Psychological Adjustment For Employability

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  • 1. Research Proposal in Economic Outcomes David Paschane, Ph.D. Psychological Adjustment for Employability This research would help support many of our policy goals, including service integration, veteran-centric, lifecycle interventions, and treatment before compensation. The recent focus on PTSD will lead to some important changes, but I think it needs to be backed up with a more complete service of mental health needs. VA should also consider what it is willing to contract to providers, given the potential need for pre-clinical and clinical adjustment psychology in our new cohorts, the veteran propensity to delay help due to travel burdens and self-perceptions, and the lack of capacity in VA to adjust and respond quickly to the mix of needs in a non-bureaucratic manner. Scope of psychology-oriented issues that need to be taken into consideration: • Demographic – percent of men with available men psychologist • Resiliency reinforcement during and after service • Leaving racially integrated communities • Civilian communication • Changes in vigilance requirements • Less than usual adrenaline • Lingering fear without targets • Depression about loses • Anxiety about lifecourse • Mentality for civilian employability • Translation of employment experience • Change in management responsibilities • Leveraging operational and leadership mentality • Responding to family needs • Responding to anti-military biases • Filing the absence of a mission • Seeking mental health care • Psychological response to injuries • Recalling grave events • Interpretation of injuries as disabilities • Work function thinking The two main foci for examining employability and its mental health needs are (1) positive psychology for civilian adjustment and (2) institutional response to PTSD.
  • 2. 1. Positive Psychology for Civilian Adjustment Positive psychology is an approach to behavior and cognition that defines and solves problems primarily through methods of enhancing individuals’ productivity and personal satisfaction. Arguably, the military is an institution of positive psychology because it works towards making servicemembers people of greater character, who fulfill higher callings, and are satisfied with their work and commitments. The Army slogan, “Be All You Can Be,” communicates a positive psychology. The positive psychology message in the military is aligned with a tiered system of opportunities, so as to attract a broad range of people with various potential and backgrounds. The intent of the military is to maximize the potential in each servicemember, while preparing them for their military mission. The military’s positive psychology is an important framework for thinking about the continuum of experiences that affect the veteran lifecycle. From basic civilian adjustment after discharge to the reability process after injuries, the psychology of the individual will affect long-term outcomes in their lives. We can define the problem to solve as psychological risk for poor adjustment during and after military service. The positive psychology that can mitigate this risk and promote desired outcomes, such as veteran economic security, has not been developed as a continuum from DOD through the VA. Military Training, Deployment, and Psychological Risk Military training is largely about tactical functions. However, it can mitigate risk from pre- military life, such as being a ward of the state (e.g., foster child) or having education failures (e.g., GED). Military training also builds physical endurance and psychological resiliency. These efforts by the military are often made as a reinforcement of existing personal strengths. For example, researchers are examining the positive psychology notion of grit in military academies. They define grit as the perseverance towards an ambitious goal that could take years to reach and therefore requires the ability to overcome obstacles, difficulties, or discouragement. The following points are some basic ways for organizing the scope of military training in terms of combat deployments and levels of psychological risk (as illustrated in the table below): • General military training provides integrated, controlled, and focused activities to promote tactical readiness for missions. • Combat specialized training provides simulated stressors and exercise fatigue in order to produce psychological resiliency. • Special operation training programs identify and reinforce capacity for those who demonstrate psychological resiliency and physical endurance for intensive combat operations. • A significant lag in deployment could diminish psychological resiliency due to low expectations of combat; and among reserve components, it could produce possible atrophy in
