Treating Traumatic Stress Injuries in Military Personnel

An EMDR Practitioner's Guide

Mark C. Russell, Charles R. Figley

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415889773
• eBook ISBN: 9781136817328
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Treating Traumatic Stress Injuries in Military Personnel offers a comprehensive treatment manual for mental health professionals treating traumatic stress injuries in both male and female veterans. It is the first book to combine the most recent knowledge about new paradigms of combat-related traumatic stress injuries (Figley & Nash, 2006) and offers a practical guide for treating the spectrum of traumatic stress injuries with EMDR, which has been recognized by the Department of Veterans Affairs and Department of Defense clinical practice guidelines as one of the most studied, efficient, and particularly well-suited evidence-based treatments for military-related stress injuries.

Russell and Figley introduce an array of treatment innovations designed especially for use with military populations, and readers will find pages filled with practical information, including appendices that feature a glossary of military terminology, breakdowns of rank and pay grades, and various clinical forms.

Section II

The EMDR Protocol
for Military Populations

5 Phase One:
Client History, Rapport, and
Treatment Planning

The first of eight phases in EMDR therapy is by far the most critical. In working with military clients, there are many prominent considerations that the provider must remain cognizant of that we will describe below. In many respects, the successful negotiation of Phase One will make or break treatment. Phase One involves establishing trust and rapport while obtaining a comprehensive client history that is comprised of the standard clinical intake and discussing the all-too-important limits of confidentiality, which is especially meaningful for military populations, as well as screening for suitability of EMDR and developing a treatment plan by identifying past, present, and future experiential contributors of the client’s current symptoms. However, before focusing on EMDR suitability and case formulation, practitioners will likely want to prepare themselves for working with military clients.

THERAPIST PREPARATION FOR WORKING WITH MILITARY CLIENTELE

Stepping into the therapeutic setting is likely to be experienced by a majority of military personnel as part of a deployment to a threat-rich foreign land. Here are some ways that practitioners can build some credibility and trust in preparation for working with military clients:

• Develop an understanding of issues related to the entire deployment cycle, as well as experiences and exposures that America’s most recent combat veterans have undergone in an effort to recognize the connection between certain health effects and military service;

• Become familiar with and anticipate common military stressors and occupational hazards associated with the warrior class other than war and combat;

• Become familiar with military culture, including military ranks and the difference between Active, National Guard, and Reserve components (see http://www.defenselink.mil/specials/insignias/);

• Understand ethical and legal considerations specific to military personnel, particularly around limits of confidentiality and mandated reporting;

• Be acquainted with the nuances of military culture and values, including norms of high standards of self-discipline, the warrior ethos of loyalty and self-sacrifice, military customs and etiquette, the emphasis on group cohesion and esprit de corps that connects service members to each other, and mental health mistrust, stigma, and barriers to care;

• Compile a resource listing with contact information for crisis management options with uniformed personnel in particular, as well as referral information for base or clinic hospital emergency department, pastoral care, substance abuse treatment, family counseling and support centers, sexual assault prevention and program coordinator, family advocacy programs, and warrior transition services offered at nearby military installations;

• Review treatment resources that are available in the DoD, including eligibility criteria to join the TRICARE provider network (see www.tricare.mil);

• Develop partnerships with medical, mental health, and other support staff at nearby military installations, especially Family Readiness Groups and Warrior Transition programs (see www.nationalresourcedirectory.org);

• Learn about the spectrum of war stress injuries, including TBI;

• Become knowledgeable of the Accelerated Informational Processing (AIP) model underlying EMDR therapy and how it relates to the full spectrum of war stress injuries (see Shapiro, 2001), including medically unexplained conditions (see Chapter 9, this volume);

• Obtain copies of free brochures and fact sheets available on the websites of VA National Center for PTSD (see www.ncptsd.gov), Center for Deployment Psychology (www.cdp.mil), and the DoD’s Centers of Excellence for Psychological Health and Traumatic Brain Injury (see www.dcoe.health.mil), which provide critical updates and resources for both the healer and warrior classes;

• Complete the No-Cost, National Center of PTSD “PTSD 101” Web-Based Course. This DVA course is also open to any non-VA or DoD practitioners and awards 10 CE (see www.ncptsd.va.gov).

Establishing a Client-Centered Therapeutic Alliance in Military Culture

It is paramount that the therapist’s initial focus is squarely on building rapport and a trusting relationship with the military member. In doing so, the practitioner should adopt a client-centered perspective—the natural therapeutic stance in EMDR—by taking time to learn what the client’s concerns, needs, and goals are and by offering practical solutions when appropriate.

Clinical Skills that Enhance Therapeutic Alliance: (a) accurate empathy; (b) demonstrating that (c) the therapist cares about the client; (d) genuine, honest, and respectful demeanor; (e) communicating a clear case conceptualization that makes sense to the client; (f) pacing of interventions to client readiness; (g) cultural sensitivity and appropriateness; (h) willingness and ability to repair client experience of mis-attunement; and (i) at a minimum, the need to assure sufficient alliance to be confident of current and accurate reporting of client symptoms and treatment response.

