#
#
%

!"


"!&#""!
'#



(
#

!#




#
##
#
"
%

)*+,&-
(
##$#%"


"."


""
)*/,&



##0

1"

#



%#

!#&



"
"#"#""%


#""

""!&




#"
##


##

#
)*,&

	#
"#

#"#


 

 "
! "

  
   

#

"
"
#
"# %

"!
#

""&
"



"

"
!&

2




"

"

!3

(
#!"
&

These groups are designed to consolidate gains by providing

booster sessions to review therapeutic techniques as well as

to identify and address roadblocks or setbacks encountered in

everyday life. Rehabilitation contracts are also reviewed and

modified as needed.

Veterans complete follow-up assessment during the

sixth and twelfth month to determine change from baseline

in specific and overall symptoms, as well as provide ratings of

usefulness and satisfaction with the program. To date, the

standard self-report measures have not indicated change,

however, subjective assessment did suggest improvement.

One possible explanation for this discrepancy is that veterans

do not perceive that their symptoms have changed, but rather

that they are better able to cope with their symptoms. Therefore, it may be helpful to include measures of coping strategies and quality of life to assess treatment effectiveness. When

asked to assess personal change, 66% of veterans (N = 29)

indicated the program was helpful in improving overall symptomatology at six months. Veterans also listed specific areas

of change and percentage of improvement in that area

through a forced choice format in which percentages were

listed in increments of 15 (See Table 2). Interestingly, 53%

of veterans initially indicating

 Table 2. Results of Subjective Assessment of Change

 at Six-months

 Mean %

 Area of Improvement N of Change

Understanding PTSD 6 62%

Relationships 11 36%

Anger Management 21 46%

Sleep 10 44%

Depression 6 32%

Isolation 4 46%

In summary, a time-limited, comprehensive group

therapy program that emphasizes rehabilitation and personal

responsibility for recovery was designed to maximize diminishing clinical resources and provide effective, efficient treatment to the high number of veterans presenting for PTSD

treatment. Preliminary data indicate that this format is beneficial to both veterans and clinical staff. Veterans have benefited from receiving a structured, therapeutic regimen that addresses major components of PTSD treatment. In addition,

cohorts become highly cohesive as they progress

TIME-LIMITED OUTPATIENT GROUP PTSD

TREATMENT

REPASKY, UDDO, FRANKLIN, & THOMPSON
	

		

 !



through the program, and veterans within a cohort consistently prove to be an excellent source of social support and

feedback for one another. Further, despite the group format,

veterans are provided individualized treatment planning and

support by their case manager. Clinicians have benefited

because the number of veterans seen by each clinician has

increased, while overall time expenditure has decreased, resulting in improved staff productivity and service delivery.

The TRP provides a practical and attractive treatment option for the majority of veterans presenting for treatment.

Treatment outcome will be assessed on an ongoing basis, and

the program will be modified as needed to ensure that efficient treatment is provided without sacrificing the level of

care.

References

1. Foy, D.W., Glynn, S. M., Schnurr, P. P, Jankowski, M. K.,

Wattenberg, M. S., Weiss, D. S., Marmar, C. R., &

Gusman, F. D. (2000a). Group therapy. In E. B.

Foa, T.M. Keane, & M. J. Friedman (Eds.), Effective

treatments for PTSD (pp. 155-175). New York:

Guilford Press.

2. Harney, P. A. & Harvey, M. R. (1999). Group

psychotherapy: An overview. In B. H. Young & D.

D. Blake (Eds.), Group treatments for post-traumatic

stress disorder (pp. 1-14. Philadelphia: Brunner/

Mazel.

3. Lubin, H., Loris, M., Burt, J., & Johnson, D. R. (1998).

Efficacy of psychoeducational group therapy in reducing symptoms of posttraumatic stress disorder

among multiply traumatized women. American Journal of Psychiatry, 155, 1172-1177.

4. Ford, J. D. & Stewart, J. (1999). Group psychotherapy

for war-related PTSD with military veterans. In B.

H. Young & D. D. Blake (Eds.), Group treatments

for post-traumatic stress disorder. (pp. 75-100).

Philadelphia: Brunner/Mazel.

5. Foy, D. W., Glynn, S. M., Schnurr, P. P, Jankowski, M.

K., Wattenberg, M. S., Weiss, D. S., Marmar, C. R.,

& Gusman, F. D. (2000b). Group therapy. In E. B.

