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Journal of Gerontological Social Work Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wger20

Aging, Depression, and Wisdom: A Pilot Study of Life-Review Intervention and PTSD Treatment With Two Groups of Vietnam Veterans a

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Lori R. Daniels , James Boehnlein & Phillip McCallion a

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Portland Vet Center, Portland, Oregon, USA

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Mental Illness Research, Education & Clinical Center (MIRECC), Portland VAMC, Portland, Oregon, USA c

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Center for Excellence in Aging Services, University of Albany, Albany, New York, USA Accepted author version posted online: 09 Mar 2015.Published online: 09 Mar 2015.

To cite this article: Lori R. Daniels, James Boehnlein & Phillip McCallion (2015): Aging, Depression, and Wisdom: A Pilot Study of Life-Review Intervention and PTSD Treatment With Two Groups of Vietnam Veterans, Journal of Gerontological Social Work, DOI: 10.1080/01634372.2015.1013657 To link to this article: http://dx.doi.org/10.1080/01634372.2015.1013657

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Journal of Gerontological Social Work, 00:1–17, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0163-4372 print/1540-4048 online DOI: 10.1080/01634372.2015.1013657

Aging, Depression, and Wisdom: A Pilot Study of Life-Review Intervention and PTSD Treatment With Two Groups of Vietnam Veterans LORI R. DANIELS Downloaded by [134.117.10.200] at 22:38 06 May 2015

Portland Vet Center, Portland, Oregon, USA

JAMES BOEHNLEIN Mental Illness Research, Education & Clinical Center (MIRECC), Portland VAMC, Portland, Oregon, USA

PHILLIP MCCALLION Center for Excellence in Aging Services, University of Albany, Albany, New York, USA

Vietnam War veterans are a sometimes overlooked subgroup of the aging baby boomer generation. Forty years after the war ended, war veterans still seek out VA or Vet Center counselors to assist with traumatic stress symptoms. However, there currently are no specific age-related protocols for treating older war veterans suffering from posttraumatic stress disorder (PTSD), nor have established PTSD interventions incorporated gerontology content for these older trauma survivors. This pilot study juxtaposed life review within regular PTSD group counseling for 12 Vietnam veterans at a community-based Vet Center using a partial crossover design. The Life Review and Experiencing Form (LREF) structured the delivery of the life review component. T-tests and repeated measures ANOVA were used to examine depression and self-assessed wisdom outcomes using measures previously tested with older adults. Findings suggest that life review prior to PTSD group therapy has clinical benefits for reducing symptoms of depression and increasing self-assessed wisdom. The study illuminates the possible relationship of Received 26 August 2014; revised 26 January 2015; accepted 27 January 2015. Address correspondence to Lori R. Daniels, Portland Vet Center, 1505 NE 122nd Avenue, Portland, OR 97223, USA. E-mail: [email protected] or [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wger. 1

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traumatic stress symptom effects on the natural reminiscing process for older veterans and provides insights into methods for more age-appropriate treatment for trauma survivors participating in Vet Center and VA programs nationwide. KEYWORDS veterans, aging, PTSD, life review, depression, reminiscence, reminiscing, traumatic stress, Vietnam War, older veterans, self-assessed wisdom

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BACKGROUND AND THEORETICAL PERSPECTIVE It is no secret to most professionals working in either social work or other mental health fields that services for older adults will be in great demand over the next few decades. The baby-boomer generation, currently aging into their late-60s and early-70s, represents an increase of millions of people entering older adulthood, contributing to a burgeoning crisis among healthcare and community-based programs. Included within the baby-boomer generation, those born between 1946 and 1967 (Schaie & Willis, 2002), is the subset of veterans from the Vietnam War, over 50% of whom will be over the age of 65 by the year 2015 (Chatterjee et al., 2009). Over the past 30 years, Vietnam veterans have been at the forefront of posttraumatic stress disorder (PTSD) counseling through the Department of Veterans Affairs (VA) special programs and community-based Readjustment Counseling Centers (Vet Centers) to assist with traumatic stress symptoms; however there are no existing protocols for treating older war veterans suffering from PTSD. Previous research with veterans from the Vietnam War indicates that between 18% and 30% of those serving in the war have met the diagnosis for PTSD sometime in their lives (Kulka et al., 1990). These war veterans face developmental challenges related to aging, which includes the natural inclination to reminisce and recall their past. This can be a daunting task for those veterans diagnosed with PTSD who struggle with intrusive traumatic memories. A possible reason why there are no clear protocols for treating older war veterans diagnosed with PTSD may be the lack of integration of advances made in the respective fields of traumatic stress and gerontology. However, theoretical perspectives from each field have been merged in our intervention model. This study addresses possible age-appropriate interventions for older war veterans by incorporating methods from the gerontology field to supplement current traumatic stress treatment options. Specifically, this study investigated the potential impact on depression symptoms and selfassessed wisdom scores by adding facilitated life-review as a logical adjunct to existing war trauma group therapy. In addition, this project considered differential effects that might arise from the sequencing of the two different

