Does War Zone Impact Treatment Response for Veterans with PTSD?

Back when I was a psychology intern at the Portland VA Medical Center, the majority of the veterans I worked with were Vietnam era. Veterans from the wars in Afghanistan and Iraq were trickling in, but were not a large presence yet. I’ve heard that’s changed in the last few years, and the Veteran’s hospitals are serving increasing numbers of younger vets.

A new study by Yoder and colleagues looks at whether there’s a difference among veterans in response to treatment for PTSD. The treatment is Prolonged Exposure (PE) therapy, an empirically-supported exposure-based therapy for PTSD. The study compares veterans of Vietnam, the Gulf War, and what are known as OEF (i.e., “Operation Enduring Freedom” aka the war in Afghanistan), OIF (i.e., “Operation Iraqi Freedom”), and OND (i.e., “Operation New Dawn” coined to indicate the shift from combat to stabilization in Iraq).

What Did They Look At?

Conducted at the VA Hospital in Charleston, SC, the researchers used archival data to test their hypotheses. What this means is that the study was not originally designed to answer the questions posed. This in itself is not a problem, but it means that the results should be taken with a bit more caution until replicated.

The study looked at veterans who completed PE for PTSD. There were 112 participants total: 61 OEF/OIF/OND; 34 Vietnam; and 17 Gulf War. Veterans were treated by one of three therapists using PE.

Gulf War Veterans May Respond More Slowly to Treatment

Overall, veterans improved with treatment regardless of war background. Interestingly, Gulf War veterans responded less well to PE than Vietnam and OEF/OIF/OND veterans even though all showed comparable scores of PTSD and depressive symptoms prior to treatment. Gulf War veterans were slower to respond to therapy.

Why did Gulf War veterans respond different? The researchers aren’t sure. What they suggest is that:

“It may be due to population differences related to variable stress-diathesis selection processes for chronic fear experiences versus acute types of trauma or to variable self-selection pressures and concurrent treatment seeking behaviors that may vary in some important, though unmeasured, ways among war-zone cohorts.” (p. 8)

This is just a long-winded, gobbledygook way of saying: We don’t know. Maybe Gulf War veterans are different.

My Thoughts

The good news is that veterans seem to respond well to PE for PTSD regardless of war. Why Gulf War veterans responded more slowly to treatment may be a fluke. I also wasn’t clear whether the researchers statistically accounted for this or not, but given that there were fewer of Gulf War veterans (n = 17) compared to Vietnam (n = 34), and OEF/OIF/OND (n = 61), it’s possible that the results may be skewed by a few Gulf War veterans who were poor responders to treatment (aka outliers).

For these reasons, I’d wait until the results are replicated with another sample before we can say with any confidence that Gulf War veterans may respond differently to treatment.

• PTSD

Rape Survivors Who Rely on Avoidant Coping May Respond Better to Exposure-Based Treatment

One of the hardest things to predict in psychotherapy is how well someone will respond to a particular treatment. A brief report in an upcoming issue of Journal of Consulting and Clinical Psychology by Leiner and colleagues offers some insight into this question. The researchers look at the impact of avoidant coping on PTSD treatment.

What’s Avoidant Coping?

As defined in this article, avoidant coping involves attempts to reduce or block out distress and discomfort. Although not directly referenced in this article, there’s an interesting research literature that suggests avoidance behaviors may maintain PTSD symptoms over time, and that reliance on these strategies is related to greater PTSD symptom severity above and beyond the severity of the original trauma (see Batten, Follette, & Aban, 2001; Polusny & Follette, 1995; Rosenthal, Hall, Palm, Batten, & Follette, 2005). Not wanting to engage painful memories and triggers is very natural, but it may exacerbate and prolong posttraumatic stress symptoms in the long run.

What the Researchers Found

The researchers used data from a previous study comparing Prolonged Exposure (PE) therapy and Eye Movement Desensitization and Reprocessing (EMDR) for adult women rape survivors with PTSD. Both PE and EMDR are exposure-based treatments. (Some EMDR proponents would object to being classified as exposure-based treatments, but that’s another debate entirely.)

The researchers found that greater use of avoidant coping strategies at pretreatment was related to lower PTSD severity after treatment. The researchers then divided up the sample according to greater and lesser scores on a measure of avoidant coping (i.e., Coping Strategies Inventory – Disengagement subscale). They found that women who scored higher in avoidant coping were much more likely to respond to treatment. Conversely, women with lower scores in avoidant coping were less likely to respond to treatment.

What Does This Mean?