  • 3. tactical readiness, physical endurance, and psychological resiliency because of irregular or under challenging training exercises. Theoretical Differences in Not In In Theater, No Few Critical Many Critical Psychological Risk Theater Critical Incidents Incidents Incidents General Military Low Moderate High Very High Combat Specialized None Low Moderate High Special Operations None None Low Moderate Deployment Lag, Reserve Low Moderate High Very High Deployment Lag, Regular None Low Moderate High Psychology of Exiting the Military In WWII soldiers could decompress with their unit as they traveled home (1-2 weeks), or they could take a break in non-combat locations in European. This offered them opportunities to process the experiences and keep cohesion with their surviving unit. This opportunity does not exist today because soldiers can return home within 24 hours of leaving combat. Some may go through TAP briefings for a few hours or days, but this has not proven to have the some effect on decompression and reorientation. What do we know about the psychology of life course ambiguity, and the decision to discharge or return to service? Reability process (DOD) – combined individual strategies following injuries: • Restoration of psychological and body-mind health (physical symptoms due to psychological angst are the poorest monitored and the greatest cause of primary care visits) • Rehabilitation of physical function (to what end if they are discharged with injury?) • Augmented Function through body enhancing devices (is DOD is the leading investor?) • Enabling Technology to enhance work capabilities (may not occur until veteran status) • Accommodation in environments to enhance participation (to what degree in DOD for servicemembers, or private sector for veterans?) What are the rates of return to service, choice factors, and accommodations? What are the economic strategies in civilian work, including employability, career planning, and job networks? What are the strategies and resources for managing domestic changes in family roles and community supports? Post-Military Risk Mitigation Reability process (VA) – unique alignment problems: • Interpretation of disabling injuries in terms of work function
  • 4. • Reability protocols before labeling disability as life-long status • Awareness of and access to community service providers • Effective transition from DOD in terms of psychological continuum • Employer readiness for hiring (SDVOB partnerships?) • Integration with career strategies and coaching Civilian Adjustment • Decompression—managing the adrenaline change and vigilance requirements • Reorientation—adopting new mission, goals, strategies, and fit in social dynamics • Reengagement—translating military strengths through civilian-oriented informal (coaching) and formal (certification) strategies • Reemployment—preventing loss of motivation, confidence, and self-determination Common Post-Military Symptoms • Depression (about losses and separations) • Anxiety (about life course and new social dynamics) • Fear (without reasonable causes) • Anger (response to anti-military biases) • Recall (seeking meaning in grave events) Do we understand the help-seeking and help-avoidance behaviors, and their connections to community and government resources? No Do we know who adapts best to civilian communication and expectation, especially in the workplace? No Do we know how well we can facilitate military management skills crossing over to civilian workforce and expectations, to increase and sustain employment? No Service Capacity • Among service providers, are there sufficient numbers of providers and of the right orientations and backgrounds to provide to the demographic mix of veterans and their levels of support—from community or peer coaching for civilian adjustment, to focused or comprehensive psychological treatment, including preferences by sex, age, race, or military background? • When will VA have the capacity to monitor the service provisions and decisions that it makes within the psychology continuum of care? • Does VA avoid services to the high-risk veteran by making access to care contingent on unreasonable or arbitrary requirements? • Who picks up the slack in service provision (if there is one), and how effective are these efforts in the long run?
  • 5. • How can alignment to community services be reinforced, regardless of who provides services or supports? Unmitigated Risk and Unwanted Outcomes Risk pathways to unwanted outcomes: • Poor economic and psychological adjustment to civilian life after discharge • Untreated substance abuse during military service that escalates after discharge • Unemployability after discharge because of incomplete reability process following injury • Inability to afford stable housing because of under-employment or unemployment • Untreated depression, anxiety, or fear after combat that becomes chronic or complex • Aging into disability while living on a fixed or limited income • Decision to not work, abuse substances, or commit crimes Unwanted outcomes: • Employment Failures / Unemployable • Family Support Failure • Fixed-Income Dependency • Mortgage Default / Homeless • Crime / Incarcerated Research http://www.ppc.sas.upenn.edu/ppcactivities.pdf http://www.greenwood.com/psi/book_detail.aspx?sku=C8300
  • 6. 2. Institutional Response to PTSD Strategic coordination of VA policies pertaining to PTSD begins with sufficient knowledge about processes affecting the impact of grave events on veterans. While the institutional processes are controlled by DOD and VA, several of the relevant stages in the process are controlled by the veteran. Most importantly, it is the veteran who self-reports the event as traumatic, and his or her reaction as persistently distressing and intrusive; otherwise, there is no other indication of PTSD. The following diagram illustrates 13 stages that should be examined in order to develop sound policy. The stages in the diagram organize the subsequent questions. 1. State at 2. DOD Entry Training 3. Exposure 4. DOD DOD to Event Intervention Stages in the Process of DOD and VA Affecting 5. Recovery the Impact of Grave Events on Veterans from Event 7. Pursue 10. Claim Claim Adjudication 6. State at 9. Diagnosis 12. Health 13. Economic Discharge Process Outcome Outcome 8. Pursue 11. Activate Treatment Treatment VA Questions that VA needs to address on PTSD I. The PTSD diagnosis: There are many possible symptoms that get included in the PTSD framework, but the relevant ones must fit under the categories used as diagnostic criterion. These criteria are (a) reoccurring thoughts that are distressing and include a sense of re-experiencing the past event, (b) avoidance of things associated with the event, and (c) a high level of emotional reactivity. Furthermore, the
