Comparing Mindfulness and Psychoeducation Treatments for Combat-Related PTSD

Comparing Mindfulness and Psychoeducation Treatments for
Combat-Related PTSD Using a Telehealth Approach
Barbara L. Niles
National Center for Posttraumatic Stress Disorder (PTSD) and
Veterans Administration (VA) Boston Healthcare System,
Boston, Massachusetts, and Boston University
Julie Klunk–Gillis and Donna J. Ryngala
National Center for PTSD and VA Boston Healthcare System,
Boston, Massachusetts
Amy K. Silberbogen
VA Boston Healthcare System, Boston, Massachusetts, and
Boston University
Amy Paysnick
Boston, Massachusetts
Erika J. Wolf
Boston,
Massachusetts, and Boston University
This pilot study examined two telehealth interventions to
address symptoms of combat-related posttrau-

matic stress disorder (PTSD) in veterans. Thirty-three male
combat veterans were randomly assigned to
one of two telehealth treatment conditions: mindfulness or
psychoeducation. In both conditions, partic-
ipants completed 8 weeks of telehealth treatment (two sessions
in person followed by six sessions over
the telephone) and three assessments (pretreatment,
posttreatment, and 6-week follow-up). The mind-
fulness treatment was based on the tenets of mindfulness-based
stress reduction and the psychoeducation
manual was based on commonly used psychoeducation materials
for PTSD. Results for the 24 partici-
pants who completed all assessments indicate that: (1)
Telehealth appears to be a feasible mode for
delivery of PTSD treatment for veterans; (2) Veterans with
PTSD are able to tolerate and report high
satisfaction with a brief mindfulness intervention; (3)
Participation in the mindfulness intervention is
associated with a temporary reduction in PTSD symptoms; and
(4) A brief mindfulness treatment may
not be of adequate intensity to sustain effects on PTSD
symptoms.
Keywords: PTSD, mindfulness, Telehealth
The ongoing wars in Iraq and Afghanistan have intensified the
need for effective psychological interventions to assist veterans
returning from war. In addition to the nearly half million
veterans
from Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) estimated to have posttraumatic stress disorder
(PTSD), a substantial portion of the five million other Veterans
Health Administration (VHA) patients also suffer from PTSD
related to military experiences (VHA Office of Public Health,
2009). Military-related PTSD is associated with psychosocial

and
health ailments that severely impact veterans and tax the VHA
system and society at large. Veterans with chronic PTSD
manifest
myriad impairments in functioning, such as problems in family
relationships (Riggs, Byrne, Weathers, & Litz, 1998),
unemploy-
ment and income disparities (Sanderson & Andrews, 2006;
Savoca
& Rosenheck, 2000), and increased morbidity (O’Toole, Catts,
Outram, Pierse, & Cockburn, 2009) and mortality (Boscarino,
2006).
Although evidence-based treatments for PTSD offer relief for
many sufferers (Foa, Keane, Friedman, & Cohen, 2009), many
service members with PTSD diagnoses do not seek mental
health
treatment (Hoge et al., 2004). A proportion of individuals who
do
seek treatment for PTSD either drop out or are not substantially
helped by it (Chard, Schumm, Owens, & Cottingham, 2010;
Gar-
cia, Kelley, Rentz, & Lee, 2011; Schottenbauer, Glass, Arnkoff,
Tendick, & Gray, 2008). Emerging evidence suggests that OEF/
OIF veterans may be difficult to engage and likely to drop out
This article was published Online First November 14, 2011.
Barbara L. Niles, National Center for PTSD–Behavioral Science
Division,
and VA Boston Healthcare System and Boston University
School of Medicine,
Boston, Massachusetts; Julie Klunk-Gillis and Donna J.
Ryngala, National
Center for PTSD–Behavioral Science Division, and VA Boston
Healthcare

System, Boston, Massachusetts; Amy K. Silberbogen, VA
Boston Healthcare
System and Boston University School of Medicine, Boston,
Massachusetts;
Amy Paysnick, National Center for PTSD–Behavioral Science
Division, and
VA Boston Healthcare System, Boston, Massachusetts; Erika J.
Wolf, Na-
tional Center for PTSD–Behavioral Science Division, and VA
Boston Health-
care System and Boston University School of Medicine, Boston,
Massachusetts.
This research was supported by grant 1 EA-0000043 from the
Samueli
Institute for Information Biology and by funding from the
National Center for
PTSD, Behavioral Sciences Division, VA Boston Healthcare
System.
Correspondence concerning this article should be addressed to
Barbara L.
Niles, PhD, National Center for PTSD–Behavioral Science
Division, VA
Boston Health Care System, 150 South Huntington Avenue
(116-B-2), Bos-
ton, MA 02130. E-mail: [email protected]
Psychological Trauma: Theory, Research, Practice, and Policy
In the public domain
2012, Vol. 4, No. 5, 538 –547 DOI: 10.1037/a0026161
538
(Erbes, Curry, & Leskela, 2009). It is critical to find innovative

ways to address barriers to treatment and new ways to reduce
symptoms. The current study examines a novel mode of
treatment
delivery—telehealth—and evaluates the efficacy of two treat-
ments—mindfulness and psychoeducation—that have the
potential
to address the symptoms of PTSD.
Telehealth
The use of telecommunications technologies to provide or en-
hance health care has become increasingly popular. Therapy ad-
ministered over the telephone has gained attention as mobile
telephones have become commonplace, are easy to use, and pri-
vate (Mohr, Vella, Hart, Heckman, & Simon, 2008). Telephone
therapy addresses two important barriers to treatment: inconve-
nience and privacy. Telephone calls can be easily scheduled at
convenient times to accommodate busy schedules. Because ses-
sions are not held in a clinic, they bypass the perceived stigma
associated with mental health care. Furthermore, telephone
inter-
ventions are less costly than face-to-face visits, as the financial
and
time costs of travel are eliminated.
Challenges associated with telephone mental health treatment
have also been identified. Building rapport may be more
difficult,
and there is the potential for both therapist and client to be
distracted by their environments (Haas, Benedict, & Kobos,
1996).
It is important that safety and ethical issues (e.g., assisting a
suicidal client) may be more challenging when the therapist is
geographically distant from the client (Haas et al., 1996). None-
theless, studies investigating efficacy and client satisfaction of
telehealth interventions have been quite promising. A recent

meta-
analysis of telephone-delivered psychotherapy for depression
in-
dicates that it significantly reduces symptoms, with dropout
rates
below 10% (Mohr et al., 2008).
Studies evaluating telehealth treatments to address PTSD are
scant, but findings suggest that telehealth treatments for PTSD
can
be as effective as those delivered in person. No differences in
efficacy, dropout rates, or attendance were detected between
cognitive– behavioral therapy (CBT) delivered over the phone
and
CBT delivered in person for veterans with combat-related PTSD
(Frueh et al., 2007). In a trial comparing videoteleconferencing
versus in-person modalities of anger-management group therapy
for veterans with PTSD, no significant differences were found
on
measures of attrition, adherence, satisfaction, treatment expec-
tancy, or measures of anger difficulties (Morland et al., 2010).
A
study of prolonged exposure therapy delivered via one-to-one
videoconference demonstrated feasibility and high acceptability
for this modality and resulted in significant decreases in self-
reported PTSD and depression (Tuerk, Yoder, Ruggiero, Gros,
&
Acierno, 2010). Thus, there is great potential for the use of
telehealth technologies in the treatment of PTSD.
Mindfulness
Mindfulness, frequently defined as a focused attention on pres-
ent experiences without judgment (Kabat–Zinn, 1994), has re-
ceived increasing attention in the clinical treatment literature.
One

of the most popular and well-researched mindfulness
interventions
is mindfulness-based stress reduction (MBSR; Kabat–Zinn,
1990),
an 8-week group treatment that introduces a meditative practice
and cultivates present awareness of mental processes and
physical
states. MBSR has demonstrated efficacy in ameliorating a wide
range of medical and mental health diagnoses (see Baer, 2003;
Grossman, Niemann, Schmidt, & Walach, 2004).
The use of MBSR as a stand-alone treatment for PTSD has not
been thoroughly investigated, though Santorelli and Kabat–Zinn
(2009) do not recommend the MBSR program as a first-step
treatment, due to concerns that clients may lack skills to
tolerate
difficult emotions. However, one recent pilot study evaluated
the
impact of MBSR on symptoms of PTSD and depression among
adult survivors of childhood trauma in concurrent
psychotherapy
(Kimbrough, Magyari, Langenberg, Chesney, & Berman, 2010).
Although this trial lacked a control or comparison condition,
results showed significant reductions in depression and PTSD
symptoms at posttreatment that were largely sustained at the
follow-up assessment 4 months later.
Mindfulness skills are key components of some empirically
validated treatments for conditions that frequently co-occur
with
PTSD, such as depression (Segal, Williams, & Teasdale, 2002),
borderline personality disorder (Linehan, 1993), and
generalized
anxiety disorder (Roemer & Orsillo, 2007), suggesting that
mind-

fulness may augment other therapies. A recent meta-analysis
also
demonstrated robust effects of mindfulness-based therapy on
de-
pression and anxiety symptoms in clinical samples (Hoffman,
Sawyer, Witt, & Oh, 2010).
Despite the encouraging research on mindfulness for psycho-
logical disorders, the extant research suffers from
methodological
flaws, such as a lack of control groups, small sample sizes,
inadequate adherence monitoring, failure to determine clinical
significance, and absence of follow-up assessment. Recent com-
mentaries (e.g., Davidson, 2010) have called for empirically
sound
research to address these methodological issues in order to
deter-
mine whether mindfulness interventions can be efficacious in
treating psychological problems, such as PTSD.
Psychoeducation
Education about PTSD has been recommended as a treatment or
component of treatment for persistent PTSD (Foa et al., 1999).
The
goals of psychoeducation are to increase one’s understanding of
stress reactions, readjustment difficulties, and recovery, as well
as
to normalize experiences, and assist in the early identification
of
symptoms that may reflect the development or exacerbation of a
mental disorder. Even though most empirically validated treat-
ments for PTSD begin with psychoeducation (e.g., Foa & Roth-
baum, 1998; Resick & Schnicke, 1993), there has been little
evaluation of its efficacy.