The results make sense conceptually. Exposure-based therapists structure treatment so that clients safely and collaboratively confront memories and triggers they typically avoid. Although it makes sense that people with greater avoidance benefit from a treatment that focuses on confronting the avoided experiences, I find it comforting that there doesn’t appear to be a ceiling effect. That is, the researchers didn’t find that too much avoidance negatively impacted treatment.

The study leaves me with the following questions: What about women with PTSD who are low in avoidant coping? Is there another treatment that works better for them? This remains unanswered.

It also makes me wonder what other variables might be important in predicting response to treatment in PTSD. After all, avoidant coping is only one variable. There may be others that are also important. Nevertheless, this is important work that could have real-world implications for therapists who are trying to figure out who may benefit most from exposure-based treatment for PTSD. Although it’s too early to say definitively, these findings suggest that clients who are relatively more avoidant may be the best candidates for exposure therapy.

• exposure therapy
• PTSD

Getting Unstuck Part 5: Continuing to Build the Map (a.k.a., the Functional Analysis)

My last blog post continued the discussion of creating road maps as part of Community Reinforcement and Family Training (CRAFT).  Briefly, CRAFT trains family members of people with addiction how to non-confrontationally change their loved ones’ use, and to build a life not centered on their loved one’s addiction. A road map (a.k.a., a functional analysis) is an assessment of the triggers and consequences of the addicted person’s substance use.  In my last post I focused on the behavior column of the Functional Analysis Form. In this post I’d like to focus on the column titled “Short-Term Positive Consequences.”

Finding out What You and the Family Member are Up Against:  Positive Effects of Use

It’s probably not surprising to most of us, but it bears mentioning that using drugs and alcohol has positive effects for the person who is using. In addition to the pleasurable physical sensations (or the removal of unpleasurable sensations), substance use can have numerous other positive effects, such as friendships with others who use and engagement or enhancement of activities. By identifying the positives of substance use you can help the family member find non-using activities that offer similar rewards and can compete with substance use. In a sense, understanding the rewards of substance use can help you and the family member form a strategy to more effectively combat it.   

It’s probably not surprising to most of us, but it bears mentioning that using drugs and alcohol has positive effects for the person who is using. In addition to the pleasurable physical sensations (or the removal of unpleasurable sensations), substance use can have numerous other positive effects, such as friendships with others who use and engagement or enhancement of activities. By identifying the positives of substance use you can help the family member find non-using activities that offer similar rewards and can compete with substance use. In a sense, understanding the rewards of substance use can help you and the family member form a strategy to more effectively combat it.   

The column contains 6 questions:  3 questions address what the person likes about the context of their use (with whom, where, when) and 3 questions address the internal effects the person enjoys about their use (pleasant thoughts, emotions, physical sensations). I’ll go through each of the questions and provide an example to illustrate the type of information you’re looking to obtain.

• What does your loved one like about drinking [with whom]? Help the family member explore what his/her loved one enjoys about drinking with the people he/she typically drinks with. If the loved one drinks alone, what does he/she like about drinking alone?  

o   Example:  Sue (the same Sue from previous posts on CRAFT) typically drinks by herself after she arrives home from work. Her partner, Joe, believes that Sue enjoys drinking alone because it gives her a chance to unwind and reflect on her day without the pressure of having “to be on.” 

• What do you think he/she likes about drinking/ using [where]?  

o   Example:  Sue drinks at home, typically in the home office. Joe notices that when she drinks in the home office she has little to no interaction with their children. Additionally, the home office is quiet and allows Sue a chance to watch shows she enjoys or to reconnect with friends through email. Joe thinks Sue likes drinking in the home office because it’s quiet, allows her to have some “me time,” and offers a way to connect with others on her terms (no face-to-face interactions). 

• What do you think he/she likes about drinking/ using [when]? 

o   Example:  Sue typically drinks during the evenings after work. Specifically, she drinks as soon as she arrives home (between 6 and 7) and until she goes to bed (11 or midnight). Joe believes that Sue likes drinking in the evenings because it doesn’t interfere with her work (although Joe believes that her hangovers the next day are impacting her work) and she has fewer responsibilities to attend to during the evenings. 

• What pleasant thoughts do you think he/she has while drinking/using? With this question and the following 2 questions, you may have to help the family member connect the perspective of his/her loved one. Family members most likely have seen their loved ones under the influence on many occasions, so they probably have a good idea of what their family members are thinking about when they are under the influence. They most likely have heard their loved ones express certain things or discuss particular topics; these may be clues to what their loved ones are thinking about when they are using. 

o   Example:  Based on Sue’s communications with him over several years, Joe believes that Sue often thinks about their life prior to having children and when she was working at a different company. Joe thinks that Sue often reflects on the good times and relationships she formed during that time in her life. 