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group structures: a life review/PTSD group and a PTSD/life review group using a time-series, crossover research design. The impact of normal aging on traumatized war veterans diagnosed with PTSD has not been clearly delineated. Much of the information about war veterans with PTSD has focused on World War II and Korean War veterans, due to these war veterans being in their 60s, 70s, and 80s at the time these studies were conducted (Cook, 2001; Hyer, Summers, Braswell, & Boyd, 1995; Markowitz, 2007; Schnurr, 1991; Spiro, Schnurr, & Aldwin, 1994). In spite of literature suggesting that there are significant challenges of aging for war veterans struggling with posttraumatic stress and depression, there are no clear guidelines for effective age-appropriate treatment.

Reminiscence, Life Review, and Narrative The normal aging process presents significant challenges as one’s body, mind, and emotional well-being encounter numerous losses. Characteristics of “selective optimization” aging include the ability to be selective in one’s efforts to implement alternative strategies in compensating for losses throughout the aging processes (Baltes & Baltes, 1990, p. 21). Ideally, an older adult is able to function with behavioral flexibility while maintaining social supports, developing new relationships, learning techniques for stress reduction, and coping with change. Successful aging is also bolstered by a positive self-concept that is maintained by an ability to evaluate one’s performance in proper relation to one’s physical and mental capacity (Schaie & Willis, 2002). Using concepts of reminiscence, life review, and narrative, geriatric and gerontological specialists have found that integrating memories in narrative form has benefits toward the improved self-identity of an aging adult (Bohlmeijer, Roemer, Cuijpers, & Smit, 2007; Cappeliez, O’Rourke, & Chaudhury, 2005; Coleman, 2005; Webster, 1998; Wong and Watt, 1991). Reminiscence does have value toward helping older adults (Blankenship, Molinari, & Kunik, 1996; Bohlmeijer et al., 2007; Pasupathi, 2001). Rice (2005) discussed providing a social support group with elderly persons and reports that reminiscing groups can be utilized in both community and institutional settings to assist clients. The use of reminiscence can increase morale, self-esteem, and life satisfaction, as well as allow for an increased sense of control over the environment (Rice, 2005). In addition, group members can feel an increased sense of understanding of, and support for, other group members as they share their common experiences (Rice, 2005). Similar to the use of reminiscence, narrative story or life review have been found to assist individuals in developing an interaction between their memories and disclosing to others these personal stories, thereby creating a narrative identity (Hunt & McHale, 2008).

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Sharing of memories and facilitating client self-disclosure have been used in the treatment of older veterans. Hunt and McHale (2008) stated that memories and their meaning can be affected while sharing individual narratives and memories in a social venue. They suggested that social workers and mental health professionals focus on comparative concepts of time, and on recognizing the importance of continuous identity when dealing with veterans’ life stories.

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Traumatic Stress Among Older Veterans Although the gerontology literature has made numerous attempts to improve the quality of life for adults going through later stages of the aging process, experts in the area of traumatic stress have only begun to identify and address these issues. It appears as if there have been, at best, sporadic and inconsistent reports by PTSD researchers of the need to address the confluence of aging and traumatic stress among survivors (Bonwick & Morris, 1996; Brooks & Fulton, 2010; Chatterjee et al., 2009; Cook, 2001; Cook & Niederehe, 2007; Lipton & Schaffer, 1986; Markowitz, 2007; Schnurr, 1991). Friedman, Resick, and Keane (2007) have discussed future research directions for mental health treatment for older adults and advocate for a developmental perspective in order to guide theory and practice across the life span when working with older veterans with PTSD. Although encouraging in terms of suggesting a developmental perspective, these authors did not discuss the natural reminiscing process of old age. However, they did encourage providers to consider models of treatment that address coping capacity, beliefs about oneself and the environment, and social embeddedness (Friedman et al., 2007). There are a few studies that broach the relationship between war trauma, older veterans, and reminiscence/life review. One study with former POWs from WWII and the Korean War found that discussing memories in a group of older veterans had positive benefits, although group facilitators did not provide a specific life review structure (Boehnlein & Sparr, 1993). Hyer et al. (1995) shared a model of reminiscence therapy coupled with cognitive behavioral therapy techniques for combat veterans. These authors argued that one’s core belief becomes central to the person and helps them make sense of the world; narrative memory then contributes to a meaning system about one’s self, using guided exposure within reminiscence therapy to assist older clients in illuminating distortions and refuting negative core beliefs (Hyer et al., 1995). Distortions and negative core cognitions and assumptions can then lead to a more negative worldview in respect to beliefs about one’s self-worth, benevolence of the world, and random events—which can contribute to a person’s negative identity (Smith, 2002). The use of narrative can allow for possible reinterpretation of the meaning previously assigned to a traumatic event, which can result in what Hyer et al. (1995, p. 358) call “meaning revisions.”