Foa, T.M. Keane, & M. J. Friedman (Eds.), Effective

treatments for PTSD (pp. 336-338). New York:

Guilford Press.

6. Allen, S. N. & Bloom, S. L. (1994). Group and family

treatment of posttraumatic stress disorder. Psychiatric Clinics of North America, 17, 425-437.

7. Blake, D. D., & Sonnenberg, R. T. (1998). Outcome

research on behavioral and cognitive-behavioral

treatments for trauma survivors. In V. M . Follette,

J. I. Ruzek, & F. R. Abueg (Eds.), Cognitivebehavioral therapies for trauma. New York:

Guilford Press.

8. Murphy, R. T., Cameron, R. P., Sharp, L., & Ramirez,

G. (1999). Motivating veterans to change PTSD

symptoms and related behaviors. NC-PTSD

Clinical Quarterly, 8, 32-36.

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

trauma: Conceptualization, assessment, and treatment. In V. M. Follette, J. I. Ruzek & F. R. Abueg

(Eds.), Cognitive-behavioral therapies for trauma (pp.

162-190). New York: Guilford Press.

10. Beck, A. T. (1976). Cognitive therapy and emotional

disorders. New York: International Universities Press.

11. Jacobson, N. S. & Christensen, A. (1996). Acceptance

and change in couple therapy: A therapist’s guide to

transforming relationships. New York: Norton and

Co.

12. Seidel, R. W., Gusman, F. D., & Abueg, F. R. (1994).

Theoretical and practical foundations of an inpatient

post-traumatic stress disorder and alcoholism

treatment program. Psychotherapy, 31, 67-78.

13. Watson, D. L., & Tharp, R. G. (1997). Self-directed

behavior: Self-modification for personal adjustment

(7th ed.). Pacific Grove: Brooks/Cole Publishing.

14. Benson, H., Kornhaber, A., Kornhaber, C., LeChanu,

M. N. (1995). Increases in positive psychological

characteristics with a new relaxation-response curriculum in high school students. Journal of Research

and Development in Education, 27, 226-231.

TME-LIMITED OUPATIENT GROUP PTSD REPASKY, UDDO, FRANKLIN, & THOMPSON

TREATMENT
 	

		

 "

Stephanie A. Repasky, Psy. D. is a post-doctoral clinical psychology

fellow at the New Orleans VA Medical Center specializing in

PTSD and Behavioral Medicine. Her research interests include

the treatment of PTSD and related difficulties, particularly guilt

and dissociation.

Madeline Uddo, Ph. D. is Associate Director of the PTSD unit

at the New Orleans VA Medical Center and Clinical Assistant

Professor in the Department of Psychiatry and Neurology at

Tulane University School of Medicine. Research interests include

assessment and treatment of PTSD and comorbid disorders.

Karin E. Thompson, Ph.D., is a clinical psychologist and Director

of the PTSD Unit at the New Orleans VA Medical Center. She

is Clinical Assistant Professor in the Department of Psychiatry

and Neurology at Tulane University School of Medicine. Research

interests include treatment of PTSD, group treatment of

nightmares, and longitudinal sequelae of trauma.

C. Laurel Franklin, Ph. D. completed her internship at the New

Orleans VA in the PTSD specialty track. She is currently a postdoctoral fellow in the Department of Psychiatry and Human

Behavior at Brown University, where her most recent publication

(in press) examined the role of overlapping symptoms in the

comorbidity of PTSD and major depression.

Madeline Uddo, Ph. D.

C. Laurel Franklin, Ph. D.

Karin E. Thompson, Ph.D.

Stephanie A. Repasky, Psy. D.

TIME-LIMITED OUPATIENT GROUP PTSD REPASKY, UDDO, FRANKLIN, & THOMPSON

TREATMENT
	

		

 



WOMEN AND TRAUMA: A CLINICAL FORUM

 	
 



 
 		 

Training for Sexual Assault Counselors: Part II

Bridging the Science-Practice Gap

In this column we will present the outcome of a collaborative project between the National Center for PTSD (NCPTSD) and

the California Coalition Against Sexual Assault (CALCASA). Part I of this project was reviewed in NCPTSD Clinical Quarterly, 10 (1).