• What pleasant emotions do you think he/she has when drinking/ using?

o   Example:  Sue often appears more relaxed (or at least less stressed) when she is drinking. She also laughs more and makes jokes. Joe assumes that Sue feels relaxed and maybe even happy when she is drinking. 

• What physical sensations do you think he/she has while drinking/ using?

o   Example:  Because Sue appears more relaxed and sometimes happy, Joe believes that Sue feels less tense in her body, particularly in her back and shoulders where she tends to carry tension.

Well, that’s it for the short-term positive consequences column! Based on the information obtained in the functional analysis, you and the family member can begin to brainstorm non-using activities that may help the loved one gain some of the positives he/she receives from using. With Sue, for example, Joe may offer non-using activities that are relaxing such as offering to draw her bath when she comes home or scheduling her a massage right after work. These activities serve the same function as drinking (e.g., relaxation) without actually drinking. In my next blog post, I’ll describe how to complete the remaining column of the Functional Analysis Form.

• addiction
• CRAFT

Using ACT to target internalized homophobia and self-stigma

Many of our clients struggle with shame and stigma. Despite its prevalence in the therapy room, there are few clinical interventions that specifically target self stigma,  defined here as “negative thoughts and feelings (e.g., shame, negative self-evaluative thoughts, fear) that emerge from identification with a stigmatized group” (p. 48, Luoma, O’Hair, Kohlenberg, Hayes, & Fletcher, 2010). This is an issue that we at Portland Psychotherapy are exploring, both in our clinical work and in the research we are conducting. We currently have several research projects underway, looking at various aspects of stigma and shame, how they impact functioning, and ways to target stigma and shame inside and outside the therapy office.

For these reasons, I was very interested in a recent article in Cognitive and Behavioral Practice by Yadavaia & Hayestitled “Acceptance and Commitment Therapy for Self-Stigma Around Sexual Orientation: A Multiple Baseline Evaluation.”  In the article, the authors report on the effectiveness of a brief (6-10 session) ACT intervention for self stigma in those who experience same sex attraction-- sometimes referred to as internalized homophobia. While the ACT intervention in the study was individualized to each participant, similar to standard clinical practice, all 6 of the basic ACT processes were covered and expert ratings of treatment integrity were high.

The study found that participants evidenced positive changes on a variety of factors including self stigma/internalized homophobia, depression, anxiety, quality of life, perceived social support, and overall psychological flexibility. What I found to be most significant was that while participants reported a decrease in the believability of same-sex thoughts, the frequency of those thoughts did not change. This finding is consistent with previous studies using ACT to target other psychological difficulties (e.g. Bach & Hayes, 2002) and appears to support an ACT-consistent mechanism of change. In ACT, it is the workability of a thought in terms of valued action, rather than the form of the thought that is targeted. As such, we would expect, and this study did indeed find, that the frequency or even the form, of particular thoughts would not necessarily change significantly, but rather that change is found in the function that thought serves. It other words, after the intervention, participants continued to still have the same same-sex thoughts, but they were much less troubled by the thought.

Previous studies have supported the use ACT to target other forms of self-stigma, including those who struggle with substance use problems (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008) and obesity (Lillis, Hayes, & Bunting, 2009). Although power was limited because of the small sample size  (n=5), the pattern of findings in this study were consistent with previous findings and suggests that ACT may be an effective intervention for individuals who struggle with self-stigma related to sexual attraction and sexual orientation.

• ACT
• Self-Stigma

Changing PTSD Criteria for the DSM-5

As a member of the Anxiety Disorders Association of America (ADAA), I receive their monthly journal Depression and Anxiety. The September issue—I know this post is a little late, it got caught up in editing—features an article on changes that are being considered for diagnosing PTSD in the upcoming DSM-5. It’s not certain that the proposed changes will make it in there, but they provide some interest food for thought.

What Causes PTSD?

PTSD is pretty unique among diagnoses in that the definition requires an external event (criterion A) that other diagnoses—such as depression and other forms of anxiety—do not. There is no posttraumatic stress disorder without a trauma. But what counts as a trauma?