Current Study
In this pilot study, we examined two telehealth interventions—
mindfulness and psychoeducation—to address symptoms of
combat-related PTSD in veterans using a randomized
experimental
design. A combination of two face-to-face sessions, followed by
six telephone sessions was used in both treatments provided.
Primary variables of interest were feasibility and client
satisfaction
with the telehealth approach and the content of the two
therapies.
We hypothesized that both treatments would be associated with
reduced symptoms of PTSD at posttreatment and 6-week follow-
539COMPARING MINDFULNESS AND
PSYCHOEDUCATION
up, with greater and more clinically significant reductions ex-
pected for the mindfulness condition.
Method
Participants
Participants were 33 male veterans recruited through: (1) flyers
posted throughout Veterans Administration (VA) Boston Health
care System; (2) clinician referrals; and (3) an electronic
partici-
pant recruitment database. Inclusion criteria were: documented
military service in a war zone or peace-keeping theater, a
current
diagnosis of PTSD (as determined by structured interview), and
access to a telephone. Exclusion criteria were: severe organicity

or
active psychosis, an unstable regimen of psychiatric medication
over the last 2 months, psychiatric hospitalization in the last 2
months, or symptoms consistent with a diagnosis of alcohol or
drug dependence within the past 3 months. The Addiction
Severity
Index (McLellan, Luborsky, Woody, & O’Brien, 1980) and the
substance abuse module of the Structured Clinical Interview for
the Diagnostic and Statistical Manual for Mental Disorders 4th
edition (DSM–IV) Axis I Disorders (SCID-SA; First, Spitzer,
Gibbon, & Williams, 2002) were used to assess current
substance
use problems as part of the study screen to determine
participant
eligibility (see below). Substance abuse was not an exclusion
criterion.
Sixty-eight veterans completed a telephone screening, 41 com-
pleted an initial assessment, and 33 met eligibility criteria and
enrolled in the study. See Figure 1 for the study flowchart.
All participants were male, between the ages of 23 and 66
(mean
[M]age � 52.0; standard deviation [SD] � 13.0), were exposed
to
trauma in either warzone or peacekeeping theaters, and met full
criteria for PTSD as measured by the Clinician-Administered
PTSD Scale (CAPS; Blake et al., 1990, see below). Regarding
era
of military service, 30% (n � 10) were veterans of Operation
Iraqi
Freedom (OIF), 64% (n � 21) had served in Vietnam, and 6%
(n � 2) had served during peace-keeping missions (e.g.,
Bosnia).
Additionally, 76% of the sample (n � 25) identified as White,

not
Hispanic, 15% (n � 5) Black, not Hispanic, 6% (n � 2) White,
Hispanic, and 3% (n � 1) as “other.”
Participants were not required to discontinue ongoing treatment
with other mental health providers during the study. Use of and
changes in psychiatric medication were assessed through review
of
VA medical records (for participants receiving mental health
care
through the VA, n � 27) or by self report (for participants
receiving psychiatric care from other providers, n � 6). Most
participants (67%, n � 21) were taking prescribed psychiatric
medication when they entered the study.
Involvement in ongoing psychotherapy was also assessed by
review of medical records. Most of the participants who
completed
treatment (66%, n � 15 of 27) had one or more individual
sessions
with a mental health provider in addition to the treatment
provided
Figure 1. Flowchart for participant completion rates.
540 NILES ET AL.
by the study, and PTSD was the focus of at least one session for
33% (n � 9 of 27). Per medical record notes, 8 participants
(30%)
completed 4 or more individual sessions during the 8 weeks in
which the study treatment was ongoing, and the average number
of
sessions for those in individual treatment was 5.5 (range � 1 to

12).
Measures
The Clinician Administered PTSD Scale (CAPS; Blake et
al., 1990). Considered the “gold-standard” for PTSD assess-
ment, the CAPS is a 30-item structured interview that assesses
all
DSM–IV diagnostic criteria for PTSD. The scale yields a
dichot-
omous diagnosis and a continuous score of clinician—rated fre-
quency and intensity for each symptom rated on 5-point scales.
Symptom severity is determined by summing frequency and in-
tensity scores. We employed the commonly used “Frequency
�1/Intensity �2” scoring rule to determine thresholds for each
symptom. The CAPS has repeatedly demonstrated strong and
robust psychometric properties with excellent test–retest
reliability
(r � .89 –1.00; Weathers, Ruscio, & Keane, 1999), interrater
reliability (r � .92 for total severity; Weathers et al., 1999), and
concurrent validity (r � .91 with the Mississippi Scale for
Combat-Related PTSD; Weathers et al., 1999). The internal
con-
sistency for this measure in the current study was high: Time 1
� � .90, Time 2 � � .93.
The PTSD Checklist–Military Version (PCL-M; Weathers,
Litz, Herman, Huska & Keane, 1993). The PCL-M is a
self-report measure consisting of 17 items that parallel the
DSM–IV PTSD criteria. Respondents indicate on a 5-point scale
how much they have been bothered in the last month by
particular
symptoms that are related to stressful military experiences. The
PCL has been shown to have excellent test–retest reliability (r
�
.96; Weathers et al., 1993) and concurrent validity as compared

with structured clinical interviews for PTSD (r � .79 to 0.93;
Blanchard, Jones–Alexander, Buckley, & Forneris, 1996). The
internal consistency for this measure in the current study was
high:
Time 1 � � .89, Time 2 � � .95, Time 3 � � .91.
The Participant Satisfaction Questionnaire (PSQ). The
PSQ is a self-report questionnaire developed for the current
study
to gather information about participants’ levels of satisfaction
with
the interventions. Responses using a 5-point scale are summed
and
averaged to derive an overall satisfaction score. Psychometric
properties of this scale have not been established.
Procedure
Clinicians. Two female clinicians with PhDs in clinical psy-
chology served as therapists. Both served as therapists for both
conditions, were regular practitioners of mindfulness
meditation,
and had received training in assessment and treatment of PTSD
in
veterans at the National Center for PTSD, Behavioral Science
Division, VA Boston Healthcare System. Each participant was
assigned to one of the two clinicians to complete the initial
assessment and the treatment.
Informed consent. The institutional review board-approved
informed consent form was reviewed with the participant, and
the
participant’s signature was obtained at the outset of the first
visit.
Assessments. The CAPS and Addiction Severity Index were

administered to participants at the baseline (Time 1)
assessment. If
a participant screened positive on the Addiction Severity Index,
the
SCID-SA was administered, and those who met criteria for sub-
stance dependence were screened out. Self-report measures were
administered and therapy sessions were scheduled with the
clini-
cian who conducted the assessment. Dr. Niles then informed the
therapist of the group assignment that had been determined by a
random numbers generator. A stratified randomization
procedure
was used to balance the number of OEF/OIF veterans in each
condition. Clinicians and participants were blind to treatment
condition until after the first assessment had been completed.
The posttreatment (Time 2) assessment included the same mea-
sures as the initial assessment with one additional measure, the
PSQ. In order to reduce participant and therapist demand bias,
posttreatment assessments were not completed by the
participant’s
therapist, but by the other study clinician or principal
investigator.
Participants were compensated $40 for the pre- and
posttreatment
assessments.
The 6-week follow-up (Time 3) assessment was identical to the
posttreatment assessment, with three exceptions: the PSQ was
not
readministered due to redundancy, the CAPS was not readminis-
tered in an effort to reduce participant burden, and participants
were compensated $30.
Treatment. At the first session for both treatment conditions,

participants were provided with a handbook (specific to
treatment
condition) comprised of two- to three-page readings for each
week
of treatment. The handbooks for both treatment conditions were
developed to meet the needs of a veteran population (e.g., text
was
in a large and easy-to-read font, written at an eighth grade
level).
In addition to providing content, the two 45-min in-person
sessions
were used to establish rapport. The six weekly telephone
sessions
reviewed information presented in the manuals. The eighth
session
was used to review the previous seven sessions and address ter-
mination issues. Telephone sessions were approximately 20 min
in
length.
Mindfulness. The Mindfulness Handbook was developed in
collaboration with the codirector of Professional Training at the
Center for Mindfulness in Medicine, Health Care, and Society at
the University of Massachusetts Medical School. It
complemented
the information covered during the sessions and provided educa-
tion about these mindfulness topics: defining mindfulness,
notic-
ing sensations, noticing thoughts and emotions, beginner’s
mind,
choice, patience, continuing to practice. During the two initial
in-person sessions, participants were led through two
experiential
exercises. Participants were given portable CD players and CDs
with 5- to 15-min guided mindfulness exercises to practice the
mindfulness skills outside of sessions. Participants were asked

to
keep track of their practice using monitoring sheets provided,
and
to report this each week. A few minutes of each session were
spent
focusing on any difficulties participants may have encountered
with the practice.
Psychoeducation. The PTSD Education Handbook, based on
content from an introductory psychoeducation group developed
at
the National Center for PTSD, complemented the information
covered in the initial two sessions and provided additional
educa-
tion on a variety of topics: trust, safety and self-care, effects of
trauma, relationships and trauma, coping and healing, change,
and
moving forward. The treatment was focused on educating
partic-
ipants about how PTSD may affect their lives (e.g., avoidance
may
take the form of social isolation, workaholism, substance
abuse).
PSYCHOEDUCATION
Participants were encouraged to reflect on how symptoms may
be
impacting their day-to-day lives and suggestions for positive
cop-
ing were offered (e.g., listening to music, physical exercise) but
no
specific techniques for coping, such as relaxation exercises or

behavioral activation, were delivered.
Treatment adherence. At each telephone session, partici-
pants in both groups were asked to report the percentage of
assigned readings they completed. Participants in the
mindfulness
condition were also asked to keep a log of the CD track numbers
and the amount of unguided practice they engaged in each day
during the 8-week treatment. Time spent in mindfulness practice
during the 6-week follow-up period was not assessed.
To ensure therapist compliance with treatment delivery, thera-
pists completed a checklist of the major points to be covered at
each session. Each therapist met weekly with the principal
inves-
tigator for supervision regarding the cases. In addition, the
thera-
pists and investigators met weekly as a team to review session
progress and to problem solve difficulties with the protocols or
participant responses. The consultant from the Center for Mind-
fulness joined team meetings via telephone to provide guidance
regarding the mindfulness treatment.
Data Analysis
Univariate analyses were performed with a t test or chi-square
test. Repeated measures analyses of variance (RM-ANOVAs)
were used to examine differences between the two conditions
across all three time points. The type of intervention
(mindfulness
vs. psychoeducation) was the between-subjects factor and time
was the within-subjects factor. The RM-ANOVAs were then
sep-
arated by group and post hoc tests were used to determine
signif-
icance between specific cells.