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Cook and Niederehe (2007), citing several research studies, attempted to explain older adults’ perceptions of traumatic exposure in their lives and discuss the phenomenology and the course of PTSD among older adults. These authors pointed out that a mediating effect of traumatic stress in later life may be an individual’s perceptions of the effects of their traumatic exposure and whether it was a “desirable” or an “undesirable” event (p. 258). Negative perceptions of self-efficacy and lacking a sense of mastery were also suggested as contributors to higher psychological distress in older trauma survivors. The clinical implication suggested by Cook and Niederehe (2007) is that interventions assisting with increasing locus of control, perceived self-efficacy, and positive reappraisal may assist in alleviating distress and improve coping. Because reminiscence, life review, narrative gerontology, or other recollection-based interventions have been used, but only rarely, in the recovery of traumatic stress among older adults (Boehnlein & Sparr, 1993; Hyer et al., 1995; Maercker, 2002), there is no one particular intervention that appears to stand out for appropriate use among older war veterans. The observations and findings within the literature suggest that sharing one’s story through facilitated reminiscence or life review could reduce trauma survivors’ depression, facilitate more positive self-evaluations (including respecting vs. rejecting life experiences) and contribute toward greater self-wisdom. Therefore, this pilot study attempts to fill this treatment gap by beginning to elucidate the relationship of life review superimposed on PTSD counseling to help reduce a trauma survivor’s depression symptoms, increase their social support, and enhance self-assessed wisdom.

Research Questions Tested in This Study 1. Will participation in a war-veteran PTSD group with added life review be significantly different from participation in a standard war-veteran PTSD group in terms of reducing depression and enhancing self-assessed wisdom? 2. Within the life review group or standard group structures, will depression scores and self-assessed wisdom be significantly different from the pregroup time period? 3. Does the sequencing of participation in structured life review group therapy either before or after participation in less-structured group therapy make a difference in outcome measures?

METHODOLOGY Design The study was conducted at a Vet Center, part of the VA Readjustment Counseling Service. These veteran-centric storefront counseling centers

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were originally created in the late-1970s to provide peer-led counseling for Vietnam veterans in a community-based environment. Vet Centers now primarily provide individual and group psychotherapy services to community-based veterans who have readjustment issues after serving in war zones. In addition, counseling for military sexual traumatized veterans or bereavement counseling for family members of recently deceased active-duty military members is also provided in Vet Centers nationwide. A partial crossover study design was utilized. Two newly-established groups of Vietnam veterans were recruited: (a) one group was provided Vet Center standard care of PTSD group psychotherapy/support and (b) another group added a semistructured life review component to standard PTSD group psychotherapy. A crossover design was implemented at 6 months, with the life review component added to the standard care group’s therapeutic intervention, thus allowing both Vietnam veteran groups to receive the intervention. Figure 1 illustrates the partial crossover process during the intervention conditions and assessment time-periods. The study was approved by the Portland VA Medical Center’s Institutional Review Board. Group meetings began on the same day, at two different times of the day, and sessions were facilitated by one of the principal investigators (who is also a member of the clinical staff at the Vet Center). Group sessions were scheduled one time per week for 2 hr per meeting. Those beginning with life review were the AM group and those beginning with PTSD counseling were the PM group. All study assessments were independently completed by the other principal investigator, who was not on the staff of the Vet Center.

FIGURE 1 Crossover design for both Vietnam War veteran group meetings: Sessions and testing timeline.

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The third author reviewed the session content and, in telephone conferences with the investigator delivering the interventions, offered feedback on maintaining fidelity to each intervention mode. All three investigators maintained blindness to the aspects of the project in which they were not directly involved. Subjects completed study measures at the beginning of the study and every 3 months during the course of the study, and again 3 months after the end of all group meetings. Changes in outcome scores were anticipated within each group, between the two groups, and across time for each veteran throughout the 48 meeting sessions.

