Guided Imagery:A Portable, Scalable, Self-Administered, Low-Cost, Effective, User Friendly Tool for Combat Stress and MST

Belleruth Naparstek LISW, BCDGMU/Wounded Warrior Conf.May 13, 2011

Belleruth Naparstek, LISW, BCD

Author:• Staying Well with Guided Imagery (Warner Books)• Your Sixth Sense (Harper Collins)• Invisible Heroes: Survivors of Trauma & How They Heal (Bantam)

Creator & Producer: • Health Journeys Guided Imagery Audio Series

Founder & Board Co-Chair:• Health Journeys, Inc.

Clinical Social Worker:• Chas F Read Zone Center, Chicago IL• Cambridge Hospital/Harvard Medical School, Cambridge MA• Woodburn Center for Community Mental Health/Fairfax County, VA• Private Practice & Adjunct Professor, Case Western Reserve/MSASS

What is Guided Imagery?An immersive, hypnotic, self-administered audio intervention that delivers soothing words and music to drive attention inward and structure a healing experience that targets specific goals.

Why Guided Imagery is an IdealResource for Combat Stress & MST

• It’s efficacious.

• It’s scalable.

• Troops & vets will actually use it.

• It’s Self-Administered.

• It’s Portable and Sturdy.

• It’s Inexpensive.

Why Guided Imagery is an IdealResource for Combat Stress & PTS

• It’s private and non-stigmatizing.

• It assists and helps potentiate other therapies.

• It can be used in areas without qualified therapists.

• It’s equally effective for men or women, old or young, MST or combat trauma, WW2, Vietnam or OEF vets.

• It delivers the same reliable intervention each time.

Why Guided Imagery is an IdealResource for Combat Stress & PTS

• It goes to work on the same primitive, survival-based structures in the brain that are impacted by trauma.

• It re-regulates biochemistry and teaches mood & energy management.

• It can be distributed through the command structure

• It empowers the end-user and gives back keys to self-control and stress management.

• It helps with sleep.

Examples of Civilian Use

• Kaiser Permanente• Blue Shield of California• United Healthcare• American Red Cross• Oxford Health Plan• Betty Ford Clinic• Hazelden• Mayo Clinic• Cleveland Clinic• Johns Hopkins Hospital• New York Presbyterian Hospital• Beth Israel Deaconess• Duke University Medical Center

Online Guided Imagery for Kaiser Permanente Members Nationwide

Examples of Military Use

• Army’s MWR

• USMC MedCell - National Crisis Call Centers

• National Naval Medical Center & NICoE

• Scripps/Camp Pendleton

• California National Guard SARC

• Department of Veterans Affairs

• Guided Imagery Test Bed, Ft. Sill, OK

• DCoE Promising Practice

• Landstuhl Regional Medical Center

FEEDBACK“Feedback from our Combat Marine Veterans regarding the PTSD and Sleeptools is - they love them. They like that they can "plug in" to their ownrelaxation tool whenever and wherever they are and not have to "wait" tospeak with a counselor if they are feeling anxious. We have utilized theseMP3 and CDs with service members with longstanding symptoms as well asthose suffering with acute stress issues. One of the nice things about thesedevices is that it follows our recovery mindset: re-empower the Marine byletting him learn how to help himself!”

Laurie Giertz, PA-C, Team Lead, Psychological Health/TBI Programs & Crisis Call Center, USMC Wounded Warrior Regiment, Quantico, Virginia

Preferred Method of Help for TBI-related Sleep Disturbances by OIF/OEF Veterans* (n = 18)

*Modifications to Insomnia Treatments for OIF/OEF Veterans with TBI. PI: Dana Epstein PhD, RN, Phoenix V.A. Health Care System, Final Report for HSR&D QUERI Project RRP 07-309, 8/13/08

GIFT Facilitator Manual, Marian Butterfield MD, MPH and Jennifer Strauss PhD, Durham VAMC and Duke University, Durham NC 27705

*88% of users found tx to be helpful.