Results
Completion, Compliance, and Satisfaction
Of the 33 veterans who were randomized, 27 (82%) completed
the 8-week intervention and posttreatment (Time 2) assessment
and 24 (72%) completed the 6-week follow-up (Time 3) assess-
ment (See Figure 1).
Treatment and posttreatment assessment completion rates did
not differ significantly between conditions: 76% for the
mindful-
ness condition and 87% for the psychoeducation condition,
�2(1,
N � 33) � .674, p � .412. Reasons for dropping out were:
moved
away (n � 2), terminated after being frequently unavailable for
telephone sessions (n � 2), experienced a manic episode and
dropped out of all VA treatment (n � 1), and no reason
provided
(n � 1). OIF veterans had similar treatment completion rates
(80.0%) as veterans from other eras, 82.6%; �2(1, N � 33) �
.032,
p � 1.00. Three participants who completed the Time 2 assess-
ment declined the follow-up (Time 3) assessment. There was no
significant difference between groups for completion of the
Time
3 assessment, �2(1, N � 27) � .081, p � .776. For both groups,
no adverse reactions to treatment were reported during the treat-
ment or follow-up periods.
Baseline scores on most demographics (race, ethnicity, educa-
tion level, employment status, meditation experience) and
outcome
measures did not differ between the nine dropouts and the 24

completers. Although OIF veterans did not differ from others on
the completion of the Time 2 assessment, a chi-square test indi-
cated a trend for OIF veterans to be more likely to drop out of
the
study before the follow up assessment. Half (50%) of the OIF
veterans dropped out by the Time 3 assessment, as compared
with
17% of the other veterans, �2(1, N � 33) � 3.74, p � .053. A
follow-up t test showed that veterans who dropped out were
significantly younger (Mage � 42.22, SD � 10.59) than the vet-
erans who completed, Mage � 55.25, SD � 15.48, t(31) � 2.56,
p � .016.
Participants who completed the interventions were very com-
pliant: 89% reported that they completed an average of at least
75% of the readings, while 63% reported completing all
readings
in their entirety. In the mindfulness condition, compliance with
mindfulness practice was surprisingly high: participants
reported
practicing over 2 hours per week on average (M � 137, SD �
91,
range � 41 to 307 min), even though the total amount of
practice
time assigned in the study ranged from only 20 –50 min per
week.
They also reported practicing an average of over 5 days per
week,
and 69% reported practicing both with and without the help of
the
guided exercises on CDs.
All participants who completed the study reported high satis-
faction ratings on the PSQ. There were no differences in
satisfac-

tion ratings between groups, with 88% of completing
participants
reporting that the intervention was “convenient” and 81%
report-
ing they “would recommend the intervention to other
individuals.”
The remaining participants reported being neutral on both of
these
statements; none reported dissatisfaction.
Pretreatment Group Differences
No differences were found between the two intervention groups
on demographic variables (age, race, ethnicity, education level,
employment status, era of service, meditation experience).
Despite
randomization, however, PTSD symptoms for the mindfulness
group were less severe at baseline. For the 24 participants who
completed all three assessments, scores on the PCL-M were sig-
nificantly lower, t(22) � �2.18, p � .040. The repeated-
measures
analyses reported below compare the two groups on their
relative
changes in symptoms over time; due to the small sample size,
however, no additional statistical procedure was used to control
for
the unequal baseline scores in symptoms.
Posttreatment and Follow-Up Group Differences
Evaluation of CAPS scores in the 27 participants who com-
pleted treatment and the Time 2 assessment revealed a main
effect
of condition, F(1, 25) � 7.21, p � .013, �p
2 � .224, no main effect

of time, F(1, 25) � 3.27, p � .083, �p
2 � .116, and a significant
Condition � Time interaction, F(1, 25) � 5.62, p � .026, �p
2 �
.183. We examined this interaction within condition and found
that
for the mindfulness group, mean scores dropped significantly
from
60.92 (SD � 19.25) at Time 1 to 47.46 (SD � 18.29) at Time 2,
F(1, 12) � 12.11, p � .005, �p
2 � .502, while for the psychoedu-
cation group, there was no significant change in mean symptoms
over time, F(1, 13) � .094, p � .765, �p
2 � .007 (see Table 1).
For the self-report PCL-M, PTSD changes at Time 2 were
similar to those found using the interview-based CAPS. For the
26
participants with valid scores, there was a main effect of
condition,
542 NILES ET AL.
F(1, 24) � 14.86, p � .001, �p
2 � .382, a main effect of time, F(1,
24) � 8.23, p � .008, �p
2 � .255, and a significant Condition �
Time interaction, F(1, 24) � 10.44, p � .004, �p

2 � .303. We
examined this interaction within condition and found that for
the
mindfulness group, mean PCL-M scores dropped significantly
from 52.31 (SD � 11.88) at Time 1 to 41.92 (SD � 11.27) at
Time
2, F(1, 12) � 15.03, p � .002, �p
2 � .556, while for the psychoe-
ducation group, there was no significant change in mean
symptoms
over time, F(1, 12) � .086, p � .775, �p
2 � .007 (see Table 1).
At Time 3 (6-week follow-up), PTSD symptoms were assessed
only with the PCL-M. For the 24 participants who completed all
three assessments, on PCL-M scores there was a main effect of
condition, F(1, 22) � 10.60, p � .004, �p
2 � .325, no main effect
of Time, F(1, 22) � 1.41, p � .248, �p
2 � .060, and a significant
quadratic Condition � Time interaction effect, F(1, 22) �
16.15,
p � .001, �p
2 � .423. We examined this interaction within condi-
tion and found that for the mindfulness group, mean PCL-M
scores
had a quadratic change from 52.75 (SD � 12.30) at Time 1 to
42.75 (SD � 11.35) at Time 2 to 50.75 (SD � 12.27) at Time 3,
F(1, 12) � 14.98, p � .003, �p

2 � .577, while for the psychoedu-
cation group, there was no significant linear or quadratic change
over time, F(1, 11) � 1.89, p � .196, �p
2 � .147 (quadratic).
Follow-up t tests on the mindfulness group indicate a significant
drop in PCL-M scores from Times 1 to 2, t(11) � 3.47, p �
.005,
a significant increase from Times 2 to 3, t(11) � �3.57, p �
.004,
but no significant difference between Time 1 and Time 3, t(11)
�
0.89, p � .391 (see Figure 2).
We examined whether clinically significant changes pre to post
treatment for individuals were distributed equally between the
two
groups. We first calculated whether or not there was a clinically
significant change for each individual using criteria reported by
Monson et al. (2008): 20 point changes on the CAPS, 10 point
changes on the PCL-M. Participants were then categorized into
three groups: clinically significant improvement, no change
(i.e.,
change only within the a priori specified amount), or clinically
significant worsening of symptoms. For the CAPS, a chi-square
analysis indicated a trend toward significant difference between
the two groups. In the mindfulness condition, 5 of 13 (38.5%)
participants had a clinically significant improvement and the re-
mainder had no significant change. By contrast, in the psychoe-
ducation condition, 1 of 14 (7.1%) had a clinically significant
improvement, 10 (71.4%) had no change, and 3 (21.4%) had
worsening of symptoms, �2(2, N � 27) � 5.86, p � .053. For
the
PCL-M the outcomes were similar. In the mindfulness
condition,

7 of 13 (53.8%) participants had a clinically significant
improve-
ment and the remainder had no significant change. In the
psychoe-
ducation condition, 1 of 13 (7.7%) had a clinically significant
improvement, 11 (84.6%) had no change, and 1 (7.7%) had
wors-
ening of symptoms, �2(2, N � 26) � 6.97, p � .031.
No significant differences between groups were found for vari-
ables representing concurrent psychotherapy. Five participants
(15.2%) had a change in psychiatric medication; two of these
dropped out of the study and three completed. The three com-
pleters were all in the mindfulness condition and were
prescribed
additional medication during the 14-week study (two during the
intervention and 1 during the follow-up). One of these three
exhibited a clinically significant improvement in PTSD
symptoms
between Times 1 and 2 as measured by the CAPS and the PCL-
M
and two did not show clinically significant change on either
measure. To address concerns that medication change for the
individual who improved was responsible for the overall group
change between Times 1 and 2, we eliminated this participant
and
re-ran the ANOVAS. The pattern of results was unchanged from
that reported above. (Details available from Dr. Niles).
For the mindfulness group, a significant dose-response correla-
tion was found between total practice time and pre- to posttreat-
ment symptom change in the expected direction (more practice
was associated with better outcome) for CAPS scores, r(10) �
�.66, p � .02, 2-tailed, but not for PCL-M scores, r(10) � .01,
p � .97.

Discussion
This study indicates that it is feasible to deliver telehealth
treatments for PTSD, as over 80% of the participants completed
Figure 2. Change in PCL-M scores at posttreatment and follow-
up as-
sessment.
Table 1
Means and Standard Deviations for Outcome Measures
Measure Assessment
M (SD)
Mindfulness Psychoeducation
CAPSa Time 1 60.92 (19.25) 72.50 (19.66)
Time 2 47.46 (18.29) 74.00 (22.95)
Time 3 — —
PCL-M Time 1 52.75 (12.29) 63.08 (10.85)
Time 2 42.75 (11.35) 64.42 (10.84)
Time 3 50.75 (12.27) 61.33 (11.39)
Note. CAPS � Clinician Administered PTSD Scale; PCL-M �
PTSD
Checklist–Military Version.
a CAPS data were collected only at Times 1 and 2 (n � 27);
PCL-M was
collected at Times 1, 2, and 3 (n � 24).
PSYCHOEDUCATION

the 8-week intervention and over 70% completed the follow-up
assessment. These rates of completion are comparable to those
reported in a VA PTSD clinic (Erbes et al., 2009) and to rates
reported for most randomized trials of treatments for PTSD
(Schottenbauer et al., 2008). This study detected no differences
between OIF veterans and other veterans in completion of treat-
ment, a finding in contrast with that of Erbes et al. (2009) who
found that twice as many OEF/OIF veterans dropped out of
treat-
ment than did Vietnam veterans. However, three of the eight
OIF
veterans who completed treatment dropped out during the 6-
week
follow-up period. As a result, completion rates for follow-up
assessment (Time 3) indicate that the veterans from current con-
flicts were substantially (with a trend toward significantly)
more
likely to drop out and that those who dropped out were signifi-
cantly younger than those who completed. These findings
suggest
that the telehealth format may equally engage younger and older
veterans in treatment, but that the younger veterans from
current
conflicts are not as likely to complete follow-up assessments.
The
veterans who finished the interventions were very compliant
with
the treatment, completing all the telephone calls and most of the
weekly homework assignments. Participants also reported very
high rates of satisfaction with the mode of delivery, a
combination
of two in-person sessions and six telephone sessions.
The findings of this study support evidence from other recent