  • 7. individual must (a) self-report that the past event threatened possible death or serious injury, and (b) the initial response included fear or helplessness, and (c) the symptoms are significantly disabling. While these symptoms and reactions can be normal responses to the abnormal events in combat, they are designated as signs of a mental disorder when the individual interprets them as persistently distressing. They key to the diagnosis is the report of persistently distressing, but the argument that the PTSD diagnosis is valid is when the symptoms are intrusive. 1. The diagnostic criteria suggest that at the time of diagnosis it is possible for someone to have a permanent injury to the psyche caused by a past event, regardless of all other thoughts, behaviors, and experiences subsequent to the event that may be contributing to or causing current distress. Can it be verified that the injury exists regardless of other psychological experiences over time? 2. The diagnostic criteria allow for verification of diagnosis by identification of one past event as the cause; however, in the diagnosis of most diseases or disorders multiple-causality is the robust theory, thus objective evidence is required for specifying the nature and presence of the illness. What objective evidence is there that a single event causes the illness? 3. The diagnostic criteria specify the presence of significant diminishment of function; however, there is no requirement of an objective measure of the change in function, thus it is possible that individuals mistakenly attribute low function or changes in function to the diagnosis. Can it be verified that the illness alone is diminishing function? 4. The diagnostic criteria do not identify the state of the individual during lag times between the event and symptoms when function is normal; nevertheless, the diagnosis is given to individuals who attribute current distress to an event that occurred years in the past. Is there a verifiable latent state between event and symptoms, and if so, what is its nature? 5. The diagnostic criteria require that the symptoms be persistent for more than four weeks; however, this is an arbitrary parameter because an individual can have symptoms that have been resistant to weeks of treatment, symptoms that will eventually abate without treatment, or symptoms that are exacerbated by unaddressed environmental or behavioral factors. What parameters are appropriate under different scenarios of intervention? 6. What is the validity of the American Psychiatric Association PTSD diagnosis in terms of military processes, adjustment to military deployment, the role of combat readiness, and professional responses to life-threatening experiences? 7. What are the effects of aging on global functioning, and how can these effects be account for in the disability ratings given to older veterans who claim a mental illness? II. PTSD as a disability: 1. Is PTSD a disability? This is a basic question about what makes a psychological condition persistently distressing and to a level that it is intrusive, so that one can claim their function is
  • 8. diminished. Most psychological conditions are treated or managed so that they are not debilitating, how is PTSD different? 2. Is PTSD a permanent disability, regardless of function? If it is determined that one can function, then how can the PTSD condition be a disability? 3. Is PTSD treatable, and if so what factors delay treatment success? How can a treatable condition be a disability? 4. Is there an objective measure of the intrusiveness caused by PTSD? What is the meaning of intrusiveness when it is used to describe memories, distressing or otherwise? 5. Is there an objective measure of the diminished function caused by PTSD? A one-time description of psychological distress and its effects does not characterize one’s function now and into the future. 6. What are the most objective, valid, and consistent measures of psychological intrusion, avoidance, and hyperarousal, in terms of persistence, complexity, and changeability? III. VA responses to PTSD: 1. How does VA organize its services throughout the lifespan of veterans, in terms of augmenting or prevention unwanted conditions that may be presented as PTSD? 2. How has the VA establishment of a highly-visible infrastructure, focused almost exclusively on treating Vietnam veterans with the PTSD diagnosis, affect beliefs about PTSD and veterans’ behavior? 3. How has the VA establishment of walk-in centers, where veterans can seek counseling for psychological and behavioral symptoms without an emphasis on diagnosis, affect beliefs about PTSD and veterans’ behavior? 4. How has the VA establishment of financial compensation for those who receive a PTSD diagnosis through an examination, regardless of any psychological services in progress, affect beliefs about PTSD and veterans’ behavior? 5. How has the VA establishment of the compensation decision based on self-reported symptoms, rather than rigorous determination of the course and complexity of symptoms, affect beliefs about PTSD and veterans’ behavior? 6. How has excessive promotion of a single diagnosis through infrastructural investments skewed veteran and professional attention on possible explanations for behaviors and thoughts?
