From the In Box

The most recent edition of Professional Psychology: Research and Practice landed in my In Box this week, and in it was an interesting study on a multifamily group program for vets with PTSD at the Oklahoma City Veterans Affairs Medical Center (VAMC). 

It has long been known that while good family support helps people recover from PTSD, the PTSD itself can alienate the sufferer from family members, depriving them of support. Bad family relationships actually interfere with treatment. With this in mind, the Oklahoma City VAMC set out to adapt a multi-family group approach to the specific needs of veterans. They call it REACH, for Reaching out to Educate and Assist Caring, Healthy families. 

They've collected data from about 95% of their participants, over a period of a little over four years, and they believe that it works. But it's the first such study specifically with veterans diagnosed with PTSD, and it's a small study so these results are very preliminary.

This was a longitudinal study with no control group, meaning there were no vets wait-listed for it or in some other form of treatment (comparison groups of both types would have been ideal). And the data on improvement was reported by the study participants themselves, to the therapists who both provided the treatment and conducted the research. As with any study of this nature, it may appear to work better than it apparently does, for a couple of reasons:

1. People can get better over time, either because 'time heals all wounds,' or due to other things occurring in their lives during the course of the study. The authors performed a statistical test for this, but still, a control group would have helped to tease out how much improvement is due to the program itself, and how much due just to life going on. And since some study participants were receiving other treatments at the same time, there's no telling exactly what improvements are due exclusively to REACH.
2. It is well known that when people invest a lot of time and energy in something, there's a psychological bias towards finding it worthwhile. This is true for researchers and participants, and is bound, in this kind of study, to influence the reporting and interpreting of results.

One thing that makes the results stronger in this case than in some studies to come out of the VA system in recent years is that the researchers didn't "cherry-pick" their participants, which is to say that nearly everybody who wanted in, got in. Cherry-picking is frequently a problem with treatment efficacy studies, as anyone with co-existing conditions, or who is taking medications, is ruled out, and definitions of the diagnoses that get you into the study are very narrowly defined. This results in the study population not looking much like a typical clinical population. For the purposes of this study, persons with active addictions or who were suicidal or homicidal were screened out, but these are criteria that are almost universally applied in clinical practice as well, so does not much affect the applicability of the results. 

Even better, their definition of "family" was open and welcoming: A veteran could bring her or his adult significant other of nearly any description -- a lover, a spouse, a parent, a sibling, an adult child, or even a friend. 

Veterans ranged in age from 22 to 85, which would include the Korean War if not World War II, and that both adds to and detracts from the strength of the study. Different "cohorts" (age groups) serving in different wars could have widely varying backgrounds and combat experiences and therefore respond very differently to a treatment. Also, older vets, by definition, have a more chronic form of PTSD. An average age, as in this study, of 55.8 years means that this is something that may not work as well for very young folk just back from Afghanistan or Iraq with their differing upbringings, combat experiences, and acute onset of PTSD as it does for VietNam-era or Persian Gulf veterans.

Unfortunately, the study population wound up being almost all white (non-Hispanic) straight males, so we don't know, pending further study, whether this program would be equally helpful to people of color, women, LGBTQQI folk -- never mind veterans or family members who fall into all three categories at once! 

Of course, there's no reason to believe that it wouldn't work for a wider range of folk, since groups in general have been studied for over half a century now and the results are consistent. It works for nearly everybody, for nearly every problem. It's just that with this study, the authors could not claim with any certainty that this particular protocol would work for other than adult, straight, white males of a certain age.

From the description, REACH appears to be a nicely-structured program, with a generous time allowance for assessment and engagement with the program, and a nice consolidation/follow-up phase to help families maintain and elaborate on their gains. At the same time, it does not appear to be so structured as to be a cook-book-y, overly technical approach. And folks liked it! Some of them reported that the meetings were the high point of their weeks. Participants knew more about PTSD when it ended than they had when it began, and some of their symptoms improved. They learned coping skills, and their relationships improved. 