studies (Frueh et al., 2007; Morland et al., 2010; Tuerk et al.,
2010)
indicating that telehealth modalities are feasible to deliver and
are
associated with high satisfaction rates in the treatment of PTSD
for
veterans. Telehealth interventions may be especially important
for
clients who have difficulty attending appointments due to health
constraints or travel from rural locations. However, even for
phys-
ically healthy individuals in an urban environment, the conve-
nience offered by a telephone intervention may encourage
greater
participation in treatment.
Regarding compliance with a mindfulness intervention in a
veteran PTSD population, participants in the mindfulness condi-
tion completed more of the homework assignments than antici-
pated, engaging in guided or sitting meditation over 2 hours per
week on average, substantially more than requested by the
proto-
col. The veterans who chose to participate in this investigation
may
have been particularly interested in mindfulness and meditation,
and may have been more compliant with homework than other
veterans seeking treatment for PTSD. Nonetheless, this finding
is
especially notable given concerns that mindfulness meditation
may
not be appropriate for individuals with PTSD because intense
focus on the present moment could trigger an exacerbation of
symptoms or dissociative reaction. In the current study, no
adverse
reactions to the mindfulness treatment were reported and
satisfac-

tion ratings were high. Thus, this study demonstrates that some
veterans with PTSD can engage in mindfulness meditation.
The current study provides preliminary evidence that participa-
tion in a brief mindfulness intervention may temporarily reduce
symptoms of PTSD more than the psychoeducation intervention.
Scores on both self-report and clinician-administered measures
of
PTSD dropped significantly in the mindfulness group between
Times1 and 2. The effect sizes were large, accounting for at
least
half of the variance in the scores on both measures. Over 50%
of
those in the mindfulness treatment achieved a clinically
significant
change in PTSD symptoms as measured by self-report. Given
the
brevity of the intervention, it is encouraging that the impact on
symptoms was clinically significant for a substantial proportion
of
participants. However, it is important to note that the mean
scores
on the PTSD measures indicate that even after a reduction in
symptoms, substantial PTSD symptoms remained.
The return to baseline on self-report PTSD measures at Time 3
for the mindfulness group indicates that positive effects
associated
with this brief treatment were not enduring and may reflect the
ebb
and flow of PTSD over time. Continued mindfulness practice
has
been found to be necessary for a continued positive effect (Car-
mody & Baer, 2008). Participants may have stopped practicing
or

reduced meditation time after the intervention ended. Practice
time
during the 6-week follow-up period was not measured, so we
cannot provide evidence to support this theory. However, the
correlation between practice time and change in PTSD
symptoms
as measured by the CAPS at Time 2 was significant. Thus, it
seems
very plausible that reduction of mindfulness practice is
associated
with the rise in PTSD symptoms.
The psychoeducation intervention did not appear to impact
PTSD symptoms; pre- to posttreatment mean scores on PTSD
measures were not significantly different and the majority of
participants showed no clinically significant change. One expla-
nation for this might be that additional education about PTSD
symptoms is not beneficial for those who have already received
it,
as most participants in this study had been in treatment and
educated about PTSD symptoms before. A few veterans in this
study evidenced a clinically significant worsening of symptoms
which may indicate that psychoeducation can be harmful for
some
individuals. However, a more likely explanation may be that
education about the symptoms of PTSD causes more awareness
of
symptoms and can thus increase reports of symptoms. For exam-
ple, psychoeducation may allow participants to notice trauma
cues,
the distress associated with the cues, and the subsequent
avoidant
responses. Alternatively, a desire to attain or maintain service-
connected compensation for PTSD may cause veterans to report
more symptoms and distress (e.g., Frueh et al., 2003), although
this

would be true for both conditions. Thus, despite findings that
PTSD symptoms increased slightly following the
psychoeducation
intervention, we concur with previous suggestions that psychoe-
ducation is likely helpful for traumatized individuals who are
new
to treatment (e.g., Foa & Rothbaum, 1998; Resick & Schnicke,
1993) and recommend it as an early component of treatment for
PTSD.
The small sample size for this pilot study limits the conclusions
that can be drawn. First, in terms of data analysis, participants
who
dropped out of treatment did not complete Time 2 or Time 3
assessments and the small sample precluded use of maximum-
likelihood based methods of addressing missing data at these
time
points. Intention-to-treat analyses therefore were not possible
for
this study. Thus, it must be assumed that the missing data is not
missing at random and may be biased. As this is a pilot investi-
gation, differences detected between the mindfulness and
psychoe-
ducation conditions can only be considered suggestive and
future
formal clinical trials with appropriate intention-to-treat and
miss-
ing data procedures are needed to examine whether these differ-
ences are replicable. Second, the risk of type one error was
elevated because we used several repeated-measures ANOVAs.
In
order to balance the risks of type one and type two error,
follow-up
tests were performed only after the initial omnibus F tests indi-
cated significant differences. Third, participants in the
psychoedu-

544 NILES ET AL.
cation group evidenced greater PTSD symptoms, indicating that
randomization along these dimensions was not successful; a
larger
sample size would likely have produced more balanced groups.
Because the mindfulness group had less severe PTSD symptoms,
it is not possible to know if this intervention would produce
similar
results in a sample with greater symptom severity. However, it
is
notable that treatment effects were detected in the mindfulness
group despite the lower initial scores on the PTSD measures,
suggesting a robust effect. Fourth, even though the number of
people taking psychiatric medications was balanced across
groups,
all three participants with medication changes were in the mind-
fulness group and one of the three evidenced a clinically
signifi-
cant improvement in symptoms. A larger sample would allow
inclusion of medication change as a covariate. Finally, the small
sample precluded use of regression analyses to identify
mediators
and moderators of treatment outcomes.
There are also aspects of study design that indicate these
results should be interpreted with caution. (1) Veterans in VA
treatment for combat-related PTSD are a select group and these
results may not apply to other veteran, military, or PTSD
populations. The majority of the veterans in this study were in
concurrent VA treatment. Given that VA populations have
shown lower response rates to PTSD treatments than nonveter-
ans (Bradley, Greene, Russ, Dutra, & Westen, 2005; Friedman,

Marmar, Baker, Sikes, & Farfel, 2007), it is notable that the
mindfulness condition was associated with symptom reduction.
(2) The assessors for the Time 2 and Time 3 assessments were
not blind to condition and may have been biased in the admin-
istration of the CAPS at Time 2. However, the self-report PCL
findings at Times 1 and 2 were very similar to the CAPS
findings, indicating consistency across methods of assessment.
(3) The study therapists delivered both treatments and were not
randomly assigned to condition; this raises concerns about
potential bias regarding delivery of treatment (Luborsky, Bar-
rett, Antonuccio, Shoenberger, & Stricker, 2006). They were
both mindfulness practitioners and thus may have favored the
mindfulness treatment, which may have unduly inflated the
superiority of the mindfulness intervention. However, they both
also regularly delivered psychoeducation to veterans with
PTSD. (4) Although checklists were used to assess therapist
adherence to the treatment protocol, adherence was not evalu-
ated by independent reviewers via recordings. Thus, the thera-
pists may have deviated from the protocol at times. (5) The
study design did not allow a comparison between the novel
aspects of the treatments (telehealth mode of delivery, mind-
fulness as a treatment for PTSD) and available empirically
supported treatments for PTSD.
Overall the findings from this study of veterans with combat-
related PTSD provide preliminary support for the feasibility of
(1)
a telehealth mode of delivery and (2) an intervention promoting
mindfulness. The mindfulness intervention was associated with
a
reduction in PTSD symptoms at posttreatment, and this
investiga-
tion contributes to the literature suggesting that mindfulness
train-
ing may be useful in the treatment of PTSD (e.g., Follette &
Vijay,

2009; Kimbrough et al., 2010). The brief treatment was not ade-
quate to sustain changes and may need to be extended in length
or
intensity or paired with other treatments to have lasting effects.
The mechanisms by which mindfulness can impact PTSD symp-
tomatology should be explored in future studies. For example,
the
arousal symptoms of PTSD have been shown to be important in
“driving” the other PTSD symptoms (Schell, Marshall, &
Jaycox,
2004) and decrements in arousal associated with mindfulness
practice may account for changes in symptoms. Mindfulness
prac-
tice also encourages cognitive flexibility and cultivation of non-
judgmental acceptance of thoughts and feelings, even those that
are distressing. This may serve as exposure to trauma-related
cognitions and emotions and may be effective in a manner
similar
to the way that exposure-based treatments are hypothesized to
reduce symptoms.
Mindfulness meditation has shown promise in treating many
disorders and the current study suggests that its use in the
treatment of PTSD merits further investigation. This study also
highlights that mindfulness can be delivered through a tele-
health format, a more flexible alternative to traditional face-to-
face treatment. Future treatment trials should evaluate the use
of
mindfulness for PTSD using intention-to-treat analyses with
larger samples, clinician-administered outcome measures ad-
ministered by blind assessors, and evaluation of therapist ad-
herence to protocol. Comparing current evidence-based treat-
ments for PTSD with mindfulness interventions alone and with
mindfulness interventions combined with evidence-based treat-

ments will be important in determining whether mindfulness
can enhance current efficacious treatments for PTSD. In addi-
tion, future studies should evaluate different modalities of
mindfulness treatment delivery, such as group, face-to-face
individual, telehealth with no face-to-face, or Internet-based
treatment. To provide optimal patient care, it is critical to
consider novel approaches that may complement and extend
current therapies for PTSD.
References
Baer, R. A. (2003). Mindfulness training as a clinical
intervention: A
conceptual and empirical review. Clinical Psychology: Science
and
Practice, 10, 125–143. doi:10.1093/clipsy.bpg015
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G.,
Klaaumin-
zer, G. Charney, D. S., & Keane, T. M. (1990). A clinician
rating scale
for assessing current and lifetime PTSD: The CAPS-1. Behavior
Ther-
apist, 13, 187–188.
Blanchard, E. B., Jones–Alexander, J., Buckley, T. C., &
Forneris, C. A.
(1996). Psychometric properties of the PTSD checklist (PCL).
Behav-
iour Research and Therapy, 34, 669 – 673. doi:10.1016/0005-
7967(96)00033-2
Boscarino, J. A. (2006). Posttraumatic stress disorder among
U.S. army
veterans 30 years after military service. Annals of
Epidemiology, 16,