  • 9. 7. How has 25 years of experience with the PTSD framework affected VA and its interactions with veterans, and how has this created an interpretation of post-military adjustment behavior, thinking, and interpretations of events? 8. How does VA facilitate successful post-military adjustment in support of efforts by DOD, taking into consideration how a person leaves DOD, diagnoses and treatment provided by DOD, the circumstances the person enters after leaving DOD? 9. How can VA pursue greater cooperation with DOD to improve the continuity and monitoring of services that affect post-military adjustment? 10. What strategic alignment between DOD and VA services could help mitigate veterans’ risk of poor adjustment, maintain most effective treatment and support structures for successful adjustment, and guarantee that psychological care is responsive to individually defined needs? 11. What is the cost-effectiveness of military training, adjustment services, and psychological treatment on post-military adjustment, across cohorts of non-combat veterans, non-traumatized combat veterans, and traumatized combat veterans? 12. How can veterans who only served during peacetime, or who are currently employed in the federal government or in sensitive positions, receive compensation for PTSD? 13. How had VA implemented the methods and training necessary to ensure that the appropriate examiners are performing the most valid and reliable assessments of psychiatric diagnoses? 14. Can VA develop a treatment-enabling policy? For example, require veterans who claim a mental illness to complete a battery of assessments integrated into 24 sessions of adjustment- oriented treatment, to determine the course and complexity of persistent symptoms, especially psychological reactivity, level of intrusiveness, and ability to function. 15. VA does not yet systemically monitor the quality of its psychological treatment decisions, actions, and outcomes. Does it have the capacity to adopt a VA-wide treatment quality monitoring system (e.g., VISN 19 MIRECC Mental Outcomes Core Lab)? 16. What is the effect of treatments, when symptoms are decided as debilitating? 17. Do VA adjustment and psychological services addressed veteran’s expectations in terms of accessibility, accommodations, match to personal and family needs, reinforcing their ability to self-manage moods, anxieties, and reactivity to stressors, and enabling a greater sense of control over adjustment problems? IV. VA policy and possible unwanted outcomes:
  • 10. 1. Does VA policy deter veterans from seeking appropriate and timely treatment because they may risk losing disability compensation for a condition that is tolerable or has become tolerable over time? 2. Does VA policy encourage false claims of PTSD disability because the examination process does not require a rigorous assessment of the psychological reactivity, level of intrusiveness, and ability to function? 3. Does labeling veterans with a serious mental illness, rather than providing assistance and treatment of symptoms during adjustment, affect veteran’s future economic and social activities? 4. Does possible injudicious labeling with a term that assigns disability and implies a permanent vulnerability diminish individual strengths gained in the military, such as grit and resiliency? 5. Does emphasizing PTSD as a likely explanation of thoughts and behaviors create preoccupation with a past event, thus increasing intrusive distress and producing barriers to treatment? 6. Does emphasizing that the stressor experienced during past military service is causing poor adjustment cause distorted perceptions of and reactions to the current environment? 7. Does disbursing responsibility for current behaviors and cognitions through a PTSD diagnosis cause distorted perceptions of and reactions to the current environment? 8. Does promoting the general belief that hypervigilance, dissociation, avoidance and numbing are permanent and inappropriate behaviors and thoughts affect acceptance and interpretation of what may be temporary and reasonable responses when thinking about past combat? V. Contextual aspects of PTSD: 1. What are the personal and environmental factors that affect adjustment? 2. What is the course and timing of adjustment, including the emergence and severity of symptoms that affect adjustment, and account for the psychological features in the pre-military, military/combat, and post-military experience? 3. What circumstances in the adjustment process, such as volition, preparation, continuity, recuperation, familiarly, assimilation, and security affect adjustment? 4. What characteristics in the person, such as psychological resiliency and grit, past mental health, substance abuse, physical health, physical functioning, competency and confidence, and family and social foundation affect adjustment? 5. How does substance abuse and substance-abuse environments affect adjustment?
  • 11. 6. How have institutional structures in VA, DOD, and others affected circumstances in the adjustment process and characteristics in the person? 7. How will post-military adjustment change in the context of the complex psychological factors pertaining to culture and technology that are found in Fourth Generation Warfare? 8. How did the 1970s popularity of the notion of PTSD affect veterans’ adjustment after returning from the Vietnam War? 9. What is the potential impact of private-sector innovations in communication, assessment, and outreach Internet tools on individual control over adjustment processes, including maintaining function and appropriate support structures, organizing needs, overcoming language comprehension, and integrating materials pertinent to physical and psychological health? 10. What are the contributions of positive psychology (e.g., grit, resiliency, reasoned caution, resourcefulness, adaptability, hopefulness, humanitarianism) to veterans throughout their lifecycle? 11. What are the opportunities for DOD and VA to promote and preserve psychological strengths in service members and veterans, as a means of preventing poor post-military adjustment?
