This case study examines challenges in working with military veterans who are difficult to engage and hard to experience Healthy Adult, by introducing intensive working and outdoors. The idea of using intensive working allows the client to truly exploring trauma in an unrushed way, which is considered as a quality of a healthy adult. The therapy was also delivered entirely outdoors, which allowed the client to draw upon the power of nature and safety, both of which were important for veterans who appreciate such through their combat training, and again, this further encouraged the establishment and integration of healthy adult in the client in a much efficient way. The study highlights the challenges and successes of the treatment, showing light on effective strategies for managing complex trauma treatment in military veterans that went beyond the traditional PTSD treatment protocols outside Schema Therapy community.

Introduction:

Complex Post-Traumatic Stress Disorder (CPTSD) that is caused by both combat trauma and early life trauma due to adverse childhood experience (ACEs) has a higher rate in military veterans, particularly men, than general population (Blosnich et al 2014). An early 2000 meta analysis showed that up to 79% of treatment seeking veterans for PTSD in an in patient unit also would have a comorbid personality disorder (Bollinger et al 2000). This makes treatment of PTSD in veterans using standard therapy approaches a complex matter. Traditional treatment protocols all focus on the trauma narratives, with few making references or dedicating appropriate time to address anything outside combat trauma. By using Schema Therapy approach, this would allow the therapists and clients to address the symptoms of PTSD as part of their maladaptive coping mode network. This approach then will allow the client to truly heal from the inside out. However, conventional delivery of therapy, 1-1.5 hours a time, done on a weekly basis, and inside a clinical room, can become an obstacle for veterans seeking help. The culture of veterans: being in a tight unit with others all the time, physical trainings and appreciating outdoors etc demand therapists be creative in creating conditions that will meet such needs. In addition, guild and shame caused by moral injuries can make them feel even more ashamed when they attend therapy, especially at a clinical room, which remind them of being disciplined in the military. Usually, it takes a long time for therapists to gain the trust and later encourage healthy adult within veterans. Veterans have higher drop out rate than general population, and many cited these as the reasons for them to feel less trusting of the process. This case study wished to highlight an alternative to get to the vulnerable child and encourage quicker establishment of healthy adult by giving them what they are looking for in the journey.

Patient Presentation:

Mr. A, a 37-year-old male, presented with recurring nightmares, flashbacks, and heightened anxiety, as well as active suicidal thoughts, anger outbursts and addictive behaviours with alcohol and heroine. He reported experiencing several traumatic events during his military service overseas, which led to him being referred to my team, veterans NHS Wales, for treatment. However, upon assessment, he reported a history of family violence perpetrated by both parents towards each other and towards him, as well as exposure to alcohol from a young age (first given alcohol as a toddler by a baby sitter, and later recalled given wine aged 8 by parents. He also suffered from bullying after deployment by senior officers in the military for years, and started to use alcohol and heroine as coping method. At the time of us starting his treatment, he was reported to be actively suicidal as well as displaying destructive behaviours that showed traits of Anti Social Personality Disorder.

Treatment:

Treatment for Mr. A went beyond conventional CBT, EMDR, CPT, prolonged exposure and narrative exposure, all of which could be delivered within the service. I chose to use Schema Therapy for him due to his complexity and we saw his combat trauma symptoms being part of his maladaptive modes (punitive critic, detached self soother, avoidant protector, anger protector, etc) . I used intensive treatment programme, delivering a course of therapy with initial six 1.5-hour sessions for assessment/education, and followed by 4 days of 8-hour sessions delivered in two of my local national parks, and wrapped up with 2 follow-up sessions to monitor progress. The four 8-hour days were spaced out into weekly appointments, instead of being delivered over four days. The first 8-hour day was three weeks from the last 8-hour day. The delivery of therapy (on each day) consisted of 1 hour of experiential approach (using either imagery rescripting or “standing up chair work” – chair work delivered whilst the client was asked to stand in different positions instead of sitting down, and in vivo Mindfulness practice to draw upon the nature to inspire Healthy Adult) followed by 30 minutes of hiking/climbing whilst I engaged the client for consolidation of learning from the experiential time, allowing the client to use me as external reasoning board to further synthesize healthy adult responses. Outcome: Following the delivery of therapy, a total 40 therapy hours, delivered over 2 months period Mr. A showed significant improvement. He reported a reduction in nightmares, fewer flashbacks, and an increase in sleep quality. His hypervigilance diminished, and he began to engage in social activities. He also stopped taking heroine and drinking alcohol all together (same reduction of symptoms and abstinence of alcohol and drugs reported in his 1 month follow up and 6 months follow up).

Discussion:

– The use of intensive treatment is not new and is currently gaining recognition around the world. Same as nature based/outdoor therapy sessions being used with veterans suffering from PTSD. However, the combination of both in a structured way is less talked about. This is one of the latest “up and coming” trends in therapy world and I would like to see more Schema Therapists doing so. I believe this helps to improve the healthy adult in the clients and by-pass the avoidant protector earlier.

– The use of Schema Therapy is effective in treating complex trauma and personality disorders, but on average, it takes a long time for therapists to get pass the detached protector, or to encourage internally established healthy adult (where the significant change happen is when clients start using healthy adults themselves in experiential works). Conventional approach – 1 hour sessions weekly – sometimes can also lead to drop out due to perceived lack of progress or change of personal circumstances.

– Working with veterans, therapists must be able to identify their cultural needs, instead of approaching the same way as general population, and working with these military culture will enhance their experience. Downside:

– Not everyone can do this, some do find it too overwhelming, or physically too challenging for them. High demand on therapist’s ability to stay focused on the journey, as there is no way to take notes in the traditional way.

– Therapy drift: treating this as a day out instead of a day of therapy Conclusion: This case study highlights the successful treatment of CPTSD in a male military veteran using an intensive treatment programme, delivered outdoors, over a period of 2 months. This is just one of a cohort of clients that I have worked with in such way and almost all experience success. Further research is encouraged on this. Furthermore, moving away from conventional trauma treatment approaches, using ST, will help deeper healing in a person, rather than just symptoms.

References:

Bollinger, A. R., Riggs, D. S., Blake, D. D., & Ruzek, J. I. (2000). Prevalence of personality disorders among combat veterans with posttraumatic stress disorder. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 13(2), 255-270. Blosnich, J. R., Dichter, M. E., Cerulli, C., Batten, S. V., & Bossarte, R. M. (2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA psychiatry, 71(9), 1041-1048.