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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 1
SUPPORTING THOSE WHO SERVED: SUBSTANCE USE AND
COMPREHENSIVE MENTAL HEALTH FOR MILITARY
AFFILIATED POPULATIONS
PRESENTED BY DUANE K. L. FRANCE, MA, MBA, LPC
SAMSON TEKLEMARIAM, MA, LPC, CPTM
• Director of Training and Professional Development
• NAADAC, the Association for Addiction Professionals
• www.naadac.org
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PRODUCED BY
NAADAC, THE ASSOCIATION FOR ADDICTION PROFESSIONALS
WWW.NAADAC.ORG/WEBINARS
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 2
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WWW.NAADAC.ORG/WEBINARS
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WWW.NAADAC.ORG/MILITARY‐VET‐TRAINING‐WEBINAR‐SERIES
CE CERTIFICATE
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CE HOURS AVAILABLE:1.5 CE
REGISTRATION TO ATTEND:
$25
CE CERTIFICATE:INCLUDED
1. Watch and listen to this entire webinar.
2. Pass the online CE quiz, which is posted at: www.naadac.org/supporting‐those‐who‐served‐webinar
3. Maintain records of your invoice/receipt of payment and any CE certificate received from this series.
4. Email [email protected] if you experience any difficulty with this process.
To obtain a CE Certificate for the time you spent watching this webinar:
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5
6
NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 3
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Using GoToWebinar –(Live Participants Only)
Control Panel
Asking Questions
Audio (phone preferred)
Polling Questions
WEBINAR PRESENTER
• Duane K. L. France, MA, MBA, LPC
• www.veteranmentalhealth.com
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Family Care Center, LLC
WEBINAR LEARNING OBJECTIVES
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Describe the different aspects
of the psychological
impact of military service
1 2 3
List at least three orientations or interventions addressing
different domains of veteran mental
health
Articulate how substance use
disorders interact and influence the different domains
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 4
POLLING QUESTION #1
In addition to substance use disorders, the military affiliated population
struggles most with:
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A. Posttraumatic Stress DisorderB. Traumatic Brain Injury C. Emotional DysregulationD. Lack of Purpose and MeaningE. Disrupted Relationships
COMPREHENSIVE VETERAN MENTAL HEALTH
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Situational and Systematic Causes
of behavior
Stigma against help-seeking
Societal Judgement
Peer Judgement
Stereotypes: Villain, Victim, Hero
Barriers to Care
Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
StigmaWarrior Ethos
“Suck It Up and Drive On”
COMPREHENSIVE VETERAN MENTAL HEALTH
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Purpose and
Meaning Relationships
Needs Fulfillment
Moral Injury
Unique to Military (First Responders)No DSM5 Diagnoses
No medication
Addiction TBI
PTSD
EmotionDysregulation
Not Military ExclusiveDSM 5 Diagnoses
Medication
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 5
POLLING QUESTION #2
If a veteran is experiencing difficulty in one or more of these domains, they also likely have a substance use disorder:
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A. Strongly AgreeB. AgreeC. Neither Agree or DisagreeD. DisagreeE. Strongly Disagree
POSTTRAUMATIC STRESS DISORDER
• Exposed to death, actual or threatened serious injury, or actual or threatened sexual violence
• Intrusive symptoms
• Avoidance
• Negative alterations in thoughts and mood
• Arousal and reactivity
• Last longer than 1 month
• Creates impairment
• Not due to medications
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Posttraumatic Stress Disorder is a cognitive, behavioral, and neurological reaction of exposure to traumatic events. For an individual to be diagnosed with PTSD, the following
criteria must be met:
Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
TRAUMATIC BRAIN INJURY
• Different types: focal and diffuse
• Different severities: Mild, Moderate, Severe
• Symptoms can be cognitive, physical, behavioral
• PTSD Trauma and TBI Trauma can be the same
• Closely mimics PTSD, with the exception ofnightmares and intrusiveness
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Traumatic Brain Injury is a physical injury to the brain that is the result of a blow or jolt to the head, an object penetrating the brain, or widespread injury
across the brain.