V.A. Clinic Users’ Attitudes re: Self-Help & Guided Imagery (n = 89, 16% women)

Root L, Koch E, Reyntjens K, O’Brien C, Alexander S, Gaughf N. Trauma-Specific Guided Imagery: A Systematic Evaluation of an Adjunct Intervention to Group Psychotherapy. Poster Session, ISTSS Annual Meeting, New Orleans, 2001.

Research

Research

Evaluate effectiveness of trauma-specific guided imagery with veterans, ages 51-80 with war-related PTS.

Non-randomized convenience sample, pre-test/post-test design.

22 Male veterans participated in one of 5 groups for five, 45-minute sessions of guided imagery immediately following regular therapy sessions. Pre and Post measures were taken at Session 5 and by telephone after 3 months. Of 27 recruited, 22 completers, 18 for follow up.

Objective:

Design:

Method:

Findings

• Significant number (p<.05) no longer met Dx Criteria for PTSD as measured by PCL-Military (before tx: 26; after tx: 20)

• More frequent moments of well-being (p < .05) - Stronger yet at 3 mos. follow-up

• Would recommend for others: average rating 7.25 on 1-9 scale

• Significant others would recommend for others: 7.25 on 1-9 scale

• Would recommend for others 3 mos. later: 8.08 on 1-9 scale

• A surprising 89% continued to use the tape, with over 70% listening either daily or a couple of times a week

• Participants unanimously recommended the intervention for other veterans with PTSD. When asked why, they most often responded with “It helps.”

Takeaways

• Start with less evocative guided imagery before introducing trauma-specific content.

• Expand # of sessions of imagery intervention.

• Peer group support may mediate anxiety, account for high retention/low attrition

• Efficacy increases over time.

Jennifer L. Strauss, et. al. GIFT*: A Tele-Mental Health Approach to Enhancing Treatment Engagement and Symptom Self-Management for Women Veterans with PTSD Related to Military Sexual Trauma: RCT Results. VA Mental Health Conference, August 2010, Durham, North Carolina.

Research

*Guided Imagery for Trauma

CAPS Modeling ResultsObserved (dashed line) and Predicted (solid line) Mean Trajectories by Treatment Group

PCL Modeling ResultsObserved (dashed line) and Predicted (solid line) Mean Trajectories by Treatment Group

Sustained Treatment Gains: Imagery vs. Controls As Measured by the PCL (PTSD Checklist)

• 8 weeks vs. 12 weeks, since 80% of improvement occurs by week #6, and attrition due to improved status occurs by week #8.

• Skills training language vs therapy language

• Replace 2 emotionally evocative imagery tracks with 5 segments with more variety, emotional neutrality

• Self-Regulation through Conscious Breathing• Word and phrase repetition• Progressive Body Scanning• Deep Relaxation/Guided Imagery• Restful Sleep Imagery

• Allow for choice of any tracks: 30 minutes of any content per day, 5 days/week

Takeaways

• N = 20 male combat veterans (5 OEF/OIF)

• Demographically similar to prior sample

• Open pilot

• Large reductions in PTSD symptoms were observed

CAPS Cohen’s d = 1.45

PCL Cohen’s d = 0.82

Findings for Revised Protocol: SMART (Self-Management Audio for Recovery from Trauma)

Some Lessons Learned

• Have credible military personnel introduce the imagery.

• Use Skills Training Language vs. Therapy Language.

• Structure a protocol, e.g. listen 30 min/day, 5 days/wk for eight weeks.

• Provide a variety of audio files from which to choose.

• Provide both emotionally neutral and evocative imagery from which to choose.

• When in doubt, start with the sleep imagery – everyone wants it.

• Lower attrition when used in the context of peer group support.

• Works well with biofeedback, prolonged exposure, EMDR, Reiki and Healing Touch.

• Works well with many people and can be tweaked to reach even more.