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Monday, September 25, 2017

The Takeaways from Adaptive Disclosure

The Takeaways from Adaptive Disclosure
This post serves as an overview of the book "Adaptive Disclosure: A new treatment for military trauma, loss, and moral injury," and how the concepts apply to the work therapists do.

The VTSC is very lucky to have Dr. Matthew Jakupcak as one of our trainers, aka subject matter experts. Some of you may remember his training on Moral Injury and Adaptive Disclosure this past summer. Unfortunately, I was unable to attend but still wanted to learn something about the topic. I read the book Dr. Jakupcak chose to work out of in his training, Adaptive Disclosure, by Brett T. Litz, Leslie Lebowitz, Matt J. Gray, & William Nash. This book presents an innovative, research based treatment for service-members and veterans who are struggling with combat stress injuries. This treatment combines elements of emotion-focused experiential strategies, cognitive behavioral therapy, and exposure therapies. What makes adaptive disclosure different is that it incorporates military culture into the treatment to provide an effective care experience.

In this text, I observed a few reoccurring concepts. For one, other trauma treatments do not necessarily apply to the experience of a combat veteran. Secondly, it is possible to re-commit to past morals or values that were broken. Lastly, incorporating the use of homework can be what makes all the difference in the efficacy of the treatment.

  • Other trauma treatments do not necessarily apply to the experience of a combat veteran
  • Adaptive Disclosure emerged due to a gap in treatment options for service members with moral injury. Moral injury is a “term used to describe a syndrome of shame, self-handicapping, anger, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are transgressed” (Litz, Lebowitz, Gray, & Nash, 2016). Many causes for moral injury in a military population (i.e. acts of violence, knowledge of MST, exposure to the aftermath of battle) are essentially perpetration behavior. Most therapists will not treat perpetration-based moral injury within a prolonged exposure (PE) or cognitive processing therapy (CPT) framework. In PE it is prohibited to work with perpetration-based behavior. The premise of CPT is that there are distorted beliefs causing the misery; this would not be the case with most combat related moral injury. The facts and beliefs are clear and valid.

    Adaptive Disclosure is also primed to work with military culture rather than having the veteran/service-provider fit him/herself into a civilian framework. Other trauma treatments work off the assumption of traumatic equipotentiality, or rather, all traumas and traumatic contexts are basically the same. This lens does not take into consideration unique cultural and contextual elements of military trauma (such as chain of command, power/control, societal norms around emotions, etc.), the phenomenology of service-members, or clinical issues around combat/operational stressors. Adaptive Disclosure uses this knowledge to help the therapeutic process; it is the therapist’s responsibility to learn cultural factors and admit when they don’t know something (Litz et al., 2016).

  • It is possible to re-commit to past morals or values that were broken
  • The authors of this text describe the aftermath of moral injury as a struggle with feelings of shame, guilt, & unworthiness, which result in self-handicapping and potentially self-harm. Self-compassion may be at the forefront of most therapists’ mind during this stage, however, there may be a prerequisite component needed. This prerequisite is done through corrective learning and incorporates an imaginal “confession” paired with a re-commitment to past values (Litz et al., 2016). If thinking about this through the lens of DBT, one could use the dialectic of acceptance and change. On the acceptance side: not assigning culpability or reworking thoughts (as would be required in other modalities). On the change side: reclaim goodness and humility. The therapist will need to balance this dialectic to ensure efficacy.

  • Incorporating the use of homework can be what makes all the difference in the efficacy of the treatment
  • Like other treatment modalities, adaptive disclosure is only as helpful as the work being put into it. What this translates to, is that the client would be expected to work on their treatment outside of sessions. Litz et al. (2016) recommend utilizing a verbal contract for care, this way the expectations for both therapist and client are discussed and agreed upon. Homework assignments are designed to kick start the change process; since “the work” occurs outside of the walls of the therapy room, the client should be informed of this lifestyle change. Homework is such a key piece of this treatment, that there are seven pages of ideas for homework.

    Litz, B.T., Lebowitz, L., Gray, M.J., Nash, W.P. (2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury.. New York, NY: The Guilford Press.