Transcript An Integrative Approach to Therapy

An Integrative
Approach to Recovery
POTENTIAL FOR RECOVERY AND HEALING WITHIN A VETERAN’S FAMILY
DANIELLE CENTOFRANCHI, MA, LCSW
JUNE 14, 2016
Learning Objectives
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1. Clinicians will be able to identify the five roles family members or
loved ones adopt when there are issues of substance abuse in the
family & how to identify which type of communication is necessary
to address these roles in order to assist clients with restoring balance.
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2. Clinicians will integrate Cognitive Behavioral Therapy,
Motivational Interviewing and Seeking Safety to organize the family
or client’s difficulty with providing a healthy and supportive
environment for the Veteran trying to remain sober and thus, resolve
the family dynamic.
Physiological & Psychological Effects
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All branches are trained to be aware of and pay attention to every
single detail causing a state of consistent hypervigilance
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Military service is difficult, demanding, and dangerous
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The insurgency warfare and guerilla tactics characteristic of post
9/11 war zones are unprecedented and produce significant
consequences

Over 75% of post 9/11 injuries are results of explosions from
improvised explosive devices (IEDs), car bombs, and suicide bombs

TBI is the most common physical injury

Moral injuries include exposure to traumatic events, multiple
deployments, and unpredicted deployment length

Invisible injuries present cognitive, behavioral, and interpersonal
challenges
Consequences of Deployment
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Frequent relocations and an ever-present concern for the service
members well-being during deployment
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Military families move every 2-3 years, hindering a partner’s ability to
maintain a social network and achieve educational or career goals,
including any long term plans

Emotional impact on partner and children, who report being lonely,
anxious and depressed

78% of OEF/OIF veterans reported at least one family issue

25% report that their children are afraid of them
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40% felt like a guest in their own home
Impact of Deployment on a Family
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Service member’s children demonstrate more behavioral problems
in school and when with peers versus civilian children
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Partners experience increased psychological stress and decreased
psychological functioning
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Increased rates of child abuse, maltreatment, and neglect
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Higher divorce rates (statistically observed in the Army)
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The reorganization of roles within a family can be ambiguous and
anxiety-producing for children
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Injuries that cause prolonged hospitalization and rehabilitation limit
a parent's ability to effectively interact with his/her child(ren)
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The three most common deployment injuries include: TBI, PTSD, and
depression
Homecoming & Reintegration
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Service members must adjust to a drastically different environment,
daily schedule, and set of relationships that illicit new or different
emotions
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Struggle with the positive and negative stress of incorporating the
service member back in to the family
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Mourning the loss of who the service member was before
deployment and acclimating to who the service member is now

If physically injured, can result in impairments in parenting and family
function

Exposure to parental irritability, aggression, and hostility can increase
poor child adjustment leading to family disequilibrium
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Re-conditioning self back to a civilian and civilian way of life
Substance Misuse
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OEF/OIF veterans are facing an estimated co-occurrence rate of
between 25 and 50%
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In 1980 a study found that 74% of Vietnam Veterans with PTSD had
comorbid Substance Abuse Disorder (SUD)

Alcohol misuse, hazardous drinking, binge drinking, and abusing or
misusing prescription medications are common among OEF/OIF
veterans

Common causes of substance misuse/abuse include using it as a
way to self-medicate, to feel numb, to forget about the difficult
feelings and to erase the memories related to their experiences