People such as Harvard’s Richard McNally have criticized the current parameters of what can be considered a traumatic antecedent as being too broad. Some of this controversy came out of 9-11, where people were diagnosed with PTSD after seeing news footage of the collapse of World Trade Center, even though they didn’t know anyone who died or were endangered. Anthropologist Allan Young called this “PTSD of the virtual kind” (quoted in McNally, 2009). The point of this is not to diminish the impact of people’s subjective experiences; rather, that a definition that runs the spectrum from rape, torture, and combat violence all the way seeing something distressing on TV may not be clinically useful.

The authors of the proposed DSM-5 revision tighten up the definition and limit criterion A events to those involving threat of harm or death that are either witnessed by the individual or involve a close relative or friend. Additionally, they cut out entirely the second component—that the person experience “fear, helplessness, or horror.” The authors suggest that this second part is not clinically useful.

Expanding Symptom Clusters from Three to Four

Currently, the DSM clusters PTSD symptoms according to three categories: Re-experiencing (e.g., memories, nightmares, flashbacks); avoidant/numbing (e.g., avoiding internal/external reminders, psychic numbing); and hyperarousal (e.g., easily startled, hypervigilant). By contrast, the authors of this article expand the total number of symptoms from 17 to 20, and they categorize them according to four clusters.

The newly added symptoms are “erroneous self- or other-blame regarding the trauma,” “negative mood states,” and “reckless and maladaptive behavior.” I have no problem with the addition of negative mood states, and I think incorporating reckless and maladaptive behavior helps to capture aspects of PTSD that are often exhibited in military veterans.

I’m concerned, however, with the entire notion of “erroneous” beliefs. This is part of the new symptom category, “Alterations in Cognitions and Mood,” which puts more of a cognitive therapy spin on the diagnostic criteria. I find the word “erroneous” troubling, as it places the therapist in the role of deciding what’s realistic and what’s not. This is a problem I have with cognitive therapy, in general, so I’ll admit my bias here. And in fairness to the authors, they have obviously thought deeply about this change and cite their reasoning. Nonetheless, the label strikes me as less descriptive and more evaluative.

Additionally, the DSM in general tends to draw an imaginary and arbitrary line between thinking and feelings. For example, the new suggestions recast “detachment from others” as “Feeling [italics mine] of detachment or estrangement from others.” The use of the word “feeling” seems imprecise, as it’s impossible to imagine this experience except as filtered through thinking. For example, a dog may feel fear, but I doubt it ever feels estranged from others. This imprecision in the use of language is hardly unique to the PTSD, but pervades the DSM, unfortunately.

What About Complex PTSD?

Coined by psychiatrist Judith Herman, there’s a growing faction of people such as Bessel van der Kolk clamoring for the inclusion of Complex PTSD aka Disorders of Extreme Stress Not Otherwise Specified. They argue that the current definition of PTSD fails to describe victims of severe and prolonged abuse (e.g., some childhood sexual abuse survivors or tortured political refugees). These survivors demonstrate complex clinical pictures which may include features that overlap with borderline personality disorder and dissociative disorders. The authors examined the available research and concluded that there’s not enough evidence to include complex PTSD as a separate disorder. I think this is a reasonable position, and at the very least, provides motivation for advocates to refine their research, which is a little sparse to date.

Final Thoughts

It’s impossible to predict which of these suggestions will make it into the next edition of the DSM. The authors take pains to state that their suggestions remain speculative and should be subjected to further inquiry. At the very least, this article provides a wonderfully concise summary of current PTSD research, and I highly recommend anyone interested in trauma check it out.

Reference:

Friedman, M.J., Resick, P.A., Bryant, R.A., & Brewin, C.R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28(9), 750-769.

• PTSD

Getting Unstuck Part 4: Continuing to Build the Map (a.k.a., the Functional Analysis)

My last blog post continued the discussion of creating road maps as part of Community Reinforcement and Family Training (CRAFT).  Briefly, CRAFT trains family members of people with addiction how to non-confrontationally change their loved ones’ use, and to build a life not centered on their loved one’s addiction. Briefly, a road map (a.k.a., a functional analysis) is an assessment of the triggers and consequences of the addicted person’s substance use.  In my last post I focused on the trigger columns (external triggers and internal triggers) of the Functional Analysis Form. In this post I’d like to focus on the behavior column of the form. I think it can be easy to overlook the behavior column because the information seems too simple or not that interesting clinically; however, the behavior column can give you valuable and surprising information!

Don’t Overlook the Behavior Column!

