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7. Associated complaints
 
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7. Associated complaints
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About associated complaints

There is a range of complaints that are often associated with common mental health problems in veterans or in their own right. Practitioners should be aware of such problems when assessing veterans’ mental health.  

Problematic anger

About problematic anger

Problematic anger and aggression are common problems for veterans and present a potential risk to others, yet there is limited evidence-based information available for practitioners. While problematic anger is not in itself an accepted diagnosable condition, it is a commonly reported presenting problem of veterans from Australia and the United States. For example, just over one in ten US veterans of Iraq and Afghanistan report having problems controlling violent behaviour (Elbogen et al., 2010). The anger may well be treated as part of interventions for other disorders, such as PTSD or depression, but there may also be some benefit in using interventions specifically designed to address anger. The following recommendations are based on the available literature on evidence-based interventions for problematic anger among veterans and other populations (Moreland et al., 2012).

Screening and assessment

There are a range of key questions that GPs and mental health care practitioners can ask to identify the severity of problematic anger in veterans, and to screen for risk of aggression and harm to others. Practitioners should be mindful to consider the possibility of violence to loved ones and others. Some useful screening questions for problematic anger include:

  • Do you find that you are often bothered by feelings of anger?
  • Does your anger interfere with your mood, relationships, work or physical health?
  • Are there times when you feel so angry that you have thoughts of harming someone?

If the veteran answers ‘yes’ to the final question, screen for risk of harm to others with questions such as:

  • What is it you have thoughts of doing and to whom?
  • Do you have access to ... (check means and opportunity to use guns or other potentially lethal implements)?
  • Have there been times in the past when you have become so angry that you have harmed someone? If so, what happened?

A useful tool for assessing the presence and severity of anger in veterans is the Dimensions of Anger Reactions 5 scale (DAR5; Hawthorne, Mouthaan, Forbes, & Novaco, 2006). In a more complete assessment of anger, practitioners should:

  • identify key triggers and cues to anger and the extent of the veteran’s anger responses
  • investigate the chronicity and pattern of poorly controlled anger
  • identify vulnerabilities to anger, including:
    • intoxication and withdrawal from alcohol and/or drugs
    • acquired head injury from physical trauma
    • alcohol dependence or overdose
  • identify key people related to anger (i.e., who is the anger directed towards, or who is present when anger occurs)
  • assess a veteran’s social network to help identify people who are likely to play an important role in treatment
  • take a history of all forms of violence, including injuries to others and road rage, and make an appraisal of the veteran's potential to engage in violence
  • explore the veteran’s legal position, including existing orders and charges pending
  • assess the veteran’s ability to keep his or her partner and family safe from physical violence
  • seek the veteran’s agreement to ongoing monitoring of progress and practitioner contact with family members.

The assessment of anger needs to be part of a broader assessment of mental health problems. Identification of any untreated mental health disorder (such as depression, PTSD, panic disorder or alcohol misuse) may not preclude participation in anger-specific treatment, although treatment of these primary mental health disorders may address the anger problem.

Include partners and family in assessment

Ideally, where problematic anger and aggression are likely to be present, the assessment process should include a session including the veteran’s partner and, where appropriate, other family members. Wherever possible, the veteran’s consent to family members being interviewed should be obtained. Whether the veteran provides consent or not, it is recommended that at least one assessment session should be undertaken with family members without the veteran present, to ensure that safety concerns of family members are identified. It may be necessary to negotiate that family members are seen by another practitioner or service if the veteran does not wish his or her own practitioner to see them. The important principle here is that the practitioner maintains responsibility to also address the family’s safety needs and risk of harm. The family assessment may act as another source of information about the veteran's current and past levels of violence, readiness to change and violence potential. Joint sessions with the family and the veteran should only be conducted where the partner and children feel safe in the counselling session and at home following the session. Practitioners may consider combined sessions, after separate assessments, provided the following criteria are met:

  • the couple is choosing to remain together
  • the veteran’s partner expresses a wish to participate
  • there is no history of severe violence
  • violence is not severe enough to elicit substantial fear in the partner
  • both members of the couple acknowledge aggression or violence is a problem (where aggression or violence is present)
  • the partner’s mental or emotional state is sufficiently stable
  • the partner possesses adequate support resources
  • a safety plan for partners and family has been established (Campbell, 2001; O'Leary, 2001).