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 6
ADDICTION
• Normalization (glorification?) of drinking culture in the military
• Chronic pain resulting from constant physical stress and injuries
• Opioid dependence due to access to prescription pain relief while in the military
• Process addictions
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Up to 75 percent of veterans with a history of PTSD in their lifetime met criteria for substance abuse or dependence
(Kulka et al., 1990)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
EMOTION DYSREGULATION
• Anger, Anxiety, Depression
• Not adjusting from protective behavior while deployed or in the military to maladaptive behavior when in different environments
• Lack of ability to achieve desired goals through individual effort
• Toxic leadership and unavoidable aversive stimuli while in the military leads to assumption of helplessness after the military
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While many veterans are resilient and adaptive, often the constant barrage of negative experiences can wear down
even the most hardy of service members.
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
PURPOSE AND MEANING
• In the military, service members were part of something larger than themselves
• Loss of camaraderie and mutual connection can lead to disengagement
• Confusion and anger about the loss of purpose and meaning is not explained by PTSD and TBI
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Many veterans with PTSD live with profound doubts about the meaning of a life dominated by suffering, guilt, and death. This loss of meaning and purpose has pronounced
effects on all areas of psychosocial functioning (Southwhick, Et. Al, 2006).
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 7
MORAL INJURY
• In the military, service members were part of something larger than themselves
• Loss of camaraderie and mutual connection can lead to disengagement
• Confusion and anger about the loss of purpose and meaning is not explained by PTSD and TBI
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Moral Injury can be defined as “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”
(Litz, et al., 2009)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
NEEDS FULFILLMENT
• Learning how to fulfill needs in new ways, rather than changing the needs being met
• The “shadow side” of Maslow’s Hierarchy: meeting needs in socially unacceptable ways, such as using force and aggression to meet safety and aesthetic needs
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Once a veteran has developed a sense of achievement and mastery in the military, they then have to pivot to developing
mastery in an entirely different arena.
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
RELATIONSHIPS
• Disrupted relationships
• Cross‐generational combat operations
• Multiple deployments compounding impact on family
• Domestic Violence
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When military parents fulfill occupational duties during wartime, children and families face multiple challenges, including extended separations, disruptions in family routines, and potentially compromised parenting
related to traumatic exposure and subsequent mental health problems (Paley, Lester, & Mogil, 2013).
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 8
POLLING QUESTION #3
There is a single intervention that is best at addressing all or most of the aspects of comprehensive SMVF mental health
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A. Strongly AgreeB. AgreeC. Neither Agree or DisagreeD. DisagreeE. Strongly Disagree
POSTTRAUMATIC STRESS DISORDER INTERVENTIONS
• Cognitive Processing Therapy
• Prolonged Exposure
• Cognitive Behavioral Therapy
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
TRAUMATIC BRAIN INJURY INTERVENTIONS
• Treating co‐morbid psychological disorders: TBI
• Medical interventions: Pain management
• Physical interventions: Balance, Physical rehabilitation
• Cognitive restructuring: Neurofeedback, biofeedback, speech‐language pathology
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 9
ADDICTION INTERVENTIONS
• Contingency Management
• Motivational Interviewing
• Cognitive Behavioral Therapy
• Relapse Prevention
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
EMOTION DYSREGULATION INTERVENTIONS
• Cognitive Behavioral Therapy
• Dialectical Behavior Therapy
• Learned Helplessness (Toxic leadership, unavoidable aversive situations)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
PURPOSE AND MEANING INTERVENTIONS
• Existentialism: Rollo May, Irvin Yalom, Viktor Frankl
• “Veterans appeared to be particularly attracted to complementary health approaches because these therapies addressed spiritual issues and questions of meaning not inherent in conventional medical approaches” (Schuman, 2016)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 10
MORAL INJURY INTERVENTIONS
• Adaptive Disclosure
• Prolonged Exposure
• Acceptance and Commitment Therapy
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
NEEDS FULFILLMENT INTERVENTIONS
• Maslow’s Hierarchy of Needs
• Community‐based intervention: Homelessness, employment
• Connectedness: peer groups
• Acceptance and Commitment Therapy
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
INTERPERSONAL RELATIONSHIP INTERVENTIONS
• Inter‐generational and Intra‐generational
• Family systems theory
• Marriage and Family Therapy
• Dialectical Behavior Therapy (Interpersonal Relationships)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 11
POLLING QUESTION #4
Comorbid substance use disorders are an exacerbating factor of the other aspects of comprehensive SMVF mental health
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A. Strongly AgreeB. AgreeC. Neither Agree or DisagreeD. DisagreeE. Strongly Disagree
ADDICTION AND PTSD
• Increase avoidance of traumatic memories
• Impact vivid reexperiencing
• Alterations in mood and cognitions impacted by substance use
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
Individuals with co‐occurring PTSD and substance use may be using substances in an attempt to forget or block out trauma related recollections…several substances including alcohol have been found to impair cognitive
capacities such as memory and thus may serve as a viable means of suppression (Walton, Et
al., 2018).
