Case Formulation and Treatment Planning
Many veterans suffer from more than one mental health issue, such as posttraumatic stress disorder (PTSD), depression, anxiety, or alcohol abuse. Workforce research commissioned by DVA found that some professionals felt overwhelmed when faced with the challenge of prioritising for effective treatment. In response, DVA in conjunction with the Australian Centre for Posttraumatic Mental Health and FutureTrain Pty Ltd has developed Case Formulation, an online training program for mental health professionals.
The new Case Formulation online training program will help front line therapists to make better sense of complexity, and design and plan treatment in collaboration with their patient.
The online program assists providers to identify and focus on the presenting problems that are likely to have the most impact on recovery and help set priorities for treatment. The program explains the case formulation approach, and gives practitioners the opportunity to hear from experts, watch demonstrations of case formulation, and then practice case formulation based on veteran case studies.
The program offers mental health professionals skills in:
- Using a simple and practical model that considers presenting, predisposing, precipitating, prognostic and perpetuating factors;
- Organising information gathered during assessment and identifying any further need for assessment
- Developing hypotheses about factors that impact on a client’s distress and mental and physical health problems on a day-to-day basis, and using these to inform treatment planning;
- Using a functional analysis technique to assist with assessment, case formulation and treatment planning; selecting treatment targets and evidence-based interventions and sequencing interventions for complex cases; and
- Working collaboratively with clients on case formulation and treatment planning.
The program is free, interactive and engaging, and provides easy to use practical tools to assist with learning and adoption of case formulation, and additional resources to help their work with veterans.
The Case Formulation program can be accessed from DVA’s At Ease Professional web site. Completion of the course can be done over time, with progress automatically bookmarked on exit. On completion, providers can print a certificate in order to claim Continuing Professional Development points as per the requirements of their professional association.
For further information on Case Formulation and other veteran mental health related education programs, please go to www.at-ease.dva.gov.au/professionals/professional-development
Challenging Wounded Warriors
Evidence suggests that adaptive sports and recreation activities can help to build resilience and promote reintegration following injury. Psychological and physiological benefits include increased endurance, a decrease in depression, improvements in self-perception, and higher ratings of quality of life.
Soldiers have sometimes been referred to as ‘tactical athletes’, and most participate in sport as part of their physical training. A systematic review of the use of sport and physical activity for wounded military personnel found enhanced subjective well-being through active coping, PTSD symptom reduction, positive mood effects, and improved quality of life. Impact on psychological well-being included determination, focus on ability, broadening of horizons, improved self-concept, sense of achievement and social well-being.
The United States Marine Corps Wounded Warrior Trials are a Paralympic-style invitational event held inCalifornia. In March, this year, two young Australian veterans, Michael Clarke and Warren Guse-Ware, joined a small Australian Defence Force (ADF) contingent to participate in the Trials. The Trials comprise two teams of marines, one of Marine veterans and an Allies team of ten countries who served in Afghanistan or Iraq.
Michael and Warren had survived severe injuries from an explosion whilst serving in Afghanistan, and completed rehabilitation after extensive surgery. Both were medically discharged from the ADF and their treatment is ongoing four years later, and neither had participated in competitive sport or vigorous training since their injuries.
The Trials provided an opportunity to further the rehabilitation of minds, bodies, and spirits through intensive training, competition and camaraderie and are a chance to focus on abilities, not disabilities.Warrendescribed it as “focussing on what we could do, rather than what we couldn’t.”
World class coaches intensively prepared the athletes for their events. All participants competed in three sports, with Michael and Warren electing to compete in cycling, shooting and swimming. Other Australians entered archery, track and field, sitting volleyball and wheelchair basketball.
Both veterans appreciated competitive shooting, but it was road cycling that challenged previous clinical advice ‘not to push it’ or ‘take risks’. Both performed well in the race, but especially relished the group training and the competitive nature of the Trials.
In the swimming races the Michael and Warren formed half of the gold medal winning Allies team in the marquee final event, the 4x50m relay, and Michael also won three individual medals. They, and the Allies team, were ecstatic with their performances. Both were mentally and physically exhausted by the demands of intensive training and competition.