248 –256. doi:10.1016/j.annepidem.2005.03.009
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D.
(2005). A
multidimensional meta-analysis of psychotherapy for PTSD.
The Amer-
ican Journal of Psychiatry, 162, 214 –227. doi:10.1176/appi.ajp
.162.2.214
Carmody, J., & Baer, R. (2008). Relationships between
mindfulness prac-
tice and levels of mindfulness, medical and psychological
symptoms and
well-being in a mindfulness-based stress reduction program.
Journal of
Behavioral Medicine, 31, 23–33. doi:10.1007/s10865-007-9130-
7
Chard, K. M., Schumm, J. A., Owens, G. P., & Cottingham, S.
M. (2010).
A comparison of OEF and OIF veterans and Vietnam veterans
receiving
cognitive processing therapy. Journal of Traumatic Stress, 23,
25–32.
doi:10.1002/jts.20500
Davidson, R. J. (2010). Empirical explorations of mindfulness:
Conceptual
and methodological conundrums. Emotion, 10, 8 –11.
doi:10.1037/
a0018480
PSYCHOEDUCATION

Erbes, C. R., Curry, K. T., & Leskela, J. (2009). Treatment
presentation
and adherence of Iraq/Afghanistan era veterans in outpatient
care for
posttraumatic stress disorder. Psychological Services, 6, 175–
183. doi:
10.1037/a0016662
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W.
(2002).
Structured clinical interview for DSM–IV–TR axis I disorders-
patient
ed. (SCID-I/P, 11/2002 revision). New York, NY: New York
State
Psychiatric Institute.
Foa, E. B., Davidson, J. R. T., Frances, A. Culpepper, L., Ross,
R., & Ross,
D. (Eds.). (1999). The expert consensus guideline series:
Treatment of
posttraumatic stress disorder. Journal of Clinical Psychiatry, 60,
4 –76.
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A.
(Eds.). (2009).
Effective treatments for PTSD. New York, NY: Guilford Press.
Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of
rape:
Cognitive-behavioral therapy for PTSD. New York, NY:
Guilford Press.
Follette, V. M., & Vijay, A. (2009). Mindfulness for trauma and
posttrau-
matic stress disorder. In F. Didonna (Ed.), Clinical handbook of

mind-
fulness (pp. 299 –317). New York, NY: Springer Science �
Business
Media.
Friedman, M. J., Marmar, C. R., Baker, D. G., Sikes, C. R., &
Farfel, G. M.
(2007). Randomized, double-blind comparison of sertraline and
placebo
for posttraumatic stress disorder in a Department of Veterans
Affairs
setting. Journal of Clinical Psychiatry, 68, 711–720.
doi:10.4088/
JCP.v68n0508
Frueh, B. C., Elhai, J. D., Gold, P. B., Monnier, J., Magruder,
K. M.,
Keane, T. M., & Arana, G. W. (2003). Disability compensation
seeking
among veterans evaluated for posttraumatic stress disorder.
Psychiatric
Services, 54, 84 –91. doi:10.1176/appi.ps.54.1.84
Frueh, B. C., Monnier, J., Yim, E., Grubaugh, A. L., Hamner,
M. B., &
Knapp, R. G. (2007). A randomized trial of telepsychiatry for
post-
traumatic stress disorder. Journal of Telemedicine and Telecare,
13,
142–147. doi:10.1258/135763307780677604
Garcia, H. A., Kelley, L. P., Rentz, T. O., & Lee, S. (2011).
Pretreatment
predictors of dropout from cognitive behavioral therapy for
PTSD in
Iraq and Afghanistan war veterans. Psychological Services, 8,

1–11.
doi:10.1037/a0022705
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004).
Mindfulness-based stress reduction and health benefits: A meta-
analysis.
Journal of Psychosomatic Research, 57, 35– 43.
doi:10.1016/S0022-
3999(03)00573-7
Haas, L. J., Benedict, J. G., & Kobos, J. C. (1996).
Psychotherapy by
telephone: Risks and benefits for psychologists and consumers.
Profes-
sional Psychology: Research and Practice, 27, 154 –160.
doi:10.1037/
0735-7028.27.2.154
Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010).
The effect
of mindfulness-based therapy on anxiety and depression: A
meta-
analytic review. Journal of Consulting and Clinical Psychology,
78,
169 –183. doi:10.1037/a0018555
Hoge, C. W., Castro, C. A., Messer, S. C., Cotting, D. I.,
Koffman, R. L.,
& McGurk, D. (2004). Combat duty in Iraq and Afghanistan,
mental
health problems, and barriers to care. The New England Journal
of
Medicine, 351, 13–22. doi:10.1056/NEJMoa040603
Kabat–Zinn, J. (1990). Full catastrophe living: Using the
wisdom of your

body and mind to face stress, pain and illness. New York, NY:
Dela-
corte.
Kabat–Zinn, J. (1994). Wherever you go, there you are:
Mindfulness
meditation in everyday life. New York, NY: Hyperion.
Kimbrough, E., Magyari, T., Langenberg, P., Chesney, M., &
Berman, B.
(2010). Mindfulness intervention for child abuse survivors.
Journal of
Clinical Psychology, 66, 17–33. doi:10.1002/jclp.20624
Linehan, M. M. (1993). Skills training manual for treating
borderline
personality disorder. New York, NY: Guilford Press.
Luborsky, L. B., Barrett, M. S., Antonuccio, D. O.,
Shoenberger, D., &
Stricker, G. (2006). What else materially influences what is
represented
and published as evidence? In J. C. Norcross, L. E. Beutler, &
R. F.
Levant (Eds.), Evidence-based practices in mental health:
Debate and
dialogue on the fundamental questions (pp. 257–298).
Washington, DC:
American Psychological Association. doi:10.1037/11265-000
McLellan, T. A., Luborsky, L., Woody, G. E., & O’Brien, C. P.
(1980). An
improved diagnostic evaluation instrument for substance abuse
patients,
the Addiction Severity Index. Journal of Nervous and Mental

Disease,
168, 26 –33. doi:10.1097/00005053-198001000-00006
Mohr, D. C., Vella, L., Hart, S., Heckman, T., & Simon, G.
(2008). The
effect of telephone-administered psychotherapy on symptoms of
depres-
sion and attrition: A meta-analysis. Clinical Psychology:
Science and
Practice, 15, 243–253. doi:10.1111/j.1468-2850.2008.00134.x
Monson, C. M., Gradus, J. L., Young-Xu, Y., Schnurr, P. P.,
Price, J. L.,
& Schumm, J. A. (2008). Change in posttraumatic stress
disorder symp-
toms: Do clinicians and patients agree? Psychological
Assessment, 20,
131–138. doi:10.1037/1040-3590.20.2.131
Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D., Reilly, P.,
Shore, J.,
. . . Frueh, B. C. (2010). Telemedicine for anger management
therapy in
a rural population of combat veterans with posttraumatic stress
disorder:
A randomized noninferiority trial. Journal of Clinical
Psychiatry. Ad-
vance online publication. Retrieved from:
http://www.ncbi.nlm.nih.gov/
pubmed/20122374.
O’Toole, B. I., Catts, S. V., Outram, S., Pierse, K. R., &
Cockburn, J.
(2009). The physical and mental health of Australian Vietnam
veterans
3 decades after the war and its relation to military service,

combat and
post-traumatic stress disorder. American Journal of
Epidemiology, 170,
318 –330. doi:10.1093/aje/kwp146
Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing
therapy for
rape victims: A treatment manual. Thousand Oaks, CA: Sage.
Riggs, D. S., Byrne, C. A., Weathers, F. W., & Litz, B. T.
(1998). The
quality of intimate relationships of male Vietnam veterans:
Problems
associated with posttraumatic stress disorder. Journal of
Traumatic
Stress, 11, 87–102. doi:10.1023/A:1024409200155
Roemer, L., & Orsillo, S. M. (2007). An open trial of an
acceptance-based
behavior therapy for generalized anxiety disorder. Behavior
Therapy, 38,
72– 85. doi:10.1016/j.beth.2006.04.004
Sanderson, K., & Andrews, G. (2006). Common mental
disorders in the
workforce. Recent findings from descriptive and social
epidemiology.
Canadian Journal of Psychiatry, 51, 63–75.
Santorelli, S. F., & Kabat–Zinn, J. (2009). Mindfulness-based
stress re-
duction professional training resource manual: Integrating
mindfulness
meditation into medicine and health care. Worcester, MA:
Center for
Mindfulness in Medicine, Health Care, and Society.

Savoca, E., & Rosenheck, R. (2000). The civilian labor market
experiences
of Vietnam-era veterans: The influence of psychiatric disorders.
Journal
of Mental Health Policy and Economics, 3, 199 –207.
doi:10.1002/
mhp.102
Schell, T. L., Marshall, G. N., & Jaycox, L. H. (2004). All
symptoms are
not created equal: The prominent role of hyperarousal in the
natural
course of posttraumatic psychological distress. Journal of
Abnormal
Psychology, 113, 189 –197. doi:10.1037/0021-843X.113.2.189
Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V.,
& Gray,
S. H. (2008). Nonresponse and dropout rates in outcome studies
on
PTSD: Review and metholodological consideration. Psychiatry,
71,
134 –168. doi:10.1521/psyc.2008.71.2.134
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002).
Mindfulness-
based cognitive therapy for depression: A new approach to
preventing
relapse. New York, NY: Guilford Press.
Tuerk, P. W., Yoder, M., Ruggiero, K. J., Gros, D. F., &
Acierno, R.
(2010). A pilot study of prolonged exposure therapy for
posttraumatic
stress disorder delivered via telehealth technology. Journal of

Traumatic
Stress, 23, 116 –123. doi:10.1002/jts.20494
VHA Office of Public Health and Environmental Hazards.
(2009). July
2009 analysis of VA health care utilization among US global
war on
546 NILES ET AL.
terrorism (GWOT) veterans: Operation Enduring
Freedom/Operation
Iraqi Freedom. Washington, DC: Author.
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., &
Keane, T. M.
(1993, October). The PTSD checklist (PCL): Reliability,
validity, and
diagnostic utility. Paper presented at the meeting of the
International
Society of Traumatic Stress Studies, San Antonio, TX.
Weathers, F. W., Ruscio, A. M., & Keane, T. M. (1999).
Psychometric
properties of nine scoring rules for the Clinician-Administered
PTSD
Scale (CAPS). Psychological Assessment, 11, 124 –133.
doi:10.1037/
1040-3590.11.2.124
Received July 16, 2010
Revision received September 2, 2011