The interventions outlined in this chapter are not suitable for veterans engaging in violence where anger is not a significant feature of the presentation, but should be managed according to the current principles for the prevention of family violence. For example, anger management does not adequately address issues of power and control that are the main feature of most family violence presentations. Referral options for practitioners not experienced in family violence are provided at the end of this section.  

Treatment of problematic anger

Therapeutic alliance

Therapeutic alliance is a significant factor contributing to beneficial treatment outcomes. This is particularly pertinent here as veterans with anger problems often have difficulty forming a working alliance with therapists. For example, therapists and veterans may fail to agree on the goals of therapy. Therapists may want to address a veteran’s anger, but the veteran may want to focus on changing the behaviour of the targets of their anger or getting revenge. In addition, in the context of posttraumatic presentations, the information processing bias towards threat detection may result in the therapist being perceived as a threat, and the veteran’s attendance at treatment prematurely terminated. Problems in establishing or maintaining the therapeutic alliance have the potential to reduce the benefits of treatment and may result in the treatment being terminated prematurely. For posttraumatic populations, presentation of the ‘survivor mode’ model of bias toward threat detection may be helpful in pre-empting threats to the alliance. Problematic anger differs somewhat from other mental health problems in that a veteran may be slower to recognise the problem and less receptive to treatment. Veterans with problematic anger are more likely to present to treatment at the behest of others, rather than through self-recognition of their own distress and difficulties. Therefore, there is a greater emphasis on education for problematic anger as it helps to build the case to the veteran on the need for treatment. In this way, the veteran is more likely to recognise the problem and its impact, and be motivated to address it.

Psychoeducation and self-management strategies

The education phase of the treatment is critical for establishing a therapeutic alliance through personal validation, empathy and addressing motivation for change. Adopting a collaborative approach based on mutual respect when working with veterans with problematic anger is important. Essential components of education include:

  • monitoring of anger frequency, intensity or duration, preferably recorded in a diary
  • identification of anger cues and triggers
  • identification of contextual factors that influence anger
  • discussion of the individual's anger response in terms of physiological arousal, cognitive and behavioural components.

Education may also address the following:

  • Costs of anger – help the veteran to see the problems caused by dysfunctional anger and the likely benefits of anger management, both in the short and long term.
  • The potential impact of military training on the development of the anger response. Part 1 provides useful background information for this discussion. Other useful material on this topic can be sourced from VVCS - Veterans and Veterans Families Counselling Service.
  • Other causes of anger. For example, the introduction of concepts such as the ‘survivor mode’ of functioning can be helpful. This view proposes that anger in posttraumatic presentations is intrinsically linked to the perception of threat and to survival needs, and that threat perception and anger are reciprocally influenced (Novaco & Chemtob, 2002).
  • The potential impact of community attitudes towards a given conflict, particularly for veterans of Vietnam, Iraq, and Afghanistan. See Part 1 for more information on community attitudes and the homecoming experience.

Psychological interventions

Interventions addressing anger should be based on a CBT model and typically include the following elements:

  • Arousal management – Breathing techniques, progressive muscle relaxation, and distraction techniques help the veteran to recognise and manage the physiological arousal associated with anger.
  • Cognitive therapy – People with anger problems do not often process information accurately and are likely to appraise relatively benign situations as threatening. Treatment needs to address faulty attribution and evaluation styles, and assist the veteran to develop ways of challenging those thinking styles. Cognitive interventions for anger and anger-related aggression should also identify and address core beliefs about gender, and explore where and how these beliefs are related to the presence of abuse and violence.
  • Self-instruction training – This helps the veteran to identify the stages of their anger reaction, such as preparation prior to entering the anger-provoking situation, coping with encountering the situation and evaluating the aftermath of the situation. The veteran learns a series of statements that act to control the negative affect in the situation and that can be rehearsed to prepare for the event and used in managing reactions after the event.
  • Imaginal exposure – In anxiety disorders, exposure is maintained with the expectation that habituation will occur and the level of anxiety be reduced over time as the person learns that the situation or image is not dangerous. In anger, maintaining exposure can sometimes exacerbate the problem. Exposure in anger should include assisting the veteran to imagine anger-triggering events and practicing skills of anger management in response. As the anger reaction emerges, techniques of relaxation and breathing retraining are used along with self-instructions that act to defuse the anger. Situations are re-evoked until the veteran is able to imaginally manage each situation effectively. People or aspects of each situation that influence the level of anger experienced are also identified, to assist the veteran to manage the imaginal exposure.
  • Behavioural techniques – People with anger problems often have difficulties identifying alternative strategies for solving problems, especially interpersonal problems, without resorting to aggressive behaviour. Therefore, specific skills training in problem solving, social skills, communication skills, assertion techniques, and negotiation and conflict resolution, need to be incorporated. ‘Short circuit’ techniques, such as time-out and time management, should also be discussed. These interventions can be introduced later in the treatment program after the veteran has developed more effective anger management skills.