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SAMPLE Convenience sampling method was implemented, as veteran subjects were referred to the study by their Vet Center case managers. Each consenting Vietnam veteran completed a pregroup packet of measures for the study. Inclusion criteria were Vietnam War veterans receiving counseling for PTSD, with no current active alcohol abuse, no current active drug abuse, and no dementia. All participants were men; ages ranged from 61 to 70 years, with a mean age of 65.17 years. Over 58% (7) of the subjects who started the study were in the Army, 33.3% (4) were in the Marine Corps, and 8% (1) was in the Navy while serving in the Vietnam War. Nearly 92% of participants were Caucasian, and one subject was Chinese/Hawaiian. Regarding marital status, 7 (58%) were currently married; 3 (42%) were currently divorced; 6 (54%) had a history of being married more than once; 2 (18%) had been married at least 3 times in their lives, and one had never married (8%). Twelve veterans consented to the study prior to being randomly assigned to either the AM/Morning group (who started the study with life review structured meetings) or the PM/Afternoon group (who started the study with less-structured, here-and-now focus). All subjects were already prescribed medications that were not changed during the study for various health and mood issues (e.g., depression, anxiety, sleep, nightmares), and each had varying degrees of previous PTSD counseling ranging from “brand new” (e.g., a few monthly sessions prior to the start of the study groups) to several years of monthly individual psychotherapy. None of the subjects had participated in a Vet Center group prior to the study or were on the caseload of the study group facilitator. After groups were assigned, one group met in the morning for 2 hr, and the other group met the same day during the afternoon for 2 hr. Although 12 subjects were originally enrolled in the study, one subject dropped-out from the life review structured group after completing the premilitary component; another veteran also dropped out 9 months into the study; and a third veteran suffered a stroke, which prevented him from returning to the meetings for the rest of the study. Data were analyzed for the 9 veterans who completed the entire 15-month study.

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INTERVENTIONS There were two 6-month interventions: group delivered life review and group delivered PTSD counseling. Both group structures included a brief psycho-educational presentation about PTSD symptoms and the goals of recovery during the very first day of group meetings; regardless of group structure, each group session started with veterans sharing 2–3 emotions to check-in to the group, and 2–3 emotions to check-out at the end of the meetings. Life review group. Veterans during the life review group meetings used a guided life review questionnaire to structure their disclosures: The Life Review and Experiencing Form (LREF; Black & Haight, 1992; Haight, 1992; Haight & Bahr, 1984). However, the LREF lacked questions regarding military or war history; therefore, we added additional questions regarding these aspects of a veteran’s life. Subjects were told that they could use the LREF as a guide-sheet and to help them think through their life story. The LREF was also split into three sections: childhood/premilitary life, military life (including additional war-related questions), and postmilitary life. Most subjects used the LREF sheets to start their sharing, but then found the LREF unnecessary as they would continue to disclose their respective stories without needing the LREF to prompt them. Each subject was given four sessions across 6 months to complete his sharing of his autobiography. Regular PTSD group. The structure of the usual Vietnam veteran psychotherapy groups at the Vet Center has been based upon a peer-support, client-centered, emotion-focused, present-centered intervention model. This model does not include facilitated life review or reminiscence but is, instead, focused on here-and-now issues related to one’s war-related PTSD symptoms, which may contribute to current functioning problems. For this study, the same intervention format was utilized to emulate the typical war veteran meetings already taking place.

Dependent Measures In addition to gathering demographic data (i.e., age, marital status, branch of the military, ethnicity, number of years deployed during the Vietnam War) from the Vet Center initial intake paperwork, the study used several different outcome measures selected because of prior use with older adults, reported psychometric validity and reliability, and/or previous use with veterans. OLDER ADULT HEALTH

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MOOD QUESTIONNAIRE (OAHMQ)

The OAHMQ instrument for geriatric depressive disorders is based upon Diagnostic and Statistical Manual of Mental Disorders third edition, revised

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(DSM-III-R; American Psychiatric Association, 1987) criteria, while differentiating depression among older persons (Kemp & Adams, 1995). The OAHMQ is a 22-item questionnaire with acceptable psychometric properties and high validity. The scaling of the OAHMQ is: 0–3 indicates no depression; 4–10 indicates a mild depressive episode; and 11–22 suggests a major depressive episode. The OAHMQ also reports severity of reported depressive symptoms from normal to clinically significant depressive symptoms to probable major depression. The measure has construct validity of .87 for major depression, and .92 for sensitivity and .87 for specificity for any depressive disorder, as well as measured instrument sensitivity of .80 (Kemp & Adams, 1995).