Substances are used as an aid to cope with stressful or traumatic
events and to subdue mental health problems (sleep, anxiety,
depression)
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Reduces pain, lessens fatigue and help to cope with boredom or
panic that accompany battle
How to Support Veteran with SUD
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Family members should be mindful of behaviors by making
nonjudgmental statements, not reacting negatively to situations,
and by reducing the capacity for trauma-related triggers
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Understanding of psychological flexibility: the ability to fully
experience the present moment while engaging in behavior that is
consistent with chosen values even when the present moment
includes difficult emotions or thoughts
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Acceptance has been posited to be particularly appropriate for
service members and their partners because of the rigidity and
avoidance that typify PTSD
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Observe behavioral changes within family roles
6 Common Roles in Family with SUD
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Dependent or the alcoholic, substance user
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Enabler
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Hero
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Scapegoat
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Lost Child
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Mascot
Substance User/Dependent
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Experiencing emotional and/or physical pain, shame, and denial
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Loneliness
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Uses defenses to hide shame and guilt by acting irrationally angry,
charming, rigid, grandiose, perfect, socially withdrawn, hostile or
depressed
Enabler/Co-dependent/Caretaker
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Usually the spouse or significant other
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Will do anything and everything possible to make behaviors stop
(except what works)
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Rarely will they confront the dependent or leave the relationship
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Enabling is anything that protects the dependent from the
consequences of their actions, and this becomes habitual
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Tends to everyone’s needs in the family
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Loses sense of self in tasks of domestic nature
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Purpose is to maintain an appropriate appearance to the outside
world
Hero
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This is the person in the family who sees and hears what is
happening and takes responsibility for the family by becoming
successful and popular
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Often the oldest child
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Forms alliance with sober members of family
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Source of stability and dependability
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May compensate for dependent’s behaviors through over
achievement
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Feeling of responsibility to fix family’s pain
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Inner needs are rarely met because only receiving attention for
achievements
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Purpose is to raise family’s esteem
Scapegoat
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Goes against rules, acts out to take focus off dependent
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Feels hurt and guilt because of behavior
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Direct message is that they are responsible for the family’s chaos
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Child has issues with authority figures
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May show self-pity, strong identification with peer values, defiance
and hostility
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Inside they feel lonely, angry, and guilty
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Allows other a pretense of control, without it family would dismantle
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Purpose is to put the focus off the dependent, thereby allowing
them to continue using substances
Lost Child
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No connection to the family, difficulty learning communication and
relationship skills
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Much in common with scapegoat
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Observes more than is said
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Does not participate in activity of family
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Loners
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Isolated physically and psychologically
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Purpose is to prevent added demands on the family due to their low
maintenance
Mascot
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Usually the youngest in the family
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Conversations are usually superficial as deep meaningful
conversations can trigger pain and shame
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Make light of situation in order to relieve tension and gain parental
attention
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Immature
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Laughter prevents healing rather than produces it
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Purpose is to provide levity to the family and relieve stress and
tension by distracting everyone
Difference between Enabling &
Supporting
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Enabling looks like:
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Putting your own needs aside to care for the substance user
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Feeling resentful for taking on more than your share of
responsibilities
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Lying to others, especially yourself, about unacceptable
behavior
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Spending a lot of time focusing on fixing the substance user
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Bailing the substance user out of disasters they created
Difference between Enabling &
Supporting
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Supporting looks like:
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Establishing clear and consistent boundaries with what behaviors
are and are not acceptable from the substance user
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Utilizing appropriate consequences for negative or dangerous
behaviors
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Providing and encouraging substance user to obtain services for
their substance use
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Exploring options for self-care and self-help, including meetings
Evidenced Based Therapies
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Cognitive Processing Therapy
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Cognitive Behavioral Therapy
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Prolonged Exposure Therapy
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Eye Movement Desensitization and Reprocessing (EMDR)
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Motivational Interviewing
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Seeking Safety
Cognitive Processing Therapy
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CPT is a manualized 12-session, specific form of Cognitive Behavioral
Therapy (CBT) for PTSD that has a primary focus on cognitive
interventions
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Initial session of CPT is psychoeducational
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Clients are taught to identify the connection between events,
thoughts, and feelings and to practice this throughout assigned
homework
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Includes exposure to traumatic memory through writing and reading
accounts, with a focus on feelings, beliefs, and thoughts that
emanated from the traumatic event

Overgeneralized beliefs are challenged as they relate to self and
others
Cognitive Behavioral Therapy

