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.

Tommy Bryan on World War I

My Mom's Dad had three war stories.

In the first, he is marching toward the front when his squad passes through an olive grove. He claims that he'd always loved olives and so began picking them from trees near the road, carrying them in his helmet and eating them on the march. Which apparently made him quite sick.

In the second, he is in the trenches, watching the little aeroplanes go over, thinking that was the place to ride out the war--safe home at base every night. So he applied to be a pilot, but was not accepted. I am glad, in retrospect, because while I certainly would have wished him out of the trenches, the death rate for fighter pilots in those days was staggering.

He did manage to transfer into a supply/transportation battalion and would spend the rest of the war driving food and ammunition back and forth from the front. He might not be at home base safe every night, but he would be most nights. In this, his third war story, he is driving toward the front and is close enough that he can hear the guns. His truck slides into a ditch, sort of accidentally on purpose, and he spins the wheels "trying" to get out until he is well and truly stuck there. He is happily sitting cantilevered into the ditch, eating a sandwich, when along comes a French tanker who insists on pulling him out.

He would giggle at this point, that funny hee-hee laugh of his, and tell us that no sooner did the tanker pull him out than he promptly slid back into the ditch. Again, the Frenchman, cursing, hooks up the chains and pulls him back out. Again, my grandfather, making a big show of his incompetence, slides into the ditch. The Frenchman throws up his hands in Gallic disgust and rolls on. My grandfather ends the story by telling us that was as close to the front as he ever intended to get.

I do not think my grandfather was a coward: Quite the contrary. He never spoke of his experiences other than this. You just could not get him to. My grandmother, however, once said that he came back from the war with his health ruined, and that it was years before he got it back. You don't ruin your health sitting in a ditch eating a sandwich and giggling. So I always believed that he suffered, as infantry did in that war, horribly, and was lucky to return home alive. And that it was a combination of modesty and discomfort with painful topics that kept him to his three-funny-story repertoire.

As an adult, and later as a mental health professional, I found this pattern pretty common. Vets tend to talk to vets, and to demur with everybody else.

My father in law never said much about his World War II Navy service, either, but I watched him light up when he met my cousin who'd also served. They spent the whole time during that family gathering comparing notes on their experiences. On another occasion, we took my father-in-law to a movie about the Pacific war. I don't remember which one. But again, I remember how he perched on the edge of his seat, eyes riveted to the screen, excitedly whispering to us, "That's where we were. . . yes, it was just like that!" and so forth during various invasions and sea battles throughout the movie. And then not one word in the car on the way home, nor did he ever mention it again.

Vets are pretty sure we won't get it. They may be right, but we have to be willing to try. We owe them that, and so much more.

Veterans' Day

For those of you who like to write but are occasionally stumped for a topic, check out The One Minute Writer. Today's prompt, appropriately enough, is "write about a war veteran you have known of, or known personally."

The first vet I ever knew was my Mom's Dad, whom we called Boppa. He was in the infantry in World War I. I don't know much about his service, because he had a repertoire of three funny stories and that's all he would ever say on the subject. My father-in-law was in the Navy (Pacific) in World War II and was reportedly much damaged by the experience.

One of the best clinical supervisors I ever had served two tours in the infantry in Viet Nam before he went to medical school. As a therapist, it has been my honor to work with veterans as well as active duty personnel and military families. Some have seen combat, others have not, Some were officers, others grunts or noncoms.

Today, and every day, I would like to thank them all for their service.