Based on the information you obtain from this section, you can get an idea of the severity of the loved one’s use, an important determinant for treatment recommendations. Additionally, the column includes targets for short-term interventions for the client. For example, if a loved one is drinking a lot of alcohol on a daily basis,  short-term interventions should focus more on decreasing alcohol consumption and/or getting the loved one into detox than on having the loved one stop drinking entirely. This information can also alert you to the pattern of the loved one’s drinking, which can help you and the family member tailor the CRAFT techniques to better address the loved one’s use and to increase the probability that the techniques will be effective.

Most importantly, use it to empower the family member! Family members possess a wealth of information about their loved one’s use and can use that information to help decrease use and/or move them towards entering treatment. Even if the loved one is using in secret, family members often have a good idea of how much he/she is using and can detect the changes in their loved ones’ use.

The Nitty Gritty:  How to Complete the Behavior Column

The column contains 3 questions:  what, how much, and how long. I’ll go through each of the questions and provide an example to illustrate the type of information you’re looking to obtain.

• What does your loved one normally drink/ use? The loved one doesn’t have to be an addictions specialist—you just need enough information to get a good idea of the pattern of use.
  • Example:  Sue (the same Sue from previous posts on CRAFT) typically drinks vodka martinis and scotch neat (i.e., no ice).

Not a ton of detail, but enough to for the therapist to be aware that Sue may be consuming more alcohol than the actual number of drinks would suggest. How did I come to that conclusion? First, martinis often contain more alcohol than drinks that are mixed with non-alcoholic mixers. Second, Sue drinks her scotch neat—this suggests Sue may be consuming more alcohol than people who drink scotch with ice or who add water.

• How much? This includes amount per use and use per day/week/month.
  •  Example:  Sue drinks 3 martinis in standard martini glasses. She also drinks 2 scotches neat; her pour is about ¼ of an 8 oz. glass (No need for family members to own a set of beakers—they can estimate).

It’s important to attend to not only the size of the glass or container, but how much alcohol is poured into a glass. For people using drugs, you can ask about the number of joints, bowls, pills, lines, etc. You can also estimate by size (e.g., the length and the height of a typical line of cocaine—like a pixie stick candy tube, for example). Again, you want enough detail to get an understanding of the loved one’s pattern of use, but you don’t need the level of detail a of DEA agent.

• Over how long a period of time? This question gives you a sense of the pattern. Does the loved one binge drink (e.g., 5 or more drinks in 2 hours)? Does the loved use throughout the day? The answers to these questions will assess not only the severity of use, but also offer some potential times to intervene.
  • Example:  Sue typically drinks during the evenings after work; specifically, as soon as she arrives home (between 6 and 7) and until she goes to bed (11 or midnight). Sue appears to be drinking 12 to 16 standard drinks over 4 – 6 hours (1 standard drink = 12 oz. of beer, 8 oz. of malt liquor, 5 oz. of wine, or 1.5 oz. of liquor). A potential time to intervene with a CRAFT technique is as soon as Sue gets home. Offering a non-drinking alternative to help Sue relax may reduce her drinking for the evening.

Well, that’s it for the behavior column! Remember my tips about style from the previous post: use a conversational tone, adopt a compassionate and collaborative stance, and avoid or reduce confrontational language or tone when filling out any portion of the Functional Analysis Form. Stay tuned to the blog, I’ll continue describing how to complete the remaining columns of the Functional Analysis Form.

• addiction
• CRAFT

Treating Panic Disorder with Comorbidities: Why Focusing on the Panic May Be the Best Option

A common reason psychotherapists give for ignoring research is: “Research studies usually focus on one problem—the people I see often have multiple problems.” Whether this is reason enough to abandon evidence-based practice is debatable. The statement, however, does touch upon a very real concern: how do we choose a treatment focus for clients with multiple problems? The answer to this question isn't always clear, but it is the responsibility of practitioners to see whether there is research that can guide a decision. In the case of panic disorder, research suggests clients will get the most bang for their buck by focusing on the panic.

A Little About the Study

It’s not a new study—it was published in 2007—but I thought it was really interesting when I originally read it and haven't had a chance to write about it yet.  The first author is Dr. Michelle Craske, a professor at UCLA, and one of the most renowned anxiety researchers.

In this study, sixty-five people with panic disorder were randomly assigned to one of two groups. Everyone in the study received 12 weekly sessions of a manualized group cognitive behavioral treatment for panic disorder as well as 6 adjunct individual sessions spaced every two weeks. For half the participants, the individual sessions reinforced what was taught in the panic disorder group; for the other half, the individual session provided tailored cognitive behavioral treatment for a co-occurring disorder. The most common co-occurring conditions were major depressive disorder, generalized anxiety disorder, social anxiety, and specific phobia.