Psychological treatment setting and duration

Problematic anger can usually be treated in an outpatient setting. There is currently insufficient evidence to recommend an optimal duration of psychological treatment.

Pharmacological interventions

Anger and resulting aggression can present as primary problems or they can be seen as symptomatic of other conditions. It is important to assess the situation carefully in order to guide effective use of psychotropic medications that may be beneficial. Anger and aggression can occur in the context of:

  • mood disorders
  • anxiety disorders
  • PTSD
  • chronic pain
  • psychosis
  • brain injury and/or cognitive impairment.

It follows that effective medical treatment of these conditions will reduce the severity of abnormal anger and associated aggression. Impulsive aggression has been shown to improve with treatments including lithium and various anticonvulsant medicines. Dysregulation of the serotonin system has been demonstrated in some studies, possibly explaining the role of selective serotonin reuptake inhibitor (SSRI) antidepressants in improving anger symptoms even when anger occurs in the absence of other common mental health problems (Kamarck et al., 2009).  

Referral and coordinated care for problematic anger 

  • VVCS - Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours on 1800 011 046. (www.vvcs.gov.au)
  • Psychiatrist: For specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at http://www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
  • Family violence prevention programs: A list can be found at www.relationships.org.au/what-we-do/services/family-violence-prevention.
  • A treatment plan should be developed collaboratively with the veteran and where appropriate, their family, and coordinated across service providers.
  • Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).

 

Self-management resources for problematic anger

  • Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
  • MensLine Australia is a professional telephone and online support, information and referral service, helping men to deal with relationship problems in a practical and effective way. They can be contacted 24 hours a day on 1300 78 99 78, and have useful information on their website: www.mensline.org.au.
  • Other useful websites include the Australian Psychological Society (www.psychology.org.au) and mindhealthconnect (www.mindhealthconnect.org.au).
  • The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.

 

Practitioner resources for problematic anger

  • Kassinove, H. & Tafrate, R.C. (2002). Anger management: The complete treatment guide for practitioners. Atascadero, California: Impact Publishers.
  • O’Leary, K.D. (2001). Conjoint therapy for partners who engage in physically aggressive behavior: Rationale and research. Journal of Aggression, Maltreatment and Trauma, 5, 145–164.

 

Insomnia

About insomnia

Most people will experience periods of sleep disturbance at some stage of their lives, and disturbed sleep is common among veterans. Usually, sleep disturbance will last for less than three weeks. These short-term sleep difficulties could be caused by illness, stress, increased caffeine intake or other changes in diet. Some people, however, will have more long-lasting difficulty in initiating or maintaining sleep, or will have chronic non-restorative sleep, indicating they may have insomnia. People with insomnia may also show a decline in social, occupational or other areas of functioning, and may report cognitive impairments such as attention or memory problems, mood disturbance such as irritability, or behavioural problems including hyperactivity or aggression. Note that the presence of hyperactivity may mean that insomnia clients do not appear tired, despite subjective reports of sleepiness. Scant evidence exists about the prevalence of insomnia, although one Australian study reported a prevalence of approximately five per cent in the general practice client population (Knox, Harrison, Britt, & Henderson, 2008). Given the increasing proportion of women in younger veteran cohorts, it is worth keeping in mind that females are more likely to suffer from insomnia than males (Zhang & Wing, 2006). It should be noted that sleep problems are often related to other mental health conditions (such as depression, anxiety or PTSD), substance misuse and general medical conditions (such as sleep apnoea or pain). Therefore, it is important to screen for these disorders if chronic sleep problems are detected. For veterans, sleep problems may also stem from military experiences. There may be a lingering impact of disturbed sleep routines resulting from prolonged periods of sentry or ‘picket’ duty shifts during the night. Veterans may have frequent nightmares related to military experiences, or hypervigilance may have a negative impact on the sleep process.