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THE SELF-ASSESSED WISDOM SCALE (SAWS) The SAWS is a 30 item instrument using a 6-point Likert scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with items that include statements like “I have had to make many important life decisions” and “I often find memories of my past can be important coping resources.” This instrument is designed to better understand how people of different ages perceive themselves with respect to life experiences, and whether or not these perceptions change as one grows older (Webster, 2003). Webster (2003) determined a mean cut-off for wise of 137.24 (SD = 22.45) and for foolish of 96.59 (SD = 18.04), and he contended that self-assessed wisdom was inherent to reminiscing and life review. Testing of psychometric properties of the SAWS in three different studies demonstrated good reliability (alpha = .78) and a factor structure assessing five interrelated components of wisdom (Webster, 2003). The SAWS also demonstrated acceptable construct validity when measured with an ego integrity measure (r2 = .225; p < .05) and a generativity measure (r2 = .439; p < .01). The SAWS also has a five factor structure of experience, emotional regulation, humor, openness, and reminiscing/reflecting; and although the correlation coefficients are considered low–moderate correlations, construct validity for the SAWS was established (Webster, 2003).

RESULTS Data analysis using SPSS version 20 used repeated measures one-way ANOVA, and considered six data points; measurement at baseline and then after every 12 sessions, plus 3-months after all group sessions had ended. Paired samples t-test and independent samples t-test were used for specific pretest and posttest comparisons between Vietnam veteran groups on outcome measures. Given the smallness of the sample and the pilot nature of

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the study, this level of analysis was considered appropriate. Data points for each scale were also graphed.

Findings

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To answer the first research question, a paired samples t-test was conducted and found no significant differences for all veteran subjects comparing their depression or subjective well being mean scores from Time 1 (pregroup meetings) to either Time 5 (groups ended) or Time 6 (3-month follow-up). It was not until the outcome measures were split by group membership (AM group compared with PM group) that differences in both outcome measures were noted. Due to the clinical nature of the study with a very small sample size, outcome scores were appraised for clinical significance and statistical significance (with p set at .10). DEPRESSION Figure 2 displays the trends for the two groups across the study time-periods, with the crossover into the alternative group therapy structure at Time 3. Mean scores on OAHMQ for all study subjects in both groups (9 veterans who completed the entire year of the interventions) were the same at pregroup assessment (M = 12.11, SD = 5.18), within the major depression range established by the OAHMQ authors. Paired samples t- test showed no statistically significant change in depression levels at Time 6 (3 months postgroups ending); t(8) = 1.39, p = .22; although mean scores for all subjects trended toward reduced depression levels into the depressive episode range of the OAHMQ (M = 8.88, SD = 7.16). Analyzing a comparison between the AM/morning and PM/afternoon groups using repeated measures oneway ANOVA showed depression means at the first 3 months (Time 2) and throughout the group meetings diverging, and especially between the 9th month of group (Time 4) and end of the group meetings (Time 5) and continued at the 3-month follow-up (Time 6); and indicated a nearly statistical significant difference; F(5) = 3.42; p = .107. Based on the OAHMQ authors’ original evaluation of the instrument (0–3 no depression; 4–10 depressive episode; 11–22 major depression; Kemp and Adams, 1995) the Figure 2 line graphs of each group’s depression scores illustrate that the AM (morning) group (who received facilitated life review for the first 6 months, followed by regular group therapy) reported clinicallysignificant reduced depression by the end of the group meetings (Time 1: M = 12.25, SD = 5.19; Time 5: M = 3.75, SD = 4.50), with reported scores dropping toward the no depression level. This trend toward no depression scores continued with the AM group at the 3-month follow-up (Time 6: M = 3.00, SD = 3.16). This also demonstrates clinical significance, which is highly relevant for a clinical therapy setting—even with a small group. Subsequent

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Legend: AM = Morning Group; PM = Afternoon Group; • Top green line = PM Group mean scores; • Bottom blue line = AM group mean scores Paired samples t-test between Time 1 and Time 6 for OAHMQ: t = 6.19 (p=

Aging, Depression, and Wisdom: A Pilot Study of Life-Review Intervention and PTSD Treatment With Two Groups of Vietnam Veterans.

Vietnam War veterans are a sometimes overlooked subgroup of the aging baby boomer generation. Forty years after the war ended, war veterans still seek...
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