Whereas Part I focused on identifying the science-practice gap in the training of front-line rape crisis counselors, Part II will focus on

bridging this gap by describing the development and evaluation of a new training manual for rape crisis counselors.

Our goal in developing a manual for rape crisis counselors was to integrate empirical information on the prevention and

reduction of post-traumatic stress reactions into existing curriculums for training sexual assault counselors. More specifically, we set out

to create a step-by-step guide for how to assess and address common trauma reactions in survivors of sexual assault. After reviewing a

representative sample of training manuals (see Part I), we crafted an initial manual that included several modules, each one addressing

different topic areas: (1) information on trauma and trauma reactions; (2) negative and positive coping; (3) challenging negative beliefs;

(4) disclosure and; (5) referral guidelines. This manual was reviewed by three “content experts” for accuracy and for appropriateness of

use with a sexual assault population. 1

In order to obtain input and feedback from a diverse group of rape crisis counselors, three rape crisis centers in California were

asked to participate in a three-hour workshop. The initial center, the Harvest of Wellness (HOW) foundation, serves rural and suburban

communities in Southern California. Both new and seasoned sexual assault counselors reviewed the manual and provided important

feedback on its length, tone, appropriateness, usability and readability. Large sections of the manual were eliminated, research information

was placed in appendices, the number of modules was reduced, and the survivor handouts were made less clinical. The second center,

the YWCA Rape Crisis Center of Santa Clara Valley, serves an urban and ethnically diverse community. Feedback from this center

included helpful distinctions between what can be covered in one follow-up contact versus several follow-up contacts, examples of beliefs

that may be unique to different cultural groups, additional input on the readability of the survivor handouts, and obstacles to making

follow-up appointments. The last center, A Woman’s Place of Merced, serves a large rural and Mexican population. Many of the sexual

assault counselors attending this training provide counseling services concurrent with other activities (e.g. court accompaniment,

hospital contacts). Consequently, feedback from this center included the importance of an easy to use checklist, shorter handouts, as well

as the availability of handouts in Spanish.

After twenty-three drafts and iterations, a final product was circulated for evaluation. The final product includes three modules

each with specific steps, “back-up” information, and survivor handouts (including handouts in Spanish). The first module, Psychoeducation and Coping, is designed for first-time follow-up contacts. It includes an assessment tool to assess common reactions to trauma

as well as information on the recovery process and what aids (positive coping) and hinders (negative coping) recovery. It also includes

concrete suggestions for how to set up another appointment, and specific guidelines for when a referral is needed. The second module,

Challenging Beliefs, is better suited for multiple contacts and will often require additional training. In addition to challenging rape

myths, this module focuses on challenging other frequently held negative beliefs such as the ability to cope and beliefs about the future.

The third module, Disclosure, focuses on what is known about the importance of disclosure and the consequences of concealment. It

provides specific suggestions for how to disclose as well as information on when to disclose and to whom.

Preliminary analysis of the evaluation data indicates that the number of initial follow-up contacts did not increase significantly.

However, there was an increase in the number follow-up appointments once an initial contact was made. Furthermore, counselors

reported that they had become more effective in educating survivors about the recovery process, making a referral, challenging negative

beliefs, and stressing the importance of disclosure. New counselors found the step by step guide more helpful than seasoned clinicians,

and most reported that the handouts were helpful for those clients who could read above an eighth grade level.

The manual and its evaluation were recently presented at the California Coalition Against Sexual Assault Leadership Conference.

Although there are still some changes to be made, the manual was seen as being consistent with the philosophy and needs of most rape

crisis counselors. Indeed, this project has been a good exercise in how the scientist-practitioner gap can be lessened by including and

incorporating the practitioner’s perspective in the development of empirically sound training materials.

We thank Patty Resick, Heidi Resnick, and Elizabeth Meadows for their review of the manual.

A copy of the manual can be obtained from: California Coalition Against Sexual Assault (CALCASA), 1215 K street, Suite

1100, Sacramento, CA 95814 email: >dan@calcasa.org< Phone: (916) 446-2520
 	

		

 

There is a growing recognition of the importance of

family involvement in the care of PTSD. This emphasis

originates from veterans/families who are requesting services

and from VA staff who see family issues impacting on veterans’

functioning. This article looks at the literature on relationship

functioning, PTSD family treatment, and barriers to care.