Did such demanding participation have an impact on Michael and Warren’s functional independence, physical fitness or self esteem? Immediately after it did: “Motivation, fitness, confidence to be able to finish. I haven’t had … a reason to finish anything”, said Michael, adding “it wasn’t about the medals… it was about having a crack.”
Whether this immediate effect will have a longer lasting impact on Michael andWarren’s recovery is yet to be assessed. In coming months DVA will again talk to Michael and Warren to establish whether such a short but intensive challenge can have longer term effects in younger veterans.
DVA offers the Heart Health program to assist veterans to increase their physical health and wellbeing through practical exercise, nutrition and lifestyle management support over a 12 month period. Heart Health has been found to improve older veterans’ sense of control and PTSD symptom management.
How clinicians can use the ON TRACK with The Right Mix app
The ON TRACK with The Right Mix phone app is a useful tool for serving and ex‑serving Australian Defence Force (ADF) personnel who may have concerns about high-risk alcohol consumption. The app has several features which make it ideal for use as a complement to formal treatment.
The app has been developed in consultation with serving and ex-serving personnel as well as health clinicians, with functionality to help users and clinicians better understand a client’s drinking behaviour:
1) Users can track their alcohol consumption in real time or add drinks retrospectively, entering their consumption and spending at a more suitable time without compromising the data. This retrospective function is extremely useful if users stop using the app while drinking or don’t want to use the app while in public.
2) Users can also view their drinking behaviours in a graphical display which can help them learn about the impact of their drinking behaviour over time. This may also help users and clinicians understand which time periods the client is most susceptible to risky drinking behaviour, thereby helping to identify triggers to this behaviour.
3) The app calculates how much exercise is required to burn off the alcohol kilojoules users have consumed. This was identified as a major motivator for current serving personnel who are required to undergo regular fitness tests.
4) Finally, all data collected by the app can be emailed to a clinician as an adjunct to treatment.
Together, the features in the ON TRACK app offers treating clinicians a greater insight into their patient’s drinking behaviour than may be possible with a traditional paper drinks diary, particularly with younger clients more accustomed with technology.
Note: Some features of this app may not be accessible on earlier model iOS and Android phones
At Ease goes mobile
The Department of Veterans’ Affairs has released a mobile-friendly version of the At Ease website making it easier to view on smart phones and tablets.
The Game On: Exploring the Impact of Technologies on Young Men’s Mental Health & Wellbeing research found that young men who reported higher levels of psychological distress were more likely to access health information on the internet. DVA’s own research has found that more than half of the visitors to the At Ease website are doing so via mobile devices. The release of a mobile version of At Ease increases the avenues serving and ex-serving members and their families can access information about mental health.
At Ease Mobile is a simplified version of the full website and focuses on information more likely to be needed by current or ex-serving ADF personnel while on the go. The mobile site features include:
- Recognise the Signs. If users are worried about how they’re feeling, what they’re doing, or are struggling with everyday life, they can follow the prompts to source advice on whether what they are experiencing is of concern.
- Take Action. This section offers self-help tools and advice across a range of mental health issues. Families can also find advice on how to keep their family healthy while caring for someone with a mental health condition.
- Find Support. Users can access urgent help and professional support in-service and in the community.
- Real Stories. Normalising mental health is important and DVA has a collection of personal stories from serving and ex-serving personnel, including videos.
- Mobile Apps. DVA has a collection of mobile apps including PTSD Coach Australia and ON TRACK with The Right Mix, with more in development.
The website address for At Ease Veterans is www.at-ease.dva.gov.au. Those using a mobile device will be automatically directed to the mobile website.