Accepted September 10, 2011 �
PSYCHOEDUCATION
1
Paper Title
Student Name
Professor Name
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Date
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creates interest about your paper. This paragraph might also
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areas that the company changed or modified in their rebranding
efforts. Describe how those areas were changed and how
changing these area helped to reach the goal of the rebranding.
Compare the
Success of the Rebranding
Delete this text and answer the fourth question in this Written
Assignment, “Do you think the rebranding was successful?
Explain why or why not.” Explain and validate if you feel the
rebranding was a success or not. Use your own opinion based
on what you have learned in MKT100 so far, as well as data
collected through research to validate whether the rebrand was a
success. You might want to look for facts such as sales data,
grown of the business, etc. to validate the success of the
rebrand. Make sure to list citations for facts found during
research.
Conclusion
Delete this text and compose a Conclusion Paragraph that
briefly summarizes your paper and emphasizes the key points
you want your reader to take away from reading your paper.
References
Iacobucci, D. (2014). MM4: Marketing Management. Mason,

OH: South-Western Cengage Learning.
Delete this. List all other references used in your paper. List
references using APA format. Citations should also be listed
within the text to show which references facts were taken from.
1
Theory Into Practice: Four Social Work Case Studies
In this course, you select one of the following four case studies
and use it throughout
the entire course. By doing this, you will have the opportunity
to see how different
theories guide your view of a client and that client’s presenting
problem. Each time you
return to the same case, you use a different theory, and your
perspective of the problem
changes—which then changes how you ask assessment questions
and how you
intervene.
These case studies are based on the video- and web-based case
studies you encounter
in the MSW program.
Table of Contents
Tiffani Bradley

...............................................................................................
.................. 2
Paula Cortez
...............................................................................................
.................... 9
Jake Levey
...............................................................................................
..................... 10
Helen Petrakis
...............................................................................................
................ 13
2
Tiffani Bradley
Identifying Data: Tiffani Bradley is a 16-year-old Caucasian
female. She was raised in
a Christian family in Philadelphia, PA. She is of German
descent. Tiffani’s family
consists of her father, Robert, 38 years old; her mother,
Shondra, 33 years old, and
her sister, Diana, 13 years old. Tiffani currently resides in a
group home, Teens First,
a brand new, court-mandated teen counseling program for
adolescent victims of

sexual exploitation and human trafficking. Tiffani has been
provided room and board
in the residential treatment facility for the past 3 months.
Tiffani describes herself as
heterosexual.
Presenting Problem: Tiffani has a history of running away. She
has been arrested on
three occasions for prostitution in the last 2 years. Tiffani has
recently been court
ordered to reside in a group home with counseling. She has a
continued desire to be
reunited with her pimp, Donald. After 3 months at Teens First,
Tiffani said that she
had a strong desire to see her sister and her mother. She had not
seen either of
them in over 2 years and missed them very much. Tiffani is
confused about the path
to follow. She is not sure if she wants to return to her family
and sibling or go back to
Donald.
Family Dynamics: Tiffani indicates that her family worked well
together until 8 years
ago. She reports that around the age of 8, she remembered being
awakened by
music and laughter in the early hours of the morning. When she
went downstairs to
investigate, she saw her parents and her Uncle Nate passing a
pipe back and forth
between them. She remembered asking them what they were
doing and her mother

saying, “adult things” and putting her back in bed. Tiffani
remembers this happening
on several occasions. Tiffani also recalls significant changes in
the home's
appearance. The home, which was never fancy, was always neat
and tidy. During
this time, however, dust would gather around the house, dishes
would pile up in the
sink, dirt would remain on the floor, and clothes would go for
long periods of time
without being washed. Tiffani began cleaning her own clothes
and making meals for
herself and her sister. Often there was not enough food to feed
everyone, and Tiffani
and her sister would go to bed hungry. Tiffani believed she was
responsible for
helping her mom so that her mom did not get so overwhelmed.
She thought that if
she took care of the home and her sister, maybe that would help
mom return to the
person she was before.
Sometimes Tiffani and her sister would come downstairs in the
morning to find empty
beer cans and liquor bottles on the kitchen table along with a
crack pipe. Her parents
would be in the bedroom, and Tiffani and her sister would leave
the house and go to
school by themselves. The music and noise downstairs
continued for the next 6
years, which escalated to screams and shouting and sounds of
people fighting.
Tiffani remembers her mom one morning yelling at her dad to
“get up and go to
work.” Tiffani and Diana saw their dad come out of the

bedroom and slap their mom
so hard she was knocked down. Dad then went back into the
bedroom. Tiffani
3
remembers thinking that her mom was not doing what she was
supposed to do in the
house, which is what probably angered her dad.
Shondra and Robert have been separated for a little over a year
and have started
dating other people. Diana currently resides with her mother
and Anthony, 31 years
old, who is her mother’s new boyfriend.
Educational History: Tiffani attends school at the group home,
taking general
education classes for her general education development (GED)
credential. Diana
attends Town Middle School and is in the 8th grade.
Employment History: Tiffani reports that her father was
employed as a welding
apprentice and was waiting for the opportunity to join the
union. Eight years ago, he
was laid off due to financial constraints at the company. He
would pick up odd jobs
for the next 8 years but never had steady work after that. Her
mother works as a

home health aide. Her work is part-time, and she has been
unable to secure full-time
work.
Social History: Over the past 2 years, Tiffani has had limited
contact with her family
members and has not been attending school. Tiffani did contact
her sister Diana a
few times over the 2-year period and stated that she missed her
very much. Tiffani
views Donald as her “husband” (although they were never
married) and her only
friend. Previously, Donald sold Tiffani to a pimp, “John T.”
Tiffani reports that she was
very upset Donald did this and that she wants to be reunited
with him, missing him
very much. Tiffani indicates that she knows she can be a better
“wife” to him. She
has tried to make contact with him by sending messages through
other people, as
John T. did not allow her access to a phone. It appears that over
the last 2 years,
Tiffani has had neither outside support nor interactions with
anyone beyond Donald,
John T., and some other young women who were prostituting.
Mental Health History: On many occasions Tiffani recalls that
when her mother was
not around, Uncle Nate would ask her to sit on his lap. Her
father would sometimes
ask her to show them the dance that she had learned at school.
When she danced,

her father and Nate would laugh and offer her pocket change.
Sometimes, their
friend Jimmy joined them. One night, Tiffani was awakened by
her uncle Nate and his
friend Jimmy. Her parents were apparently out, and they were
the only adults in the
home. They asked her if she wanted to come downstairs and
show them the new
dances she learned at school. Once downstairs Nate and Jimmy
put some music on
and started to dance. They asked Tiffani to start dancing with
them, which she did.
While they were dancing, Jimmy spilled some beer on her. Nate
said she had to go to
the bathroom to clean up. Nate, Jimmy, and Tiffani all went to
the bathroom. Nate
asked Tiffani to take her clothes off and get in the bath. Tiffani
hesitated to do this,
but Nate insisted it was OK since he and Jimmy were family.
Tiffani eventually
relented and began to wash up. Nate would tell her that she
missed a spot and would
scrub the area with his hands. Incidents like this continued to
occur with increasing
levels of molestation each time.
4
The last time it happened, when Tiffani was 14, she
pretended to be willing to dance
for them, but when she got downstairs, she ran out the front
door of the house. Tiffani

vividly remembers the fear she felt the nights Nate and Jimmy
touched her, and she
was convinced they would have raped her if she stayed in the
house.
About halfway down the block, a car stopped. The man
introduced himself as Donald,
and he indicated that he would take care of her and keep her
safe when these things
happened. He then offered to be her boyfriend and took Tiffani
to his apartment.
Donald insisted Tiffani drink beer. When Tiffani was drunk,
Donald began kissing her,
and they had sex. Tiffani was also afraid that if she did not have
sex, Donald would
not let her stay— she had nowhere else to go. For the next 3
days, Donald brought
her food and beer and had sex with her several more times.
Donald told Tiffani that
she was not allowed to do anything without his permission. This
included watching
TV, going to the bathroom, taking a shower, and eating and
drinking. A few weeks
later, Donald bought Tiffani a dress, explaining to her that she
was going to “find a
date” and get men to pay her to have sex. When Tiffani said she
did not want to do
that, Donald hit her several times. Donald explained that if she
didn’t do it, he would
get her sister Diana and make her do it instead. Out of fear for
her sister, Tiffani
relented and did what Donald told her to do. She thought at this
point her only
purpose in life was to be a sex object, listen, and obey—and

then she would be able
to keep the relationships and love she so desired.
Legal History: Tiffani has been arrested three times for
prostitution. Right before the
most recent charge, a new state policy was enacted to protect
youth 16 years and
younger from prosecution and jail time for prostitution. The
Safe Harbor for Exploited
Children Act allows the state to define Tiffani as a sexually
exploited youth, and
therefore the state will not imprison her for prostitution. She
was mandated to
services at the Teens First agency, unlike her prior arrests when
she had been sent
to detention.
Alcohol and Drug Use History: Tiffani’s parents were social
drinkers until about 8
years ago. At that time Uncle Nate introduced them to crack
cocaine. Tiffani reports
using alcohol when Donald wanted her to since she wanted to
please him, and she
thought this was the way she would be a good “wife.” She
denies any other drug use.
Medical History: During intake, it was noted that Tiffani had
multiple bruises and burn
marks on her legs and arms. She reported that Donald had
slapped her when he felt

she did not behave and that John T. burned her with cigarettes.
She had realized that
she did some things that would make them mad, and she tried
her hardest to keep
them pleased even though she did not want to be with John T.
Tiffani has been
treated for several sexually transmitted infections (STIs) at
local clinics and is
currently on an antibiotic for a kidney infection. Although she
was given condoms by
Donald and John T. for her “dates,” there were several “Johns”
who refused to use
them.
5
Strengths: Tiffani is resilient in learning how to survive the
negative relationships she
has been involved with. She has as sense of protection for her
sister and will sacrifice
herself to keep her sister safe.
Robert Bradley: father, 38 years old
Shondra Bradley: mother, 33 years old
Nate Bradley: uncle, 36 years old
Tiffani Bradley: daughter, 16 years old
Diana Bradley: daughter, 13 years old
Donald: Tiffani’s self-described husband and her former pimp
Anthony: Shondra’s live-in partner, 31 years old
John T.: Tiffani’s most recent pimp