THE FIRST MEETING AND CLINICAL INTAKE

The first meeting with military clients typically involves a number of standard clinical practices, some of which should be universal, and others determined by the therapist’s background and reason for referral. Such issues as client–therapist introductions, reviewing the reason for referral, informed consent of the limits of confidentiality, completion of standard clinical intake forms, and clinical interviewing and mental status exams are fairly routine across mental health care settings.

Client–Therapist Introduction

Generally speaking, it would be an accurate assumption and worth anticipating that many but not all military clients will present to a mental health appointment as quite anxious, ambivalent, tense, skeptical, frustrated, mistrustful, defensive, and, at times, even antagonistic. They may also be quite respectful, pleasant, at-ease, soft-spoken, and enthusiastic, but still with a level of mistrust. The military client’s comfort level and degree of openness to the clinical interview will be influenced by the reason for referral, as well as the possible ramifications of evaluation and treatment services in the context of critical issues like confidentiality and career implications. Needless to say, the clinician should strive to reassure the client of confidentiality and begin to establish trust as early as possible. The clinician will want to inquire whether or not this is the service member’s first-ever contact with a mental health provider, as in many cases it will be, and the client’s knowledge of therapy may be limited to popular stereotypes. For example, in some military circles, mental health providers are called “wizards,” not so much due to their magical curative abilities but to the notion that they can make service members “disappear” from military service by virtue of their diagnostic conclusions. This is an unnerving proposition for any career-minded service member.

REFERRAL QUESTION AND INITIAL TIMING CONSIDERATIONS FOR EMDR

The most clinically salient and important issues to clarify for treatment planning purposes are the reason for referral, limits of confidentiality, therapist role expectations, and desired outcomes. The reason for referral provides the therapist critical information regarding who is concerned about the client’s behavior, ethical implications in regards to confidentiality and potential ramifications for the client, and what is the expected outcome of the referral. In addition, the referral question offers essential information in regards to identifying potential timing issues related to determining the suitability for EMDR treatment in general, or the need to incorporate modifications of the standard EMDR protocol in the treatment plan. For instance, if the client and therapist are forward-deployed and the referral is for symptom reduction or stabilization, or the client is about to deploy or PCS transfer in three weeks, or the client is asking for performance enhancing strategies to perform well on an upcoming deployment, or the JAG officer informs you the client will be testifying about a military sexual trauma they experienced—all of these scenarios depict common timing considerations for developing a treatment plan that we will get back to later.

Informed Consent and Limits of Confidentiality

Immediately after introductions, the practitioner should next inform all military clientele, including their family members, of the limits of confidentiality and solicit the client’s understanding for the reason and expected outcome of the referral, if it originated outside of the client(s). To establish trust and avoid the appearance of collusion, the therapist should openly acknowledge receiving the referral and/or speaking to specific referral sources about the client. In the military, limitations of client privacy and confidentiality of therapy records are very much similar in the civilian sector. For example, adherence to HIPAA and legal mandates for disclosure to prevent imminent harm to self, others, or gross incapacitation apply with military populations; however, for military personnel there are other unique ethical and legal quandaries that often emerge. Regardless, the practitioner must provide military clients full disclosure of the limitations of confidential in regards to any assessment or treatment services.

Earning the Trust of Military Clients

It cannot be stressed enough how critically important it is for therapists to be knowledgeable and able to accurately communicate to military clientele issues around the referral question, limits of confidentiality, and access to evaluation and treatment records. An unprepared therapist who cannot adequately articulate confidentiality limitations and how external requests for information will be handled, will almost certainly be perceived as a threat by military personnel, and should not be trusted. Many service members with war-stress injury have experienced relationship difficulties after exposure to trauma. They often report that they have problems trusting, are suspicious of authority, dislike even minor annoyances, and generally want to be left alone. They also usually have not slept well, are fatigued, and generally do not feel healthy or that they have any control of their mind and body. Since the therapist–client alliance depends on the establishment of trust, respect, and openness, and since subsequently the relationship often is developed in a hectic clinical setting, the therapist might encounter a client to be withholding, negativistic, irritable, or even hostile at the initial meeting. The client may seem to have “an attitude,” or “Axis II” co-morbidity. As a result, many combat veterans feel misunderstood or misdiagnosed by otherwise competent professionals. The following is adapted from the DVA/DoD (2010) guidelines regarding establishing therapeutic alliance with military clientele:

• Adopt a stance of caring and concerned involvement that takes what the client says at face value and doesn’t judge or label this type of behavior;

• Try to avoid withdrawing into an “objective,” “professional” role;

• Relate honestly and openly is more likely to have a client who is willing to relate to him/her as a fellow human being and an effective partner in treatment;

• Develop a general understanding of what has happened to the veteran is critical in this process of developing a therapeutic relationship;

• Read some basic material on the experience of combat and watch documentaries of the same;

• Develop an understanding that wartime and military service involves some of the most intense human experiences and that those feelings of profound rage, fear, and grief can be an expected part of these experiences;

• These feelings will be present in the interview setting and must be met with respect and compassion;

• Be careful not to assume an understanding of the military experience if they have not themselves served in the military;

• Do not hesitate to ask questions when not understanding something about the military that the client is referring to.