We also discuss the South Central (VISN 16) Mental Illness

Research, Education, and Clinical Center (MIRECC) PTSD

work group’s ongoing research regarding veterans’ families.

Concern for the Family

& Their Role in the Veteran’s Care

It has long been recognized that PTSD is associated

with impaired interpersonal functioning (1-3). The extent

of PTSD’s impact is becoming increasingly clear. In a study

of married Vietnam veterans in which the veteran has PTSD,

70% report clinically significant relationship distress, in

contrast to 30% of non-PTSD couples (4). The severity of

PTSD symptoms correlates with partners perceptions of

caregiver burden (5) and marital distress (6, 7). The picture

is further complicated by the fact that some partners have

their own pre-existing psychopathology, including their own

trauma history (8).

The family’s role in treatment is also a concern from

a VA resource management perspective. An Australian study

found that domestic conflict was the most frequent precipitant

of calls to a Vietnam veterans crisis counseling line, and

that such calls were among the most complex calls received

(9). Meanwhile, a British team found that high levels of

relatives’ “expressed emotion” toward the patient (i.e.,

intrusiveness, criticism, and hostility) predicted poorer PTSD

treatment outcome (10). Thus, we are starting to see

empirical evidence of what many clinicians have long

speculated, i.e., that family conflict can impede the trauma

survivor’s recovery.

It is important to not underestimate how reliant

both the veteran and the VA system often are on the role

family members, particularly spouses, play in the veteran’s

care. Engaging families in the veteran’s treatment has been

identified as one of seven VA “priorities of quality” for clinical

services (11). Looking to the future as an aging veteran

population suffers declining physical health, veterans (and

VA) may become increasingly reliant on spouses and other

family members for the veteran’s daily care. Thus, it is

important to preserve these supportive relationships to the

extent possible. There is still time to take action. Although

38% of all veterans seeking VA specialized outpatient PTSD

care are presently either separated or divorced, 49% are still

married and with their spouse (12).

South Central MIRECC

& Families of Veterans with PTSD

Both out of humanitarian concern for quality of life

of the veteran and the family and out of pragmatic concern

for provision of efficient and effective care to the veteran,

South Central MIRECC has taken a major interest in PTSD

family issues. In its first two years of operation, MIRECC

In a study of married

Vietnam veterans in

which the veteran has PTSD,

70% report

clinically significant

relationship distress, in

contrast to 30% of

non-PTSD couples

funded three educational grants for new PTSD family

services, representing 43% of all PTSD-related studies funded

by this MIRECC. A PTSD work group is designing a phone

survey to explore what families need and want from VA and to

identify barriers that could interfere with receiving such services.

 “We Offered Services...

but Families Don’t Attend”

Many providers have assumed that family-oriented

services, if offered, would be well-received and well-attended.

The literature, however, suggests otherwise. Glynn and colleagues (13) found that 32-35% of veterans/families declined

family therapy, whereas no one declined other PTSD treatment modalities studied. Work schedules, transportation

FAMILY MEMBERS OF THE PTSD VETERAN:

TREATMENT NEEDS AND BARRIERS

JUDITH A. LYONS, PH.D. & LESLIE P. ROOT, PH.D.
	

		

 



difficulties, and lack of childcare were cited as major barriers.

Higher degrees of avoidance/numbing reported by the veteran were statistically associated with declining the offer of

family therapy.

Low attendance was also reported by Cahoon (6).

Sixty couples were divided into treatment and control groups.

Those invited to participate in conjoint therapy expressed

willingness to do so. However, only nine couples completed

the intervention (14). These rates are similar to those reported in the literature on caregivers of individuals with schizophrenia (15).

Identifying Barriers to Family Involvement

Given the stated interest on the part of patients,

families, and clinicians, what accounts for such low

participation? This is one of the questions the MIRECC

PTSD work group is seeking to answer. Pilot data are being

collected in Biloxi and Jackson, Mississippi during clinical

programs provided for veterans’ families. In Biloxi, the

sessions are topic-focused educational presentations followed

by group discussion, and clinical impressions are recorded.

In Jackson, data are collected through surveys and focus

groups within the context of all-day interactive/informational

workshops. The sessions have attracted children, parents,

siblings, husbands, wives, and friends of veterans of various

eras with varied trauma histories. Through these efforts, we have

examined several possible explanations for low attendance rates.