ADDICTION AND TRAUMATIC BRAIN INJURY
• Increased risk for self‐inflicted death.
• TBI and associated psychiatric and substance use disorders are 21 times more likely to attempt suicide (Brenner, Homaifar, Adler, Wolfman, & Kemp, 2009)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 12
ADDICTION AND EMOTIONAL DYSREGULATION
• Lack of awareness, understanding, and acceptance of emotions
• Difficulties controlling behaviors when experiencing emotional distress
• Lack of access to adaptive strategies for modulating the duration and/or intensity of aversive emotional experiences
• An unwillingness to experience emotional distress as part of pursuing meaningful activities in life
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation “Overall emotion dysregulation…fully
mediated the relation between negative affect and urges to engage in risky
behaviors, whereas lack of emotional awareness partially mediated this
association” (Weiss, Williams, & Connolly, 2015)
ADDICTION AND PURPOSE AND MEANING
• Addiction may become a purpose substitute, satisfying the need for purpose and meaning in an unsatisfied life (Keshen, 2006)
• Substance Abuse
• Pathologic Gambling
• Overeating
• Pathologic Shopping
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
ADDICTION AND MORAL INJURY
• According to Carmona‐Perera Et al. (2012), Substance use indicates
• defective decoding of moral emotions like anger or disgust
• reduced reactivity to emotionally competent stimuli
• poor affective‐based decision making
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 13
ADDICTION AND NEEDS FULFILLMENT
• Rates of medical, psychiatric, and substance disorders are substantial among homeless people (Bakhtiar Et al., 1995)
• The unemployed are more likely to consume excessive amounts of alcohol, and to use illicit and prescription drugs. They are more likely to smoke and develop dependence on alcohol and illicit drugs (Henkel, 2011).
• difficulties in achieving positive lasting social relationships because of ongoing struggles with substance abuse recovery (Padgett, Henwood, Abrans, & Drake, 2008)
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
ADDICTION AND RELATIONSHIPS
• High levels of PTSD severity combined with substance use / abuse indicated higher levels of nonphysical aggression (Hellmuth, 2012)
• Alcohol use likely exacerbates PTSD symptoms, such as difficulty tolerating and regulating strong negative emotions and heightened sense of threat perception (Steppenbeck, Hellmuth, Simpson, & Jakupcak, 2014)
• Aggression is directly related to PTSD re‐experiencing symptoms and alcohol misuse
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Purpose and
Meaning
Addiction TBI
PTSD
Relationships
Needs Fulfillment
Moral Injury
EmotionDysregulation
THERE IS A MYTH THAT VETERANS ARE BROKEN. THAT WAR HAS SOMEHOW DESTROYED THE MIND, BODY, AND SOUL. THE IDEA THAT WE AS VETERANSARE DYSFUNCTIONAL AND CANNOT REINTEGRATE BACK INTO SOCIETY IS ABSOLUTE
GARBAGE. MANY OF US DO IT TO OURSELVES, THOUGH NOT ON PURPOSE. SOCIETY HAS THIS STIGMA ABOUT WARRIORS, THAT WHAT WE DO SOMEHOW RIPS APART OUR HUMANITY AND DAMAGES US BEYOND REPAIR. SOME WILL STATE THE SUICIDE EPIDEMIC THAT PLAGUES THE VETERAN COMMUNITY ASEVIDENCE THAT WE ARE BROKEN. WE RESPECTFULLY DISAGREE, IT IS, BUT A
SYMPTOM.
‐ JOHN FANNIN, AMERICAN GRIT
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 14
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• Brenner, L. A., Homaifar, B. Y., Adler, L. E., Wolfman, J. H., & Kemp, J. (2009). Suicidality and veterans with a history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies. Rehabilitation Psychology, 54(4), 390.
• Carmona‐Perera, M., Verdejo‐García, A., Young, L., Molina‐Fernández, A., & Pérez‐García, M. (2012). Moral decision‐making in polysubstance dependent individuals. Drug and alcohol dependence, 126(3), 389‐392.
• Glasner‐Edwards, S., & Rawson, R. (2010). Evidence‐based practices in addiction treatment: Review and recommendations for public policy. Health policy, 97(2‐3), 93‐104.