6
Paula Cortez
Identifying Data: Paula Cortez is a 43-year-old Catholic
Hispanic female residing in New
York City, NY. Paula was born in Colombia. When she was 17
years old, Paula left
Colombia and moved to New York where she met David, who
later became her
husband. Paula and David have one son, Miguel, 20 years old.
They divorced after 5
years of marriage. Paula has a five-year-old daughter, Maria,
from a different
relationship.
Presenting Problem: Paula has multiple medical issues, and
there is concern about
whether she will be able to continue to care for her youngest
child, Maria. Paula has
been overwhelmed, especially since she again stopped taking
her medication. Paula is
also concerned about the wellness of Maria.
Family Dynamics: Paula comes from a moderately well-to-do
family. Paula reports
suffering physical and emotional abuse at the hands of both her

parents, eventually
fleeing to New York to get away from the abuse. Paula comes
from an authoritarian
family where her role was to be “seen and not heard.” Paula
states that she did not feel
valued by any of her family members and reports never
receiving the attention she
needed. As a teenager, she realized she felt “not good enough”
in her family system,
which led to her leaving for New York and looking for
“someone to love me.” Her
parents still reside in Colombia with Paula’s two siblings.
Paula met David when she sought to purchase drugs. They
married when Paula was 18
years old. The couple divorced after 5 years of marriage. Paula
raised Miguel, mostly by
herself, until he was 8 years old, at which time she was forced
to relinquish custody due
to her medical condition. Paula maintains a relationship with
her son, Miguel, and her
ex-husband, David. Miguel takes part in caring for his half-
sister, Maria.
Paula does believe her job as a mother is to take care of Maria
but is finding that more
and more challenging with her physical illnesses.
Employment History: Paula worked for a clothing designer, but
she realized that her true
passion was painting. She has a collection of more than 100
drawings and paintings,

many of which track the course of her personal and emotional
journey. Paula held a full-
time job for a number of years before her health prevented her
from working. She is
now unemployed and receives Supplemental Security Disability
Insurance (SSD) and
Medicaid. Miguel does his best to help his mom but only works
part time at a local
supermarket delivering groceries.
Paula currently uses federal and state services. Paula
successfully applied for WIC, the
federal Supplemental Nutrition Program for Women, Infants,
and Children. Given
Paula’s low income, health, and Medicaid status, Paula is able
to receive in-home
childcare assistance through New York’s public assistance
program.
7
Social History: Paula is bilingual, fluent in both Spanish and
English. Although Paula
identifies as Catholic, she does not consider religion to be a big
part of her life. Paula
lives with her daughter in an apartment in Queens, NY. Paula is
socially isolated as she
has limited contact with her family in Colombia and lacks a
peer network of any kind in
her neighborhood.

Five (5) years ago Paula met a man (Jesus) at a flower shop.
They spoke several times.
He would visit her at her apartment to have sex. Since they had
an active sex life, Paula
thought he was a “stand-up guy” and really liked him. She
believed he would take care
of her. Soon everything changed. Paula began to suspect that he
was using drugs,
because he had started to become controlling and demanding.
He showed up at her
apartment at all times of the night demanding to be let in. He
called her relentlessly, and
when she did not pick up the phone, he left her mean and
threatening messages. Paula
was fearful for her safety and thought her past behavior with
drugs and sex brought on
bad relationships with men and that she did not deserve better.
After a couple of
months, Paula realized she was pregnant. Jesus stated he did not
want anything to do
with the “kid” and stopped coming over, but he continued to
contact and threaten Paula
by phone. Paula has no contact with Jesus at this point in time
due to a restraining
order.
Mental Health History: Paula was diagnosed with bipolar
disorder. She experiences
periods of mania lasting for a couple of weeks then goes into a
depressive state for
months when not properly medicated. Paula has a tendency
toward paranoia. Paula

has a history of not complying with her psychiatric medication
treatment because she
does not like the way it makes her feel. She often discontinues
it without telling her
psychiatrist. Paula has had multiple psychiatric hospitalizations
but has remained out of
the hospital for the past 5 years. Paula accepts her bipolar
diagnosis but demonstrates
limited insight into the relationship between her symptoms and
her medication.
Paula reports that when she was pregnant, she was fearful for
her safety due to the
baby’s father’s anger about the pregnancy. Jesus’ relentless
phone calls and voicemails
rattled Paula. She believed she had nowhere to turn. At that
time, she became scared,
slept poorly, and her paranoia increased significantly. After
completing a suicide
assessment 5 years ago, it was noted that Paula was
decompensating quickly and was
at risk of harming herself and/or her baby. Paula was
involuntarily admitted to the
psychiatric unit of the hospital. Paula remained on the unit for 2
weeks.
Educational History: Paula completed high school in Colombia.
Paula had hoped to
attend the Fashion Institute of Technology (FIT) in New York
City, but getting divorced,
then raising Miguel on her own interfered with her plans.
Miguel attends college full time
in New York City.

Medical History: Paula was diagnosed as HIV positive 15 years
ago. Paula acquired
AIDS three years later when she was diagnosed with a severe
brain infection and a T-
cell count of less than 200. Paula’s brain infection left her
completely paralyzed on the
right side. She lost function in her right arm and hand as well as
the ability to walk. After
8
a long stay in an acute care hospital in New York City, Paula
was transferred to a skilled
nursing facility (SNF) where she thought she would die. After
being in the skilled nursing
facility for more than a year, Paula regained the ability to walk,
although she does so
with a severe limp. She also regained some function in her right
arm. Her right hand
(her dominant hand) remains semi-paralyzed and limp. Over the
course of several
years, Paula taught herself to paint with her left hand and was
able to return to her
beloved art.
Paula began treatment for her HIV/AIDS with highly active
antiretroviral therapy
(HAART). Since she ran away from the family home, married
and divorced a drug user,
then was in an abusive relationship, Paula thought she deserved

what she got in life.
She responded well to HAART and her HIV/AIDS was well
controlled. In addition to her
HIV/AIDS disease, Paula is diagnosed with Hepatitis C (Hep
C). While this condition
was controlled, it has reached a point where Paula’s doctor is
recommending she begin
a new treatment. Paula also has significant circulatory
problems, which cause her
severe pain in her lower extremities. She uses prescribed
narcotic pain medication to
control her symptoms. Paula’s circulatory problems have also
led to chronic ulcers on
her feet that will not heal. Treatment for her foot ulcers
demands frequent visits to a
wound care clinic. Paula’s pain paired with the foot ulcers make
it difficult for her to
ambulate and leave her home. Paula has a tendency not to
comply with her medical
treatment. She often disregards instructions from her doctors
and resorts to holistic
treatments like treating her ulcers with chamomile tea. When
she stops her treatment,
she deteriorates quickly.
Maria was born HIV negative and received the appropriate
HAART treatment after birth.
She spent a week in the neonatal intensive care unit as she had
to detox from the
effects of the pain medication Paula took throughout her
pregnancy.
Legal History: Previously, Paula used the AIDS Law Project, a
not-for-profit organization

that helps individuals with HIV address legal issues, such as
those related to the child’s
father . At that time, Paula filed a police report in response to
Jesus' escalating threats
and successfully got a restraining order. Once the order was
served, the phone calls
and visits stopped, and Paula regained a temporary sense of
control over her life.
Paula completed the appropriate permanency planning
paperwork with the assistance
of the organization The Family Center. She named Miguel as
her daughter’s guardian
should something happen to her.
Alcohol and Drug Use History: Paula became an intravenous
drug user (IVDU), using
cocaine and heroin, at age 17. David was one of Paula’s “drug
buddies” and suppliers.
Paula continued to use drugs in the United States for several
years; however, she
stopped when she got pregnant with Miguel. David continued to
use drugs, which led to
the failure of their marriage.
Strengths: Paula has shown her resilience over the years. She
has artistic skills and has
found a way to utilize them. Paula has the foresight to seek
social services to help her

9
and her children survive. Paula has no legal involvement. She
has the ability to bounce
back from her many physical and health challenges to continue
to care for her child and
maintain her household.
David Cortez: father, 46 years old
Paula Cortez: mother, 43 years old
Miguel Cortez: son, 20 years old
Jesus (unknown): Maria’s father, 44 years old
Maria Cortez: daughter, 5 years old
10
Jake Levy
Identifying Data: Jake Levy is a 31-year-old, married, Jewish
Caucasian male. Jake’s
wife, Sheri, is 28 years old. They have two sons, Myles (10) and
Levi (8). The family
resides in a two-bedroom condominium in a middle-class
neighborhood in Rockville,
MD. They have been married for 10 years.

Presenting Problem: Jake, an Iraq War veteran, came to the
Veterans Affairs Health
Care Center (VA) for services because his wife has threatened
to leave him if he
does not get help. She is particularly concerned about his
drinking and lack of
involvement in their sons’ lives. She told him his drinking has
gotten out of control
and is making him mean and distant. Jake reports that he and his
wife have been
fighting a lot and that he drinks to take the edge off and to help
him sleep. Jake
expresses fear of losing his job and his family if he does not get
help. Jake identifies
as the primary provider for his family and believes that this is
his responsibility as a
husband and father. Jake realizes he may be putting that in
jeopardy because of his
drinking. He says he has never seen Sheri so angry before, and
he saw she was at
her limit with him and his behaviors.
Family Dynamics: Jake was born in Alabama to a Caucasian,
Eurocentric family
system. He reports his time growing up to have been within a
“normal” family system.
However, he states that he was never emotionally close to either
parent and viewed
himself as fairly independent from a young age. His dad had
previously been in the
military and was raised with the understanding that his duty is
to support his country.
His family displayed traditional roles, with his dad supporting

the family after he was
discharged from military service. Jake was raised to believe that
real men do not
show weakness and must be the head of the household.
Jake’s parents are deceased, and he has a sister who lives
outside London. He and
his sister are not very close but do talk twice a year. Sheri is an
only child, and
although her mother lives in the area, she offers little support.
Her mother never
approved of Sheri marrying Jake and thinks Sheri needs to deal
with their problems
on her own. Jake reports that he has not been engaged with his
sons at all since his
return from Iraq, and he keeps to himself when he is at home.
Employment History: Jake is employed as a human resources
assistant for the
military. Jake works in an office with civilians and military
personnel and mostly gets
along with people in the office. Jake is having difficulty getting
up in the morning to go
to work, which increases the stress between Sheri and himself.
Shari is a special
education teacher in a local elementary school. Jake thinks it is
his responsibility to
provide for his family and is having stress over what is
happening to him at home and
work. He thinks he is failing as a provider.
Social History: Jake and Sheri identify as Jewish and attend a