Latest research from the United States National Centre for Posttraumatic Stress Disorder
Gender plays important role in age-related differences in PTSD symptoms
Epidemiological studies suggest that PTSD is less common among older than younger adults and that symptoms are less severe among older adults with PTSD. New data fromNationalCenterfor PTSD investigators show that age differences in PTSD are not the same in men and women. Investigators used baseline data from two large PTSD treatment trials with Veterans; one study enrolled women (n = 284) and the other enrolled men (n = 360). In both trials, older Veterans (age 60+) reported symptoms that were either equal to or less severe than symptoms reported by younger Veterans, depending on the symptom cluster—but men and women had different pat-terns. Older men had lower overall PTSD and numbing symptoms than younger men on the CAPS. Men’s scores on the PTSD Checklist, a self-report measure, showed similar age differences in numbing symptoms, but not in overall PTSD. The only age difference within the female sample was lower hyperarousal on the CAPS among older women.
There are several potential explanations for the observed age differences: there may be true differences in PTSD symptoms across the lifespan, clinicians may under diagnose PTSD symptoms in older patients, and older patients may underreport some symptoms. Regardless of the cause, this study indicates that age is only part of the story. Broad generalizations about age differences in PTSD symptoms should be avoided, given that the nature of these differences seems to vary by gender. For the full article please go to http://www.ptsd.va.gov/professional/articles/article-pdf/id42063.pdf
Lunney, C. A., Schnurr, P. P., & Cook, J. M. (2014), Comparison of clinician- and self-assessments of posttraumatic stress symptoms in older versus younger Veterans. Journal of Traumatic Stress. Advance online publication. PILOTS ID: 42063
CBT for Insomnia improves sleep for patients with PTSD
Sleep problems often do not remit after first-line PTSD treatment yet sleep medications may be contraindicated for many patients with PTSD. Cognitive Behavioural Therapy for Insomnia (CBT-I), an evidence-based approach, has been examined in individuals with PTSD but only in conjunction with nightmare imagery rehearsal. A study led by investigators from theSan FranciscoVAis the first to examine stand-alone CBT-I among individuals with PTSD. The investigators randomly allocated 45 male and female veterans and civilians with chronic PTSD and insomnia to 8 weeks of CBT-I or a waitlist assessment-only group. All participants were currently in psychotherapy or on a stable dose of antidepressant medications. Compared with waitlist, CBT-I led to greater improvements at post-treatment and 6-month follow-up in self-reported sleep outcomes, a sleep diary, and polysomnography. The percentage of participants with remitted insomnia after CBT-I (41%) was similar to that found in a trial of CBT-I among individuals without psychiatric comorbidities. CBT-I did not improve PTSD symptoms and its effect on nightmares was mixed; the treatment outperformed waitlist on a general measure of sleep disturbances that included nightmares but not on the CAPS nightmare item. CBT-I appears to be a good nonpharmacological option for individuals with PTSD. For the full article please go to http://www.ptsd.va.gov/professional/articles/article-pdf/id42060.pdf
Talbot, L. S., Maguen, S., Metzler, T. J., Schmitz, M., McCaslin, S. E., Richards, A., Neylan, T. C. (2014). Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: A randomized controlled trial. Sleep, 37, 327-341. P
 Cooper, R.A. 2013. Adaptive Sports and Recreation Promote Resilience and Reintegration. Presented at session Force Sustainment: Rehabilitation, Regeneration and Prosthetics for re-integration to duty, of NATO Science and Technology Organisation Symposium, Human Factors and Medicine Panel. Milan.
 Caddick, N. and Smith, B. 2014 The impact of sport and physical activity on the well-being of combat veterans: A systematic review. Psychology of Sport and Exercise. 15(1): 9-18
 Otter L, Currie J. A long time getting home: Vietnam Veterans’ experiences in a community exercise rehabilitation programme. Disabil Rehabil. 2004;26:27–34.
 Burns, JM, Davenport, TA, Christensen, H, Luscombe, GM, Mendoza, JA, Bresnan, A, Blanchard, ME & Hickie, IB, 2013, Game On: Exploring the Impact of Technologies on Young Men’s Mental Health and Wellbeing. Findings from the first Young and Well National Survey. Young and Well Cooperative Research Centre,Melbourne.Burns, JM