CBT is goal directed and semi-structured therapy that involves a
partnership between the client and the therapist
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CBT focuses on exploring relationships among a person’s thoughts,
feelings, or behaviors
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Therapist works to uncover unhealthy patterns of thought and how
they may be causing self-destructive behaviors and beliefs
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Therapist works with client to develop constructive ways of thinking
that will produce healthier behaviors and beliefs
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Core principles are identifying negative or false beliefs and
restructuring them through use of homework in between sessions
Prolonged Exposure Therapy
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PE is an evidenced based, manualized protocol effective for the
treatment of PTSD
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PE is based in Emotional Processing Theory, which posits that PTSD
symptoms arise as a result of cognitive and behavioral avoidance of
trauma-related thoughts, reminders, activities and situations.
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PE helps the client interrupt and reverse the process by blocking
cognitive and behavioral avoidance, introducing corrective
information, and facilitating organization and processing of the
trauma memory and associated thoughts and beliefs
EMDR
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Eye Movement Desensitization and Reprocessing (EMDR) is an
integrative psychotherapy approach that has been proven
effective for the treatment of trauma
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Set of standardized protocols that incorporates elements from many
different treatment approaches; however, is a non traditional form
of therapy
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EMDR is an 8 phase treatment
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Involves attention to three time periods: past, present, and future
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The therapist moves his finger back and forth in front of your face
and asks you to follow these motions with your eyes while asking you
to recall a disturbing event, then gradually will guide you to shift
your thoughts to more pleasant ones
Motivational Interviewing
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MI works on facilitating and engaging intrinsic motivation within the
client in order to change negative behavior
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Goal oriented and client centered counseling
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Non-judgmental, non-confrontational, and non-adversarial
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Increases the client’s awareness of the potential problems caused,
consequences experienced, and risks faced as a result of the
change behavior
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Main goals are to engage clients, elicit change talk, and evoke
motivation to make positive changes from the client
Seeking Safety
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Seeking Safety is evidenced-based, present-focused counseling
modeled to help people attain safety from trauma and/or
substance abuse
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Directly addresses trauma/abuse without requiring clients to delve
into the trauma narrative
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25-week curriculum therapy, styled similar to Cognitive Behavioral
Therapy
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Focuses on grounding techniques, coping skills, and inner-self
talk/dialogue
Focusing on CBT, MI, and Seeking
Safety
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Interventions are statistically proven to reduce negative symptoms
of PTSD and SUD
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Encourage open-lines of communication with family members and
peers
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Explore use of self-talk and inner dialogue
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Promote effective and assertive communication skills
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Includes homework, handouts, and psychoeducational material
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Limit recount of trauma narrative
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Increase coping skills
Importance of Psychoeducation
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Psychoeducation is education offered to individuals or families with
a mental health condition to help empower them and deal
appropriately with their condition, yielding optimal results
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Patient training courses, family training courses, and parent training
courses are examples of psychoeducation
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The goal with psychoeducation is for the consumers to understand
the diagnosis and ways to effectively manage the situation
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Resources and coping skills are strengthened and used to
contribute to the family’s emotional health and well-being, in
addition to the client’s
Different Types of Communication
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Passive
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Aggressive
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Passive-Aggressive
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Assertive
Importance of Communicating
Assertively
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Allows the expression of clearly stated opinions and feelings
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Allows the advocacy of their rights and needs without violating the
rights of others
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Encourages high-self esteem
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Stems from emotional intelligence
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Promotes healthy boundaries
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Fundamental for positive mental health and healthy relationships
How MI, CBT, and Seeking Safety
Reinforce Assertive Communication
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MI teaches the client to feel comfortable with confrontation, feel
safe setting appropriate boundaries and limits, establishes credibility,
and encourages the use of appropriate self-disclosure
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CBT reinforces positive self-esteem, appropriate self-talk/internal
dialogue, and promotes healthy boundaries
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Seeking Safety teaches positive coping skills, effective grounding
techniques, and closure to traumatic events or experiences while
promoting safety
Why Include the Family into
Treatment?
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Post-deployment reintegration strengthens family relationships
through a shared sense of purpose
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Positive family reintegration is an important determinant of longterm psychological well-being
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Physical reunion does not always guarantee emotional
reconnection
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Gearing sessions to focus on shared meaning, committing to mutual
collaboration, and using open expression and assertive
communication helps to build resiliency and facilitate positive
growth
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Clinicians should focus on prevention, psychoeducation, behavioral
management and communication style
Resources
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Where to go when loved one is using substances?
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Where to go when you are using substances?
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Importance of appropriately trained staff aware of how to address
the military culture
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Credible and current provider list
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Point of contact at nearest VA Hospital
Contact Information
Danielle Centofranchi, MA, LCSW
[email protected]
Hopeforachange.org
(516) 987-7139