The authors note that in a study of this sort, while you can say you're pretty sure the program helps, it's hard to say exactly what components of the program are most -- or least -- effective. That makes it a bit of a crapshoot whether you can replicate the results elsewhere. What if, for example, one of the only four psychologists running the study is just especially talented, and no matter what she did, her people would get better? On the other hand, if the standard curative factors of all effective groups were in operation here, you could do REACH or any other variation of multifamily group and get the same results anywhere. This is why we like to see multi-center studies, or studies replicated elsewhere producing similar results. However, when you are running only 4-6 vets and their families through at a time, and the whole process takes nine months, as this one does, we'd be waiting a minimum of four more years for the next study -- and that's not counting the time to organize and fund a study, write it up, and get it into print! So I think you will see a lot of psychologists running with this one, and soon. 

Although VA is mandated to provide some form of family education, the REACH program specifically does not appear to be available at our local (Atlanta) VAMC yet. However, the study's authors will make the materials needed to conduct the group available to any psychologist who wishes to lead one. If a half-a-dozen or so of you are interested, I think we could have one up and running by the end of summer. Just let me know!

Fischer, E. P., Sherman, M. D., Han, X., & Owen, R. R. (2013). Outcomes of
    participation in the REACH multifamily group program for veterans with PTSD and
    their families. Professional Psychology: Research and Practice (44), 127-134.

Wounded

Untitled: © Irina Sidorowicz - Visit NoHappy.com to see additional artwork and photography. The artist studies Graphic Design and Visual Communication in Buenos Aires.

This picture, posted as a writing prompt at Every Picture Tells a Story is powerfully evocative for me. My first reaction was that she is Palestinian, but she quickly became bigger than that. She is Afghan, too, married at ten or eleven to a man decades older than she. Then she became all wounded women.

Inside every battered woman, every woman who was sexually abused as a child, every rape survivor, lives a girl-woman like this. However bright and strong and confident she may look on the outside, and they do, this wounded girl-woman looks out from behind her eyes. I may see a flicker in the first session, or I may not catch a glimpse until she's been here a few times.

If I can earn her trust, sometimes she will come out.

Blackout

Just finished reading John Lescroart's Betrayal (at 1 a.m. this morning, but compulsive reading is another subject for another day). In it, a defendant has no memory for the time of the crime. The defense attorney's handling of this problem is a bit muddled.

He hopes to get in Posttraumatic Stress Syndrome (PTSD) as the explanation for the gap in memory. In a preliminary hearing, a psychiatrist with expertise in PTSD testifies that flashback-related blackouts last only a few minutes (pp. 211-217). My quibble with this is that these experiences are not technically "blackouts" at all, but dissociative episodes. The person is fully conscious, but not really present because they are re-experiencing events from another time and another place. Most likely, they will remember the content of the flashback, but not necessarily what they said or did, or what other people said or did, while they were having it. It is in that sense that it is a blackout, in that the information they forgot was never recorded in the first place, and this is why it cannot be recalled.

During the trial, the evidence proffered is that an old head injury is the cause (pp. 274-279). Unfortunately for the defense, a neurologist testifies that brain injuries do not account for extended periods of unconsciousness (after the initial trauma, that is) and the defendant has four days to account for. Not to mention that his blood alcohol at the time of his arrest shows clearly that he'd been wide awake and drinking like a fish for goodly portions of the days in question. Here the problem is that, once again, "blackout" as a term is being used by the attorney to mean one thing, and by the expert to mean another.

The defense attorney recognizes this little problem in mid-testimony and gives up on this witness, when another question or two would have established that "blackout" is not synonymous with "unconsciousness." Indeed, testimony from a VA staffer is available to show that, while still in the hospital, the defendant had experienced an episode during which he was fully awake but thought he was still in Iraq: He remembered nothing of this afterward (pp. 226-228).

And then I must have had some kind of blackout, because I started this blog entry over two months ago and never published it. I found it when I decided to write a little scribble on memory in general, and was checking to see if I'd done that already!

I have no idea any more how I intended to finish it, so here it is, as is. Scary.