local synagogue on
major holidays. Jake tends to keep to himself and says he
sometimes feels
pressured to be more communicative and social. Jake believes
he is socially inept
11
and not able to develop friendships. The couple has some
friends, since Shari gets
involved with the parents in their sons’ school. However,
because of Jake’s recent
behaviors, they have become socially isolated. He is very
worried that Sheri will leave
him due to the isolation.
Mental Health History: Jake reports that since his return to
civilian life 10 months ago,
he has difficulty sleeping, frequent heart palpitations, and
moodiness. Jake had seen
Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-
traumatic stress
disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his
symptoms of anxiety
and depression and suggested that he also begin counseling.
Jake says that he does
not really understand what PTSD is but thought it meant that a
person who had it was
“going crazy,” which at times he thought was happening to him.
He expresses
concern that he will never feel “normal” again and says that

when he drinks alcohol,
his symptoms and the intensity of his emotions ease. Jake
describes that he
sometimes thinks he is back in Iraq, which makes him feel
uneasy and watchful. He
hates the experience and tries to numb it. He has difficulty
sleeping and is irritable, so
he isolates himself and soothes this with drinking. He talks
about always feeling
“ready to go.” He says he is exhausted from being always alert
and looking for
potential problems around him. Every sound seems to startle
him. He shares that he
often thinks about what happened “over there” but tries to push
it out of his mind.
Nighttime is the worst, as he has terrible recurring nightmares
of one particular event.
He says he wakes up shaking and sweating most nights. He adds
that drinking is the
one thing that seems to give him a little relief.
Educational History: Sheri has a bachelor’s degree in special
education from a local
college. Jake has a high school diploma but wanted to attend
college upon his return
from the military.
Military History: Jake is an Iraqi War veteran. He enlisted in
the Marines at 21 years
old when he and Shari got married due to Sheri being pregnant.
The family was
stationed in several states prior to Jake being deployed to Iraq.

Jake left the service
10 months ago. Sheri and Jake had used military housing since
his marriage, making
it easier to support the family. On military bases, there was a lot
of social support and
both Jake and Sheri took full advantage of the social systems
available to them
during that time.
Medical History: Jake is physically fit, but an injury he
sustained in combat sometimes
limits his ability to use his left hand. Jake reports sometimes
feeling inadequate
because of the reduction in the use of his hand and tries to push
through because he
worries how the injury will impact his responsibilities as a
provider, husband, and
father. Jake considers himself resilient enough to overcome this
disadvantage and
“be able to do the things I need to do.” Sheri is in good physical
condition and has
recently found out that she is pregnant with their third child.
Legal History: Jake and Sheri deny having criminal histories.
12
Alcohol and Drug Use History: As teenagers, Jake and Sheri
used marijuana and
drank. Both deny current use of marijuana but report they still

drink. Sheri drinks
socially and has one or two drinks over the weekend. Jake
reports that he has four to
five drinks in the evenings during the week and eight to ten
drinks on Saturdays and
Sundays. Jake spends his evenings on the couch drinking beer
and watching TV or
playing video games. Shari reports that Jake drinks more than
he realizes, doubling
what Jake has reported.
Strengths: Jake is cognizant of his limitations and has worked
on overcoming his
physical challenges. Jake is resilient. Jake did not have any
disciplinary actions taken
against him in the military. He is dedicated to his wife and
family.
Jake Levy: father, 31 years old
Sheri Levy: mother, 28 years old
Myles Levy: son, 10 years old
Levi Levy: son, 8 years old
13
Helen Petrakis
Identifying Data: Helen Petrakis is a 52-year-old, Caucasian
female of Greek descent

living in a four-bedroom house in Tarpon Springs, FL. Her
family consists of her
husband, John (60), son, Alec (27), daughter, Dmitra (23), and
daughter Althima (18).
John and Helen have been married for 30 years. They married in
the Greek Orthodox
Church and attend services weekly.
Presenting Problem: Helen reports feeling overwhelmed and
“blue.” She was referred
by a close friend who thought Helen would benefit from having
a person who would
listen. Although she is uncomfortable talking about her life with
a stranger, Helen
says that she decided to come for therapy because she worries
about burdening
friends with her troubles. John has been expressing his
displeasure with meals at
home, as Helen has been cooking less often and brings home
takeout. Helen thinks
she is inadequate as a wife. She states that she feels defeated;
she describes an
incident in which her son, Alec, expressed disappointment in
her because she could
not provide him with clean laundry. Helen reports feeling
overwhelmed by her
responsibilities and believes she can’t handle being a wife,
mother, and caretaker
any longer.
Family Dynamics: Helen describes her marriage as typical of a
traditional Greek

family. John, the breadwinner in the family, is successful in the
souvenir shop in
town. Helen voices a great deal of pride in her children. Dmitra
is described as smart,
beautiful, and hardworking. Althima is described as adorable
and reliable. Helen
shops, cooks, and cleans for the family, and John sees to yard
care and maintaining
the family’s cars. Helen believes the children are too busy to be
expected to help
around the house, knowing that is her role as wife and mother.
John and Helen
choose not to take money from their children for any room or
board. The Petrakis
family holds strong family bonds within a large and supportive
Greek community.
Helen is the primary caretaker for Magda (John’s 81-year-old
widowed mother), who
lives in an apartment 30 minutes away. Until recently, Magda
was self-sufficient,
coming for weekly family dinners and driving herself shopping
and to church. Six
months ago, she fell and broke her hip and was also recently
diagnosed with early
signs of dementia. Helen and John hired a reliable and trusted
woman temporarily to
check in on Magda a couple of days each week. Helen would go
and see Magda on
the other days, sometimes twice in one day, depending on
Magda’s needs. Helen
would go food shopping for Magda, clean her home, pay her
bills, and keep track of
Magda’s medications. Since Helen thought she was unable to
continue caretaking for

both Magda and her husband and kids, she wanted the helper to
come in more often,
but John said they could not afford it. The money they now pay
to the helper is
coming out of the couple’s vacation savings. Caring for Magda
makes Helen think
she is failing as a wife and mother because she no longer has
time to spend with her
husband and children.
14
Helen spoke to her husband, John (the family decision maker),
and they agreed to
have Alec (their son) move in with Magda (his grandmother) to
help relieve Helen’s
burden and stress. John decided to pay Alec the money typically
given to Magda’s
helper. This has not decreased the burden on Helen since she
had to be at the
apartment at least once daily to intervene with emergencies that
Alec is unable to
manage independently. Helen’s anxiety has increased since she
noted some of
Magda’s medications were missing, the cash box was empty,
Magda’s checkbook
had missing checks, and jewelry from Greece, which had been
in the family for
generations, was also gone.
Helen comes from a close-knit Greek Orthodox family where

women are responsible
for maintaining the family system and making life easier for
their husbands and
children. She was raised in the community where she currently
resides. Both her
parents were born in Greece and came to the United States after
their marriage to
start a family and give them a better life. Helen has a younger
brother and a younger
sister. She was responsible for raising her siblings since both
her parents worked in a
fishery they owned. Helen feared her parents’ disappointment if
she did not help
raise her siblings. Helen was very attached to her parents and
still mourns their loss.
She idolized her mother and empathized with the struggles her
mother endured
raising her own family. Helen reports having that same fear of
disappointment with
her husband and children.
Employment History: Helen has worked part time at a hospital
in the billing
department since graduating from high school. John Petrakis
owns a Greek souvenir
shop in town and earns the larger portion of the family income.
Alec is currently
unemployed, which Helen attributes to the poor economy.
Dmitra works as a sales
consultant for a major department store in the mall. Althima is
an honors student at a
local college and earns spending money as a hostess in a family
friend’s restaurant.
During town events, Dmitra and Althima help in the souvenir

shop when they can.
Social History: The Petrakis family live in a community
centered on the activities of the
Greek Orthodox Church. Helen has used her faith to help her
through the more
difficult challenges of not believing she is performing her “job”
as a wife and mother.
Helen reports that her children are religious but do not regularly
go to church
because they are very busy. Helen has stopped going shopping
and out to eat with
friends because she can no longer find the time since she
became a caretaker for
Magda.
Mental Health History: Helen consistently appears well
groomed. She speaks clearly
and in moderate tones and seems to have linear thought
progression—her memory
seems intact. She claims no history of drug or alcohol abuse,
and she does not
identify a history of trauma. More recently, Helen is
overwhelmed by thinking she is
inadequate. She stopped socializing and finds no activity
enjoyable. In some
situations in her life, she is feeling powerless.

15
Educational History: Helen and John both have high school
diplomas. Helen is proud
of her children knowing she was the one responsible in helping
them with their
homework. Alec graduated high school and chose not to attend
college. Dmitra
attempted college but decided that was not the direction she
wanted. Althima is an
honors student at a local college.
Medical History: Helen has chronic back pain from an old
injury, which she manages
with acetaminophen as needed. Helen reports having periods of
tightness in her
chest and a feeling that her heart was racing along with trouble
breathing and
thinking that she might pass out. One time, John brought her to
the emergency room.
The hospital ran tests but found no conclusive organic reason to
explain Helen’s
symptoms. She continues to experience shortness of breath,
usually in the morning
when she is getting ready to begin her day. She says she has
trouble staying asleep,
waking two to four times each night, and she feels tired during
the day. Working is
hard because she is more forgetful than she has ever been.
Helen says that she
feels like her body is one big tired knot.
Legal History: The only member of the Petrakis family that has

legal involvement is
Alec. He was arrested about 2 years ago for possession of
marijuana. He was
required to attend an inpatient rehabilitation program (which he
completed) and was
sentenced to 2 years’ probation. Helen was devastated,
believing John would be
disappointed in her for not raising Alec properly.
Alcohol and Drug Use History: Helen has no history of drug use
and only drinks at
community celebrations. Alec has struggled with drugs and
alcohol since he was a
teen. Helen wants to believe Alec is maintaining his sobriety
and gives him the
benefit of the doubt. Alec is currently on 2 years’ probation for
possession and has
recently completed an inpatient rehabilitation program. Helen
feels responsible for his
addiction and wonders what she did wrong as a mother.
Strengths: Helen has a high school diploma and has been
successful at raising her
family. She has developed a social support system, not only in
the community but
also within her faith at the Greek Orthodox Church. Helen is
committed to her family
system and their success. Helen does have the ability to
multitask, taking care of her
immediate family as well as fulfilling her obligation to her
mother-in-law. Even under

the current stressful circumstances, Helen is assuming and
carrying out her
responsibilities.
John Petrakis: father, 60 years old
Helen Petrakis: mother, 52 years old
Alec Petrakis: son, 27 years old
Dmitra Petrakis: daughter, 23 years old
Althima Petrakis: daughter, 18 years old
Magda Petrakis: John’s mother, 81 years old

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