Screening and assessment

Insomnia is both a common and complex condition. Medical treatment, therefore, should always be based on a thorough assessment that includes detailed history, physical examination and in some instances, medical investigations. The assessment should also clarify the consequences of insomnia for a veteran’s functioning and quality of life. Useful questions to ask the veteran include:

  • Do you have any problems with your sleep?
  • How many hours of sleep do you usually get at night?

Screening questions should include investigations of early, middle and late-onset insomnia. For early-onset insomnia:

  • Do you have difficulty getting off to sleep at night?
  • How long does it take to fall asleep?

For middle-onset insomnia:

  • Do you wake in the middle of the night?
  • How many times do you wake?
  • How long does it take to fall back asleep?

For late-onset insomnia:

  • Do you wake early in the morning and have trouble going back to sleep?

Asking the veteran to keep a sleep diary for about a week can assist with the assessment process. Useful things to include in the sleep diary include time of retiring to bed and wake-up, time taken to fall asleep, number of awakenings during the night, total time spent awake in bed, and level of fatigue during the day. Further physical investigations of sleep problems such as suspected sleep apnoea can be conducted by sleep centres or clinics.  

Treatment of insomnia

Self-management strategies encouraged by a GP are the recommended first-line intervention for insomnia. However, if the insomnia persists after the veteran has implemented self-management strategies, it may be necessary to consider more formal interventions.

Psychoeducation and self-management strategies

Practitioners can advise veterans on a number of sleep hygiene strategies that may allow them to manage their sleep difficulties that are common to many disorders. Practitioners should:

  • reassure the veteran that most people have difficulty sleeping at some time in their lives, and that for the majority it is only temporary
  • assist the veteran to resolve, if possible, a specific problem that is contributing to the insomnia, and where necessary, refer for psychological treatment
  • discourage the use of sleeping tablets if other methods have not yet been tried
  • provide education about the principles of good sleep habits.

These strategies are based on the premise that sleep problems can be developed and/or maintained by a series of problems or habits inherently disruptive to sleep. Sleep hygiene techniques seek to re-establish sleep promoting behaviours. Key features of sleep hygiene include:

  • establishing an appropriate sleep environment — insulate the bedroom against outside noises and to block out light, and keep the room at an even temperature
  • removing from the bedroom stimuli not associated with sleep
  • reducing the time spent in bed worrying about sleep or other matters — keep a notebook next to the bed for jotting down any thoughts that come to mind for the next day, then let them go
  • avoiding alcohol, caffeine and nicotine in the late afternoon and evening
  • exercising regularly - late in the afternoon or early in the evening.

An important component of sleep hygiene is stimulus control; encourage the veteran to:

  • go to bed only when sleepy
  • limit bedtime activities to sleep and sex
  • wait for sleep for 15-20 minutes
  • get up if they do not fall asleep
  • go to another room
  • stay up until they begin to feel sleepy
  • only then go back to bed
  • repeat this process as often as they need to fall asleep
  • get up at the same time each morning, no matter how long they have slept
  • do not have naps during the day.

Psychological interventions 

In the event that insomnia does not respond to self-management strategies and more formal intervention is required, CBT is the recommended approach (Cunnington, Junge & Fernando, 2013; Okajima, Komada & Inoue, 2011). It is designed to assist clients in developing healthy sleep habits through a range of behavioural interventions and in challenging the negative thoughts or cognitions that can play a role in maintaining and perpetuating sleep disturbance. CBT may include the following components:

  • Sleep hygiene and stimulus control strategies - These strategies include removing stimuli from the bedroom that is not related to sleep, avoiding caffeine, and ensuring that the bed is only associated with sleep. Refer to the ‘Psychoeducation and self-management strategies’ box above for further strategies.
  • Cognitive therapy – This is important as negative thoughts or cognitions can play a role in maintaining and perpetuating sleep disturbance. For example, the veteran may have worrying thoughts around the feared consequences about the loss of sleep and unrealistic expectations about how much sleep is actually required.