Lack of need? It would seem that lack of need can be

ruled out as an explanation for low rates of family engagement. At both sites, family members reported being very

troubled by the veteran’s symptoms. Approximately half of

survey respondents described themselves as walking on eggshells and living in constant stress due to the veteran’s PTSD.

Consistent with the literature (4), the veteran’s emotional

and behavioral withdrawal was reported to be particularly

problematic. Respondents reported feeling lonely and pushed

away by the veteran and complained of having no social life.

Distance and scheduling. Accessibility factors have

been cited as treatment barriers by caregivers of other mentally

ill populations (16-17). Survey respondents echoed that

refrain in our samples.

Travel difficulties/distance was the barrier most

frequently cited by Jackson participants. Some families

traveled over 400 miles round trip to attend. Nearly half of

participants traveled in excess of 200 miles. Travel distance

was also a barrier noted by some participants in Biloxi.

Schedule conflicts with other role obligations (job,

school, etc.) was the second most frequently cited barrier

within the Jackson sample and the most frequently noted

barrier within the Biloxi sample. The difference across

sites may, in part, be due to the fact that the Jackson sessions

were held on Saturdays, whereas the Biloxi sessions were held

during weekday work hours.

While based on limited sampling, these results suggest the need to be creative in minimizing logistical barriers.

Clinics may need to offer evening or weekend options. Particularly in rural areas, family services may need to be bundled

into a lengthier program or scheduled to coincide with the

veteran’s appointments to reduce the cost/benefit ratio of traveling 200 miles or more. One MIRECC-funded initiative

currently underway is the development of a home-study skillstraining workbook for spouses. Researchers will be comparing home-study outcomes versus group treatment outcomes.

Procedures for invitation and veteran support for

participation. At both sites, some veterans expressed reservations about inviting families. Some feared embarrassment

in front of their family due to their degree of impairment or

worried that family would ask about traumatic experiences.

Others feared that relatives would learn facts or techniques

that they would later use to the veteran’s disadvantage. Some

were concerned that open communication with providers

might jeopardize service-connected compensation.

In Biloxi, attendance remained below 3% regardless

of whether announcements were mailed to all 300 veterans

in the PTSD clinic or mailed selectively to patients known

to have family members and judged likely to attend. In

Jackson, all patients were informed of the family workshops,

and patients were encouraged to nominate friends and family who they felt could benefit from knowing more about

PTSD. Letters were sent directly to the family member 1-4

weeks in advance and a reminder phone call was made 1-2

days prior to the workshop. Attendance was steady at roughly

20% of nominated invitees at each Jackson session. Additionally, many family members attended who were not on

the invitation list but had heard about the event from the

patient. These findings suggest the importance of testing

various procedures for inviting participation.

Content of services being offered. In a recent review, Riggs (14) conceptualized two major approaches to

PTSD-related family/marital treatment: systemic and support. Systemic approaches use traditional marital/family

therapy models to reduce relationship distress. Support

treatments focus on bolstering family support for the trauma

survivor, with the goal of reducing PTSD symptoms. Support treatments employ psychoeducational and skills training interventions to help cope with the identified patient’s

trauma-related symptoms. Our findings suggest that one reason spouses may decline to participate in therapies may be that

neither of these treatment models fully meets spouses’ need. Of

46 survey respondents in Jackson, 30 were spouses. The

   ! "#   
 	

		

!	

remaining 16 included children, siblings, parents, friends,

etc. On surveys and during focus groups, there was a

noticeable difference in tone between spouses and others.

Non-spouses reported a limited role in helping the veteran

deal with PTSD symptoms. When asked what services would

be helpful and what outcomes they would hope to achieve,

non-spouses often requested interventions that would teach

them about PTSD or reduce the veteran’s symptoms. Some

requested interventions to improve the relationship or reduce

stress experienced by both parties. Such interventions are

consistent with the support and/or systemic treatments

described by Riggs. Thus, existing intervention models

appear consistent with what non-spouses are seeking.

The greatest demand among

spouses was for therapies

addressing their own needs. We

received numerous requests for

treatments to reduce the spouse’s

own stress level (not limited to

PTSD-related stress factors).