  • 12. IOM - PTSD Subcommittee, 13 Feb 06 Richard McNally • Is on the DSM-V stress-induced disorders workgroup • Questioned NVVRS having 30.9% PTSD, while 15% were assigned to combat units • Does not see motivation in study for fabrication • Hypotheses to consider on reporting: o Over sampled combat units o Exposed to trauma though not in combat units, e.g., medics, drivers o Deployment to war zone is the stressor o Interviews were biased to avoid false negatives o Diagnose easier in DSM-IIR, it lacked severe impairment, “F criterion” o Retrospective reappraisal by veterans - a trauma narrative, “war story” • Hypotheses on treatment o Treatment toxicity - interventions create trauma interpretation o Deteriorating disease course and inert treatment effect • Chris Frueh (2005) archival study - 59% lacked verified combat trauma • 2,100-case study - 25.1% of SCD-50% PTSD lacked trauma evidence • OIG 2005 posed that there is a disincentive to get well • Trauma concepts (PTSD has a cause; mono-causal diagnoses are uncommon) o Canonical - combat, rape, confinement in prison camps o Symptom bracket creep - broad range of causes - trivializing genuine trauma by including distressful events and undermining notion of resiliency in population o Breslau’s interpretation - 90% of Americans would be trauma survivors o Notes Although psychological trauma is subjective, symptoms must exist for diagnosis. Depression, anxiety, fear symptoms get attributed to the event. No event guarantees trauma 100%. There is a combination of vulnerability and interpretation of meaning that makes it traumatic. What is the scientific evidence of latency? How do subsequent life events mediate risk of having PTSD symptoms later in life? How common is PTSD in homeless? Committee member raised the issue of background occurrences (community violence) as what should be added into the estimation of expected prevalence of PTSD. However, military environment is designed to control for such background occurrences. Positive psychology studies at academies show that bootstrap experiences contribute to resiliency, so a more challenging background environment could be a benefit. However, unexpected events in background, such a crime or draft, could be risk factors.
  • 13. Bruce Dohrenwend Reexamined the NVVRS by examining the combined probability of experiencing or witnessing traumatic events, based on MOS, KIA, assignments. The algorithm produced levels that he then matched to self-reported data. Participants in levels of probable exposure: 11.7% high/very high 68.4% moderate 19.8% low He claims that these data are similar to self-reported experiences with trauma, but his graph suggests some important variation. The variation could be interesting. If service members believe they have signed up for low exposure, but end up in moderate exposure, they are likely to interpret the events as more traumatic than if they were prepared for intense events and experienced them (e.g., pilots, Special Forces). Sally Satel PTSD is basically a fear reaction that does not diminish after the event (past 30 days in DSM). It has to have a cause, but in most diagnoses, cause is irrelevant. In some cases, the cause is easily understood, but in some cases: • Decades have past • Years without symptoms • Attribution based on interpretation of life lived These are inconsistent with the notion of a “disability” Hypotheses on claiming disability after many years: • Delayed manifestation - slow presentation or reached a tipping point • Reactivated PTSD - life disruptions trigger thoughts/dreams from acute events • Misattribution - No-fault narrative to explain life disappointments • Chronic PTSD - psychologically damaged and always off course with many layers of psychopathology and behavioral problems. • Retirement planning - rational economic choice. Need to conduct MMPI (lie scale) and examine historical records. Except for Chronic PTSD, these are all treatable with very good prognoses - not disabilities (chronic PTSD would not be a disability either) Practical steps:
  • 14. • Treat early • Treat symptoms (no PTSD-specific treatment) • Emphasize rehabilitation in chronic conditions • Remove perverse incentive to seek compensation without treatment Notes: Do service members avoid treatment in order to protect their service record? Dr. Cross says he gets pre and post deployment assessments. What value are these if we can’t tease out the normal adjustment period? We need to match them up to data on acute episodes in the field too. How does DOD determine that they have completed their training for service members that is appropriate for the levels of likely exposure to grave events and the psychological profile of the member? Features for DOD to consider are volition, preparation, continuity, rest, familiarity, assimilation, and security. Mathew Friedman This is a disorder of reactivity that can be operationalized as uncontrollable or unexpected stress. Symptoms have expanded from 3 to 17, from DSM-III to DSM-IV Criterion A1 - experienced, witnessed, or confronted by trauma is intentionally broad (many possible events) Criterion A2 - response of fear, helplessness, and horror is the narrow requirement (subjective interpretation) Clearly, A2 is not a great gatekeeper if someone is lying to get compensation benefits There may be promising breakthroughs in biological profiling OIG study on 92 cases was wrong - longitudinal studies demonstrate that participation in treatment increases with disability award (Sayer et al., 2002) How about not being I treatment at all when you make a disability claim? Rigor is being applied to prevent false positives in exams, via Dr. Cross