The individual sessions were scheduled every two weeks in order to simulate therapist “straying” from treating one condition to another. For example, someone with comorbid depression in the experimental group would receive cognitive behavior therapy for depression in the individual group, whereas someone in the control group would receive additional panic disorder treatment in the individual group. As a consequence, the control group only received panic disorder treatment regardless of comorbidities, and the experimental group received panic disorder treatment and individual sessions targeting a specific comorbidity.

The researchers assessed participants before treatment, post-treatment, and at 6- and 12-months following treatment.

“More of the Same” Wins Out

The results are by no means a slam dunk, but they suggest that people who only received panic disorder treatment did better—both for panic and the comorbid condition—than people who were treated for panic and a comorbid problem. Some of the effects were small, and superiority for panic treatment-only wasn’t across the board; however, the results suggest that not only can focusing on panic disorder result in improvements in comorbid conditions even if the co-morbid conditions aren’t directly addressed, but that it may be a better option than trying to address both. As the authors put it, “the results raise the interesting possibility that staying focused is superior to straying” (p. 1106).

Take Home Message

For therapists who are skeptical that conclusions drawn from research studies are applicable in their own work, this study probably didn’t win anyone over. The attempt at mimicking how an actual therapist would deal with comorbid conditions—devoting a session to it every two weeks—is a little contrived (although very creative!). I can see how someone might dismiss this single study.

My take? Given that panic disorder is one of the most treatable conditions in the research literature, I think this study offers some compelling evidence for treating the panic first. Once clients have learned to manage their panic, other problems may resolve on their own. If any problems remain after successful resolution of panic, then these problems may then be addressed. In a nutshell: for people with panic disorder and co-occurring conditions, it's probably best to treat the panic first.

• anxiety
• exposure therapy

Edna Foa on Prolonged Exposure

Dr. Edna Foa, the extremely influential anxiety disorder researcher and University of Pennsylvania professor, authored a brief article in the December issue of Depression and Anxiety. For those who don’t recognize her name, Foa is an enormously influential psychologist who developed the emotional processing theory as a unifying theory to guide exposure therapy, and is perhaps best known for her pioneering work in developing Prolonged Exposure Therapy, a gold standard treatment for posttraumatic stress disorder. In 2010, Time magazine include her in 2010 in their list the 100 Most Influential People in the World.

In “Prolonged Exposure Therapy: Past, Present, and Future,” Foa offers a brief summation of the work on prolonged exposure. Foa doesn’t address the recent criticisms directed at the emotional processing theory, particularly newer research that suggests habituation is not necessary in exposure therapy. However, the brief article provides a concise summary of the research on prolonged exposure. I learned that it has been adapted for use with complication grief, which I didn’t know before.

• exposure therapy

Getting Unstuck Part 3: A Map You Can Use When Creating Road Maps

My last blog post continued the discussion of creating road maps as part of Community Reinforcement and Family Training (CRAFT).  Briefly, CRAFT trains family members of people with addiction how to non-confrontationally change their loved ones’ use and to rebuild their lives not centered on their loved one’s addiction. Briefly, a road map (a.k.a., a functional analysis) is an assessment of the triggers and consequences of the addicted person’s substance use.  Creating a road map can be a difficult task. Furthermore, being flexible in your approach to creating a road map can be tough, particularly in the beginning when you are just learning how to create and work with road maps. Luckily, there’s a document that you can use to help you when you are helping family members create road maps. It’s like a key for the road map:  it tells you which direction you’re headed and how much ground (distance) you need to cover to get to your destination.

The Key:  The CRAFT Functional Analysis Form

The CRAFT Functional Analysis Form is your guide in creating the road map. It lays out all the information that you need to collect and even offers you prompts to help you gather the information. The Functional Analysis Form has 5 columns that represent the major areas of information that you need to collect to make the road map. The form offers some small differences from the form provided in Smith and Meyer’s CRAFT manual, but contains all the same major elements (the differences I’ve made to the form include additional questions and comments to gain information that I believe is useful in creating the road map and to help clarify parts of the form).

The first column is called “External Triggers” and contains questions that you can ask the family member to help elicit information about the environmental triggers associated with his/her loved one’s use (who, when, and where). The second column is labeled “Internal Triggers” and lists questions you can use to inquire about the loved one’s emotional, cognitive, and physiological triggers associated with his/her use. The third column, “Behavior,” has questions about the details of their loved one’s using behavior. What does the person use/drink? How much does the person use/drink? Over what period of time does the person use/drink? “Short-Term Positive Consequences” is the fourth column and provides questions about the possible emotional, cognitive, physiological, and environmental benefits their loved one obtains when using. The final column, “Long-Term Negative Consequences,” lists the life domains (e.g., interpersonal, financial) where possible negative consequences have occurred. In this post I am going to focus on the first 2 columns of the Functional Analysis Form (I will discuss the last 3 columns in my following posts).