Importance of Confidentiality in the Military Population

It is imperative that the therapist understand the stark differences in terms of how confidentiality is managed with military personnel, their family members, and civilian DoD personnel. Moreover, clinicians should be well grounded as to how military client confidentiality concerns relate to mental health stigma and barriers of care. In short, there are many instances where military commands have a “need to know” and therefore have access to military personnel medical records to fulfill their responsibility and duty to protect the welfare of their unit members and the military mission. In addition, many military specialties require medical (psychiatric) certification of “fitness for duty” to carry out their assigned duties, and it again falls on the back of the individual’s CO or Commander to ensure that their personnel of “fit for full duty.” Consequently, there is tremendous pressure on military members and leaders to ensure “military readiness,” another way of saying “fitness for duty.” Having a major psychological diagnosis other than maybe an Adjustment Disorder or non-clinical problems of living or DSM “V-code” (e.g., occupational problem, partner-relational problem) is in many cases considered outright disqualifying for certain military duties regardless of degree of severity (e.g., mild), such as: (a) carrying a firearm (deployed personnel, military police, security personnel, etc.); (b) piloting an aircraft (helicopter or fixed-wing); and (c) maintaining top-secret and above security clearance.

Being diagnosed and/or treated for any major psychological condition, especially if there is evidence of modest to severe functional impairment and/or strong likelihood of relapse or exacerbation of symptoms in an operational environment, can result in “unfitness” and ineligibility for: (a) deployment to warzone; (b) deployment to patrol zones; (c) military training exercises; (d) operation of military motor or armored vehicles; (e) handling ordnance; (f) permanent change of station transfer, particularly overseas duty stations; (g) accessibility to sensitive or classified information; (h) independent military assignments; and (i) military recruiter, drill instructor, or embassy guard assignments.

Military Career Ramifications, Stigma, and Barriers to Seeking Mental Health

Therapists should understand that when military members are found “unfit” for full duty and restricted from performing either one’s basic assigned duties (e.g., an EOD specialist who cannot be around ordnance) to deploy, train, or accept orders to future prohibitive assignments, for any reason (medical/mental health), the concern is that their “down-time” will translate to lower annual job performance evaluations (or Fitness Reports) when compared to peers without such limitations. Every year military personnel are ranked by their Commanding Officer/Commander (Army) along various desirable traits (e.g., leadership, mission accomplishment, military bearing, etc.). These evaluations also include the relative of ranking of the service member in terms of promotion recommendations. Being found “unfit for duty” typically will mean lower performance marks compared to their peers that can have a dramatic impact on career promotions and possibly prevent military retirement. This feeds the realistic fear of stigma and presents a barrier to seeking care that may or may not be justified. Military members can be determined unfit for duty for short periods to receive treatment (called “Limited Duty Board”), which may not have any impact on the annual evaluations as long as they are performing well at their jobs and not missing deployment. Moreover, most service members diagnosed and treated for a mental health condition are not formally placed on a Limited Duty Status, and, as long as they don’t have a sensitive job as described above (e.g., pilot), their mental health treatment will not likely impact them in any manner. Still the fears will be there, and the therapist should discuss them with the client. We will give an example later.

Therapist C...

Table of contents

• Cover Page
• Half Title page
• Series
• Title Page
• Copyright Page
• Dedication
• Contents
• Series Editor’s Foreword
• Foreword
• Acknowledgments
• Introduction
• EMDR Treatment of Military Populations
• Warriors, War, and Resilience The Warrior Class
• Overview of EMDR Therapy
• Research on EMDR and War Stress Injury
• Why Use EMDR Therapy in the Armed Services?
• The EMDR Protocol for Military Populations
• Phase One Client History, Rapport, and Treatment Planning
• Phase Two Client Preparation and Informed Consent
• Phase Three EMDR Assessment
• Phase Four Basic and Specialized Reprocessing Protocols
• Phases Five–Six Standard Reprocessing Protocols
• EMDR Treatment for Acute War/Traumatic Stress Injury
• EMDR Treatment for Chronic War/Traumatic Stress Injury
• EMDR Therapy of Pre-Military and Military Trauma and Medically Unexplained Symptoms
• EMDR Treatment of Traumatic Grief and Interpersonal Violence
• Other Military Stress Injury and EMDR Treatment Considerations
• Phases Seven–Eight Closure and Reevaluation
• Special Considerations
• Ethical and Medico-Legal Issues
• Enhancing Resilience/Performance and Preventing Compassion Stress Injury
• Appendix A Military Mental Health Referral Resources
• Appendix b EMDR Reprocessing Troubleshooting Guide
• Appendix C References
• Index