Psychological treatment setting and duration

Insomnia can usually be treated in an outpatient setting. There is currently insufficient evidence to recommend an optimal duration of psychological treatment.

Pharmacological interventions

Pharmacotherapy for insomnia should not be used in isolation, but should be part of a range of interventions, including standard sleep hygiene measures and psychological treatments. If medication is considered necessary, non-benzodiazepine hypnotic agents such as zolpidem (e.g., Stilnox) and zopiclone (e.g., Imovane) are the preferred first-line agents. These are preferred as they have a cleaner profile of action, and do not have anxiolytic, muscle relaxant or anticonvulsant properties. They are less likely to distort normal sleep architecture or to cause rebound insomnia or withdrawal syndromes than benzodiazepines. Benzodiazepine hypnotics are problematic because of the potential for tolerance and dependency, residual daytime cognitive impairment, interference with motor function and association with confusional states and falls in the elderly. Longer-acting more potent agents such as nitrazepam (e.g., Alodorm) and flunitrazepam (e.g., Hypnodorm) should be avoided for these reasons. When other agents such as antihistamines and sedating antidepressants are used for their hypnotic effects, the broader array of potential side effects must be considered and balanced against the desired benefits. As a general principle, short-term use (less than four weeks) is preferable when using hypnotic medication as this helps to prevent many potential complications. Longer-term use may be required if stopping the medication leads to greater impairment of the veteran’s quality of life, and if all other treatments for insomnia have proven unsuccessful. In the longer-term situations, intermittent use is preferable to continuous use. Withdrawal from long-term use should always be tapered slowly.  

Referral and coordinated care for insomnia

  • VVCS - Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours on 1800 011 046. (www.vvcs.gov.au)
  • Psychiatrist: For specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
  • Sleep clinics or centres are another referral option for detailed investigation and treatment of some sleep disorders. Many sleep clinics and specialists can be found at www.sleep.org.au/informaton/sleep-services-directory.
  • A treatment plan should be developed collaboratively with the veteran and their family, and coordinated across service providers.
  • Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).

 

Self-management resources for insomnia

  • Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
  • The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.
  • Information on managing sleep difficulties is available from the Sleep Health Foundation (www.sleephealthfoundation.org.au) and through the Sleep Better without Drugs program (www.sleepbetter.com.au).

 

Practitioner resources for insomnia

  • Australasian Sleep Association (www.sleep.org.au) has information for health professionals on a range of sleep disorders, links to other useful websites, and a service directory of sleep clinics and specialists.

 

Problem gambling

About problem gambling

In Australia, the term problem gambling is used to refer to a condition when an individual has difficulties limiting the money and/or time spent gambling, which then leads to negative consequences for them, their family/friends and community (Neal, Delfabbro, & O'Neill, 2005). Problem gambling is also characterised by the individual’s struggle to control gambling impulses despite adverse consequences in other areas of life. According to research conducted with Vietnam veterans, problem gambling appears to be slightly more common in veterans than in the general community, with an estimated prevalence of around four per cent compared to one to two per cent. A small but increasing body of evidence has identified a higher prevalence of problem gambling in people with mental health problems (Lorains, Cowlishaw, & Thomas, 2011), and this is also the case for veterans (Biddle, Hawthorne, Forbes, & Coman, 2005; Edens & Rosenheck, 2012). Again, the comorbidity rates of gambling and mental health problems in veterans appear comparable with those of community samples more generally.

Screening and assessment

Practitioners are advised to screen and assess for problem gambling in veterans with mental health problems. A one-item screen recommended in the current Australian guidelines (Problem Gambling Research and Treatment Centre (PGTRC), 2011) is:

  • Have you ever had an issue with your gambling?

If the veteran answers ‘yes’ to this question, further assessment of his or her gambling habits is recommended. A number of screening tools are available to assess the presence and severity of problem gambling. Scales that have been tested and validated in the Australian context include:

  • Canadian Problem Gambling Index[2](CPGI), and its abbreviated form, the Problem Gambling Severity Index (PGSI) (Ferris & Wayne, 2001).
  • Victorian Gambling Screen (VGS; Ben-Tovim, Esterman, Tolchard, and Battersby, 2001).