A very different picture emerges from spouses. A

mismatch between what PTSD programs traditionally offer

and what spouses want may present a significant barrier to

engaging these partners in treatment. Nearly all spouses reported a very active role in helping the veteran manage PTSD

symptoms, rating their role as large or “very large...more than

the treatment team.” They spoke of helping the veteran get to

appointments and remember medications, orchestrating the

family’s lifestyle around the veteran’s symptoms to minimize

relapses, taking on roles that the veteran was not able to fulfill,

etc. Many spouses discussed the difficulty of working outside

the home as the primary breadwinner plus inside the home as

the primary caretaker for children, aged parents, and/or the veteran. Just over one-third of spouses requested systemic interventions to improve the marriage or reduce stress that was shared

by both veteran and spouse. There was little interest, however, in educational sessions about PTSD. Most reported

having read about PTSD and having talked to many providers or organizations about the disorder. One woman

expressed her frustration with being offered additional

informational sessions: “What you’re offering is how he

sick he is...what I need is what I can do to cope because I’m

at the end of my rope.”

The greatest demand among spouses was for therapies addressing their own needs. We received numerous requests for treatments to reduce the spouse’s own stress level

(not limited to PTSD-related stress factors). Many spouses

wanted social activities to offset the isolation they feel. It is

notable that, in Riggs’ review of the PTSD family literature,

care directed primarily at spouses’ individual needs was not

found. The overall mission and structure of VA services, with

the emphasis on the veteran as the identified patient, may

limit the degree to which VA clinicians can be responsive to

such requests within VA clinics. Vet Centers may have somewhat more flexibility in this regard. Partnering with non-VA

community programs may also open new options for care

for spouses.

Conclusions

One comes away from such family groups with an

appreciation of the chronic stress experienced by significant

others, particularly spouses. Accompanying this is the

humbling recognition of how little we, as VA clinicians, have

been able to do to offset this distress.

Traditionally, many of the interventions VA has

offered have been informational sessions about PTSD

diagnosis and treatment (classified in Riggs’ review as

supportive interventions). Although outcome data are lacking

(14), such interventions may have been helpful to spouses

earlier in their relationship with the veteran and may be

exactly what friends, parents, and siblings are still looking

for. However, they appear unlikely to meet the overwhelming

needs currently identified by spouses.

Spouses may be far more interested in activities that

include emotional support, social interaction, and skills

training to reduce their own distress. Such emphasis on

partner (rather than veteran) outcome reflects a departure

from tradition. The effect of such spouse-focused treatment

on PTSD symptoms, relationship quality, and caregiver

burden remains to be tested. The group versus home-study

project (discussed above) will focus on enhancing spouses’

general coping skills and will measure outcome on symptoms,

relationship quality, and perceived burden.

As discussed earlier, the second broad category of

traditional PTSD-related family services is comprised of

systemic, relationship-focused services. The effectiveness of

family-wide interventions had not been empirically tested

among families with PTSD, but Riggs did find case studies

and unpublished dissertations supporting the effectiveness

of marital therapy. The treatment effects reported were

generally small, but changes on measures of global marital

satisfaction, and problem-solving communication were

   ! "#   
	

		

!



statistically significant. When surveyed, both spouses and

non-spouses in our sample expressed moderate interest in

such systemic treatments. Further study of these interventions

is encouraged.

Many questions remain to be answered. Our

preliminary data come from clinical groups. Families of

veterans not engaged in treatment had no opportunity to be

invited. Families who were unable to or chose not to attend

had no opportunity to have their views included. To assess

the needs of a broader population, we are using the present

findings to guide construction of a more detailed telephone

survey that will include both an urban (New Orleans, LA)

and a more rural (Jackson, MS) sample.

Based on what we have learned to date, we offer the

following recommendations to clinicians who are working

with traumatized patients:

 3" 
!#&

 
"
!#"#

"


"%#


&

 4   
 
 

!#"


  ! 
  #
"$

!#
"" 





&

 







&

 5 ! " 

6 



 "
7

"
   
8

##

&

 5"
"




""#
&

-"
$"
.
"!



!8

"
"


"!"
&


&8)*9,


!
#!




"

"


"
"
 
 # 
   !






8"!&

3


!