Where to Begin? Try the “External Triggers” Column.

There is no right way to start using the Functional Analysis form; however, Smith and Meyers (2004) suggest that beginning with the first column, “External Triggers,” may be easiest for family members to complete because it is focused on the external factors (i.e., the factors that can be seen by outside observers) associated with his/her loved one’s use. To obtain the needed information for the column, you need to help the family member focus on a typical episode of drinking or using.

Most individuals have a pattern of drinking/using and we are more interested in the pattern of use than the precise details of each instance of use. From the information that we gain from the person’s pattern of use, we can develop a general understanding of the types of triggers that elicit use and later, help the family member develop strategies for minimizing their loved one’s contact with these types of triggers and help them develop strategies for coping with these triggers that they cannot change. Three questions are listed in the column:  1.) Who is your loved one usually with when drinking/ using? 2.) Where does he/she usually drinking/ using? 3.) When does he/she usually drink/ use?

Let’s use an example to illustrate how you might go about getting this information from a family member. Here’s the Road Map I’ve been using in previous posts about CRAFT:

Sue gets home from work and goes to the kitchen to pour herself a drink à Joe is in the kitchen preparing dinner and asks Sue how her day at work went à Sue begins to talk about her day at work and appears more and more irritated as she talks about work. à Joe listens, but is starting to become irritated because Sue has not asked about his day à Sue continues talking about her work and pours herself another drink à Joe, irritated, says “do you really need another? You just finished that one.” à Sue, angry, snaps, “I’m the one who works all day while you get to sit around and collect unemployment. If I want a drink, I’m gonna drink.” à Joe, angry, argues “I don’t sit around all day. You know I’ve been looking for work and that I hate being unemployed.” à Sue tells Joe “when you get a job again, then you can tell me how to spend my time.” She finishes her drink, pours herself another, and walks out of the kitchen. à Joe, still angry but realizing that dinner still needs to be cooked, goes back to preparing dinner. à Dinner is eaten in silence.

So, how might you go about getting the information about the external triggers in this situation? First, it’s important that you ensure that the situation that the family member discusses with you is a typical or common drinking situation (i.e., it is a situation that happens often or regularly). At times family members have difficulty picking one situation that is common or typical. It can be helpful to remind the family member that you are looking for his/her loved one’s patterns of use.

Additionally, you can let them know that you can create additional Road Maps for other typical using situations if that applies to their loved one’s use. Once you’ve determined that the situation represents a regular, frequent, or typical pattern of use, you can ask the family the questions in the “External Triggers” column of the form. Using the Road Map from above, we might obtain the following answers to these questions:

1.  Who is your loved one usually with when drinking/ using? Alone. Although the Joe is present when Sue is drinking, Joe is not drinking with her. If Joe were also drinking and it is typical that Sue and Joe drink together, then the answer to the question would be “with Joe.
2.  Where does he/she usually drinking/ using? At home. You could even get more specific and inquire if Sue tends to drink in the kitchen, the living room, or another room in the house.
3.  When does he/she usually drink/ use? In the evening after work. Again, you could get more specific about the times Sue drinks (e.g., from 6 p.m. to 10 p.m.). You may also want to inquire about whether Sue’s drinking occurs every day after work, most days during the week, or 1-2 days during the week.

You’ve Got the External Triggers, Now It’s Time for Something a Little Tougher:  The Internal Triggers

Once you’ve obtained the information about the external triggers related to his/her loved one’s drinking or using, you can move onto the internal triggers. Internal triggers are the emotional, cognitive, and physiological states that precede using. In my last blog post I discussed how it can be difficult for family members to see the costs and benefits of using from the perspective of their loved one. Similarly, it can be difficult for family members to imagine what is happening emotionally, cognitively, and physiologically for their loved one prior to their use. You can use similar strategies as I reviewed previously to help family members identify the internal triggers for their loved ones’ use as you did to help them identify the positives and negatives of use from their loved ones’ perspectives. Additionally, it can be helpful to remind family members that identifying the internal triggers associated with drinking/using can:

1. Help you and the family member better understand the factors that contribute to the person’s drinking.
2. Help you and the family member identify non-using ways to counteract or cope with internal triggers.