 

Treatment of problem gambling

Psychological interventions

Cognitive behavioural therapy (CBT) is the recommended psychological treatment to reduce gambling behaviour, gambling severity and psychological distress in people with gambling problems (PGTRC, 2011). Practitioner delivered CBT may include some or all of the following elements:

  • Motivational interviewing – These techniques are used to increase the veteran’s readiness for making changes to their gambling behaviours.
  • Cognitive therapy – This is designed to challenge and modify any cognitive errors related to gambling (e.g., misunderstanding of randomness and the odds of winning).
  • Identification of triggers and high-risk situations for gambling, and coping strategies to use in these situations.
  • Exposure therapy – This includes techniques such as imaginal desensitisation, in vivo exposure and response prevention.
  • Activity scheduling – This encourages the veteran to schedule enjoyable activities as an alternative to gambling.

Psychoeducation and self-management strategies

It is useful for the practitioner to provide information on problem gambling and encourage the client to use self-management strategies while undergoing more targeted treatment. For example, the practitioner can:

  • Discuss the problem gambling in a non-judgemental and non-threatening manner, and listen carefully to the veteran’s reactions and concerns.
  • Advise the veteran about the degree of risk and consequences associated with his or her gambling. Refer him or her to information that dispels the myths related to gambling, e.g., odds of winning, how pokies work (www.gamblinghelponline.org.au). Ask the veteran to outline the benefits and costs of continuing to gamble at the current level.
  • Help set goals that are realistic and involve a reduction or elimination of gambling.
  • Discuss and help implement strategies to reduce gambling. The veteran may have already used some strategies with success. Begin with his or her suggestions then add others.

Psychological treatment setting and duration

Problem gambling can usually be treated in an outpatient setting. There is currently insufficient evidence to recommend an optimal duration of psychological treatment, or to suggest whether therapy is best delivered in a group or individual format.

Pharmacological interventions

There has been little research investigating the effectiveness of pharmacological interventions in the treatment of gambling problems. However, some evidence supports the use of the opioid antagonist naltrexone to reduce gambling severity (The Problem Gambling Research and Treatment Centre, 2011). At this time, naltrexone use for problem gambling is not subsidised by the Pharmaceutical Benefits Scheme (PBS).  

Referral and coordinated care for problem gambling

  • Gambling Help provides free face-to-face gambling counselling throughout Australia. They also provide financial counselling. Refer to their website for information on service locations: www.gamblinghelponline.org.au, and/or call 1800 858 858 for referral information.
  • VVCS - Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours a day on 1800 011 046.
  • Psychiatrist: For specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
  • A treatment plan should be developed collaboratively with the veteran and their family, and coordinated across service providers.
  • Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).

 

Self-management resources for problem gambling

  • Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS. (www.vvcs.gov.au)
  • Gambling Help provides confidential online, telephone and face-to-face counselling. The website also contains useful information for people with gambling issues and their families. They can be contacted 24 hours a day on 1800 858 858 or on their website: www.gamblinghelponline.org.au.
  • The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.

 

Practitioner resources for problem gambling

  • Problem Gambling Research and Treatment Centre (PGTRC). (2011). Guideline for screening, assessment and treatment in problem gambling. Clayton: Monash University.
  • Biddle, D., Hawthorne, G., Forbes, D. and Coman, G. (2005). Problem gambling in Australian PTSD treatment-seeking veterans. Journal of Traumatic Stress, 18, 759–869.
  • Raylu, N. & Oei, T.P. (2010). A cognitive behavioural therapy programme for problem gambling: Therapist manual. Sussex: Routledge.

This Advice Book has the following resources in the appendices that may be useful for veterans who are experiencing these associated complaints:

  • further explanation of CBT elements (Appendix B)
  • psychoeducation handouts on each topic for the veteran and general psychoeducation script outline (Appendix D & Appendix L)
  • self-monitoring sheets including a distress thermometer (SUDS) and daily activity schedule (Appendix E)
  • pleasant events list (Appendix F)
  • progressive muscle relaxation (Appendix G)
  • breathing retraining instructions (Appendix H)
  • information on where veterans can get more help, e.g., Veterans Line, DVA funded psychological and rehabilitation services (Appendix J).

The DVD that accompanies this Advice Book includes material relevant to problematic anger. Specifically, it includes an assessment of violence and a functional analysis that is conducted just prior to a behavioural intervention.