One-Day Life Skills Workshop for Veterans With TBI, Pain and Psychopathology

Traumatic brain injury (TBI) is the signature wound of Veterans returning from Operations
Iraqi Freedom, Enduring Freedom and Operation New Dawn (OIF/OEF/OND), with up to 20 percent
experiencing persistent post-concussive symptoms. Among those with a mild TBI (mTBI)
diagnosis, the majority also suffers from stress-based psychopathology, including depression,
post-traumatic stress disorder, and other anxiety disorders, as well as persistent pain. Poor
management of multiple conditions results in increased morbidity and mortality, increased
risk for suicide, and significantly decreased quality of life. Importantly, the association
between seeking mental health care and stigma among Veterans is high. Veterans are often
unwilling to seek mental health services due to concern that receiving such care would
negatively impact their careers and the belief that they should be able to overcome
psychological difficulties on their own. Furthermore availability of specialty services is
limited for Veterans living in rural settings. Thus the challenge for treatment providers is
to provide a unified, efficient, accessible, and acceptable intervention for Veterans with
these interdependent systemic comorbid concerns. Acceptance and Commitment Therapy (ACT) is a
trans-diagnostic (i.e., applies to more than one diagnosis) behavioral intervention aimed at
helping individuals develop the skills needed to pursue valued goals and directions in the
face of life's challenges. It provides a unified model of behavior change that has shown
promise in treating depression and anxiety, as well as chronic medical conditions.
Importantly, ACT has been effectively implemented in various treatment-delivery formats,
including 1-day workshops. This flexibility in delivery format allows focus to be placed on
how best to package and deliver the intervention to meet the needs of this Veteran patient
population, to ensure treatment adherence, and also to increase chances of dissemination into
clinical settings. Providing a 1-day ACT "workshop" for Veterans with mTBI, pain, and mental
health problems will allow unitary comprehensive care for the range of emotional, physical,
and cognitive symptoms experienced by these Veterans. Presenting the treatment as a
"workshop" rather than "therapy" will also be better suited for the Veterans who may not be
explicitly seeking specialized mental health care. Finally, a 1-day workshop ensures
treatment adherence and completion, the lack of which is often the greatest obstacle to
effective delivery of mental health services. The aims of this study are to 1) develop a
1-day (5-hour) "ACT on Life" workshop tailored specifically for Veterans with mTBI,
stress-based psychopathology, and pain; a multi-disciplinary team of a clinical psychologist,
neuropsychiatrist, cognitive psychologist, and anthropologist will provide expert input for
use in producing the therapist intervention and patient manual; 2) enroll 10 Veterans with
mTBI, stress-based psychopathology, and pain in the "ACT on Life" workshop to obtain
qualitative and quantitative feedback from Veterans about the intervention; use Veteran
feedback to refine the treatment procedures and manuals; and examine feasibility and
acceptability of the intervention; and 3) randomize 30 Veterans with mTBI, pain, and
stress-based psychopathology to the refined "ACT on Life" workshop or to Treatment as usual
(TAU) to examine the preliminary efficacy of the intervention on quality of life and
functioning, stress-based symptoms of psychopathology, and pain interference.

Inclusion Criteria:

- 18-75 years of age

- Clinically significant psychological distress as operationalized by a diagnosis of
major depressive disorder, generalized anxiety disorder, or PTSD

- Life time history of Mild TBI

- the Department of Veterans Affairs and the Department of Defense define TBI as a
traumatically induced structural injury and/or physiological disruption of brain
function that is associated with any period of loss of or a decreased level of
consciousness

- any loss of memory for events immediately before or after the injury

- any alteration in mental state at the time of the injury

- neurological deficits that may or may not be transient

- or an intracranial lesion

- Mild TBI is characterized by loss of consciousness less than 30 minutes, a period of
post-traumatic amnesia less than 24 hours or, if available, a Glasgow Coma Scale score
of 13 to 15

- Presence in medical chart of chronic pain including headache, musculoskeletal pain or
neuropathic pain

- Stable dose of psychiatric medications for the past 8 weeks

Exclusion Criteria:

- History of primary psychotic disorder, e.g.,:

- schizophrenia

- schizoaffective disorder

- A diagnosis of substance dependence in the year prior to enrollment in the study

- Active suicidal ideation

- Homicidal ideation