• Hall, L. K. (2016). Counseling military families: What mental health professionals need to know. Routledge.
• Henkel, D. (2011). Unemployment and substance use: a review of the literature (1990‐2010). Current drug abuse reviews, 4(1), 4‐27.
• Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., ... & Foa, E. B. (2010). Dissemination of evidence‐based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of traumatic stress, 23(6), 663‐673.
• Keshen, A. (2006). A new look at existential psychotherapy. American Journal of Psychotherapy, 60(3), 285‐298.
• Hellmuth, J. C., Stappenbeck, C. A., Hoerster, K. D., & Jakupcak, M. (2012). Modeling PTSD symptom clusters, alcohol misuse, anger, and depression as they relate to aggression and suicidality in returning US veterans. Journal of traumatic stress, 25(5), 527‐534.
• Kulka, R. A. (1990). The national Vietnam veterans readjustment study: Tables of findings and technical appendices. Brunner/Mazel Publisher.
• Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical psychology review, 29(8), 695‐706.
• Padgett, D. K., Henwood, B., Abrams, C., & Drake, R. E. (2008). Social relationships among persons who have experienced serious mental illness, substance abuse, and homelessness: Implications for recovery. American journal of orthopsychiatry, 78(3), 333‐339.
• Paley, B., Lester, P., & Mogil, C. (2013). Family systems and ecological perspectives on the impact of deployment on military families. Clinical child and family psychology review, 16(3), 245‐265.
• Scholten, J., Vasterling, J. J., & Grimes, J. B. (2017). Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference. Brain injury, 31(9), 1246‐1251.
REFERENCES
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• Schuman, D. (2016). Veterans' experiences using complementary and alternative medicine for posttraumatic stress: A qualitative interpretive meta‐synthesis. Social work in public health, 31(2), 83‐97.
• Southwick, S. M., Gilmartin, R., Mcdonough, P., & Morrissey, P. (2006). Logotherapy as an adjunctive treatment for chronic combat‐related PTSD: A meaning‐based intervention. American Journal of Psychotherapy, 60(2), 161.
• Stappenbeck, C. A., Hellmuth, J. C., Simpson, T., & Jakupcak, M. (2014). The effects of alcohol problems, PTSD, and combat exposure on nonphysical and physical aggression among Iraq and Afghanistan war veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 6(1), 65.
• Walton, J. L., Raines, A. M., Cuccurullo, L. A. J., Vidaurri, D. N., Villarosa‐Hurlocker, M. C., & Franklin, C. L. (2018). The relationship between DSM‐5 PTSD symptom clusters and alcohol misuse among military veterans. The American journal on addictions, 27(1), 23‐28.
• Weiss, N. H., Williams, D. C., & Connolly, K. M. (2015). A preliminary examination of negative affect, emotion dysregulation, and risky behaviors among military veterans in residential substance abuse treatment. Military behavioral health, 3(4), 212‐218.
• Wenzel, S. L., Bakhtiar, L., Caskey, N. H., Hardie, E., Redford, C., Sadler, N., & Gelberg, L. (1995). Homeless veterans' utilization of medical, psychiatric, and substance abuse services. Medical Care.
REFERENCES
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 15
WWW.VETERANMENTALHEALTH.COM
THANK YOU!
CE CERTIFICATE
44
CE HOURS AVAILABLE:1.5 CE
REGISTRATION TO ATTEND:
$25
CE CERTIFICATE:INCLUDED
To obtain a CE Certificate for the time you spent watching this webinar:
1. Watch and listen to this entire webinar.
2. Pass the online CE quiz, which is posted at: www.naadac.org/supporting‐those‐who‐served‐webinar
3. Maintain records of your invoice/receipt of payment and any CE certificate received from this series.
4. Email [email protected] if you experience any difficulty with this process.
45
Over 145 CEs of free educational webinars are available. Education credits are FREE for NAADAC members.
WEBINAR SERIES
In each issue of Advances in Addiction & Recovery, NAADAC's magazine, one article is eligible for CEs.
MAGAZINE ARTICLES
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FACE-TO-FACE SEMINARS
Earn CEs at home and at your own pace (includes study guide and online examination).
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CERTIFICATE PROGRAMS
www.naadac.org/education
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NAADAC Specialty Training Series: Addiction Treatment in Military and Veteran Culture Part 1 of 6
8/24/2019
Presented by Duane K.L. France, MA, MBA, LPC 16
Thank you for joining!
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