":'


"
&
"

%

!0

2

1"#



"
#&"
#"

:'6%*;8


3"

"

<
!+*=99*
5
&

References

*& &:&'
&4&2!&-&>
&

& )*?@A,&  
 " 
 

#
"B3
!


"
 7

&<

  3


!"!?/+=?%++C&

=& D
 '&3&"
-&&2
 <&3&
'&

E& <
4&D&:&'&-&&>

(!&3&)*??9,&


-



B'#






'7


!&F B

4


6:$&

+& &:&>"
&)*?@;,&!#
#


! #
  
 
  #%


"  & 
 & '& 2!)&,



 
B
"

!"



)##&C@%?;,&

F B4


6:$&

/& '&&4!
&3&-2&-&>E$4&&

)*??@,&G
!

#


 
B  "

#
"&<


"

**@C%*9*&

A& 4"  <&&E!4&E&>2
:&&)*??;,&

 


 #
  
 


  #
" & <

 






"!"!;/*9;@%*9C=&

;& 
&&3
.


#


#%
"


#
#!!

)"
#


##
##!,&H3"I'

/6;69*   E5 
 -

--B #B66&
"#&&

C& #7" <&  '&-& > 
! & D&)=999,&

"#
"
""





 

"


 4

 
 "
#&

<


"*+=9A%=*C&

@& -
<&&>D
$'&'&)
=999,&3



"
#
#
B!"
"


&


"J
!

?++%+A&

?& 4!
'&3&)*??@,3

!" 



8 #
 "


 "&<

 


"**A@?%A?;&

*9&  &  & >  & )*???,&

'8.#
),




"&!"":"
=?@9*%@**&

**& 3"=99*%99;)2&C=99*,&


"
&-

B


3

&

   ! "#   
 	

		

!


*=& 2

3&'
" '&#
"&(!&>E

&)=999,&
7

!


#
" 
 #



3B2"F*???"!


#
"&- 
 B #
 


3


&

*+& (!

&:&&'
#&2!&-&	

:&4.E&$(&(&E
(&4&2
(&

 <&&D$
<&-&><&)*???,&3

!#!

.#


 "% #
"  &

<






"!"!;C=/+%=A*&

*/& '&)=999,&:
!#!&
&4&2

&:& D
 >:& <&2
)&, "


  B "" 

  




"!
"
)##&

=@9%+9*,&  F B(
&

*A& 4"
&&E&-&

:

 <& J


 <& > 
 &)*???,&

'
"
"

%

#!""


""

##  "$#
& 4 <

 

!"!*C/A9A%A**&

*;& 4&&>
E&F&)*??A,&2"


"
##
##"#
&<



:

/*;/%*C=&

*C& (G
% D& 5& > 
 :& 4& )*???,& 


"


!
B



.#
"&!"""

A9 A=9%A=/&

Acknowledgments

The Jackson workshops were funded by a South Central

MIRECC grant to former Jackson PTSD team leader Mertis

Scott, F.N.P. Psychologist Jeffrey Kibler, Ph.D. will be

assisting Dr. Lyons with her MIRECC-funded comparison

of the home-study versus group skills training for spouses.

Psychologist Fred Sautter, Ph.D. coordinates the South

Central MIRECC PTSD work group and is leading

development of the phone survey that will further assess family

treatment needs and barriers to care.

For further information about the annual PTSD

conference, contact Karin Thompson, Ph.D., New Orleans

VA Medical Center, 504-568-0811 x5763,

karin.thompson@med.va.gov.

Leslie Root, Ph.D., is a clinical psychologist and has served as the director

of the PCT at the VA Gulf Coast Veterans Health Care System since 1994. For

the last three years, Dr. Root has collaborated with the University of Southern Mississippi (USM) History Department to connect students enrolled

in the History of the Vietnam War course

with Vietnam War veterans. She served as

 a mental health consultant to the first

USM-sponsored Vietnam War history study abroad course that

traveled in May 2000 to Vietnam with 16 students and three

Vietnam combat veterans. Current research interests include

PTSD family issues, the assessment of race-related trauma,

and the evaluation of a trauma-specific guided imagery intervention.

   ! "#   

Judith Lyons, Ph.D., is a clinical psychologist and associate professor at the VA

and University of Mississippi

medical centers in Jackson, MS. She is

coordinating the development of multisite studies of post-trauma family functioning for the South Central Mental Illness Research, Education and Clinical

Center (MIRECC). She also coordinates

disaster mental health services for the

 American Red Cross within Mississippi and

 for the Mississippi Psychological Association.

Judith Lyons, Ph.D.

Leslie Root, Ph.D.