Finally, it can be helpful to remind family members to take their best guesses about what is happening internally for their loved one prior to drinking. Remind them that their access to their loved one allows them to observe and learn about their family members’ motivations, feelings, and thoughts. They probably have some good information about what their loved one thinks and feels prior to using/drinking.

Returning to our Road Map example, we can answer the following questions from the “Internal Triggers” column of the form:

1.  What do you think your loved one is thinking about right before drinking/ using? Sue is probably thinking about her work, particularly the stress she has at work right now, and probably about how much she doesn’t enjoy her work. After I make a comment about her not asking about my day, she is probably thinking about how much I don’t appreciate how much she works and all that she is doing for the family.
2.  What do you think he/she is usually feeling (emotionally) right before drinking/ using? Stressed and irritable at first, then angry when I make my comment about not asking about my day.
3.  What do you think he/she is usually feeling (physically) right before drinking/ using? Sue tends to get tense in her shoulders and neck (she often rubs them and talks about how she needs a massage). I’m guessing she is feeling tense, as well as a little bit relaxed when she starts drinking.

Before I conclude this post, I’d like to say a few words about style. As best you can, complete the form using a conversational tone. Remember that the aim of the form is to be helpful to you and to the family member, thus a warm and empathic style will probably make the process of completing the form more therapeutic and enjoyable. Also, it’s important to be compassionate and non-confrontational when completing a functional analysis. Imagine that you were being asked to share a painful (and possibly shameful) family secret that was going to be analyzed. You’d probably prefer someone who is acting compassionately and not arguing or badgering you about the information you present. Finally, a collaborative stance is useful. The family member is the expert on his/her loved one’s use and the effects of this person’s use; you are the expert on how to change behavior in a non-confrontational and values-consistent manner. Combined, you make a great team that can really make an impact on their loved one’s life.

Stay tuned to the blog. I’ll be talking about the remaining columns of the Functional Analysis form in my next posts.

• CRAFT

Let’s talk about sex… what’s that?

“I've always felt that sexuality is a really slippery thing. In this day and age, it tends to get categorized and labeled, and I think labels are for food. Canned food.”

--Michael Stipe, songwriter

I teach abnormal psychology at the local community college. I’ve been teaching the same class every semester for nearly 5 years now and I absolutely love it. One of the things that I love most about teaching these engaged and engaging students is that they often ask wonderful questions that cause me to question my own assumptions.

The other night I was lecturing on sexuality and in the midst of a lively discussion, a student raised a very astute point, saying “I think we need to first talk about what we mean by ‘sex’”. It led to a discussion of how certain assumptions about what ‘sex’ is or isn’t might exclude or marginalize large portions of our community. For example, if a group is talking about ‘sex’ (and by that they are referring to penile-vaginal intercourse) and someone in that group is in a lesbian relationship, it is very likely that that individual may be made to feel like the physical intimacy she shares with her same-sex partner is somehow less than ‘sex.’

So all this got me thinking about what we as a culture consider ‘sex’ to include. Also, how does the way we, especially us therapists, talk about physical intimacy and sexuality support the diverse sexual experiences of all in our community? Are there ways that I could shift how I talk about sexual experiences with my clients that would be more consistent with my values of inclusivity and affirming diversity?

In response to this question, I went to the literature. Researchers at the Kinsey Institute at the University of Indiana published findings from a study of 486 individuals aged 18-76 who were asked about what specifics sexual acts they would consider as constituting having ‘had sex.’ While there were some overall differences based on age, with younger and older male participants having more restricted views on what they felt constituted ‘sex’ as compared to middle-aged participants, the general finding was that there was no overall consensus when it comes to definitions of sex. Researchers concluded:

“Given the diversity of opinions about what constitutes having ‘had sex,’ it is likely that people across gender and age groups may answer questions about how many partners they ‘had sex’ with or how many times they ‘had sex’ using varying criteria. They may think of different behaviours when researchers or practitioners use this phrase. Thus, the results provide empirical evidence supporting the need to use behavior-specific terminology in sexual history taking, sex research, sexual health promotion and sex education. Furthermore, researchers, educators, and medical practitioners should exercise caution and not assume that their own definitions of having ‘had sex’ are shared by their participants, students, or patients.” (p.34)

As a clinician who frequently talks with clients about their sexual experiences and desires, these findings remind me again to use more specific and behaviorally-focused language when talking about these issues. It allows for a more accurate understanding of my clients experience and may create space for a more inclusive conversation around sexual intimacy.

• relationships
• sex