One-day Life Skills Workshop for Veterans with TBI, pain, and Psychopathology: Evaluating efficacy and mechanism of change

创伤性脑损伤（TBI）是从伊拉克自由行动返回的退伍军人的标志性伤口， 持久自由行动和新黎明行动（OIF/OEF/OND），多达20%的人暴露在一个 轻度TBI（mTBI）和持续性脑震荡后症状。在那些有mTBI诊断的人中， 大多数人还患有基于压力的精神病理学（例如，抑郁症，创伤后应激障碍 广泛性焦虑症）以及慢性疼痛。为了科普悲伤、痛苦和其他困难， 退伍军人经常求助于适应不良的回避应对策略，这些策略提供了短期缓解， 加剧/维持心理健康问题，并对社会，职业， 和重返社区。不幸的是，退伍军人在从事心理健康方面面临重大障碍 治疗，包括污名化，认为一个人应该自己克服心理困难，以及 他们担心接受这种护理会对他们的职业生涯产生负面影响。实际障碍，包括时间 约束、与治疗设施的距离，以及竞争优先级（例如，工作和家庭需求）， 也是护理的障碍。即使在开始心理健康治疗的退伍军人中，也只有少数人完成了治疗。 循证治疗的推荐疗程 接受和承诺疗法（ACT）是一种跨诊断治疗模式，可帮助患者 通过促进以接受为基础的应对和参与有意义的生活活动来克服逃避。在 在这种背景下，退伍军人被要求思考他们离开军队后的“新使命”， 即使在可能困难的时候，也必须参与完成其使命的行动。ACT已建立 在治疗抑郁症、焦虑症和慢性疼痛方面的疗效，并已在 各种治疗形式，包括为期一天的小组研讨会。为期一天的ACT研讨会 患有mTBI、基于压力的精神病理学和慢性疼痛（多发性创伤三联征）的退伍军人的特定需求， 治疗的重要障碍。它1）是跨诊断的（即，适用于多个条件）; 2）目标 3）培养基于接受的应对方式，并建立在退伍军人的价值观和目标， 激励他们做出困难的决定; 4）有效地交付，因此更容易获得; 5）更少 污名化，因此是可以接受的;和6）解决治疗依从性和完成问题。 在RR&D SPiRE试点赠款的支持下，PI制定了一个为期一天的“ACT on Life”研讨会， 专门针对患有mTBI、基于压力的精神病理学和慢性疼痛的退伍军人的需求。退伍军人 然后随机分配到“ACT on Life”研讨会（N=20）或治疗， 神经性（TAU; N=12）。所有参加为期一天的ACT研讨会的退伍军人都完成了它，相对于TAU， 在3个月的随访中显示出更大的痛苦和重返社会的改善（效应量0.68和0.47， 分别）。在这些有希望的初步结果的基础上，我们现在建议进行更严格的 一项随机对照试验，212名退伍军人，比较为期1天的ACT研讨会与活性 治疗比较（教育，资源和支持; ERS）的痛苦和社会， 职业和重返社区。我们还将研究治疗的调解人和主持人 响应，以确定哪些ACT组件直接负责治疗效果，以及是否 治疗效益受到各种个人因素的制约。 确定为期1天的ACT研讨会对OEF/OEF/OND退伍军人的有效性， 共存条件解决VHA RR&D的关键优先事项：1.制定干预措施， 有特殊需求的退伍军人心理健康状况; 2.加强社区、社会和 * 使部署后退伍军人重返职业和发挥职能，以便他们能够更充分地发挥职能， 社会

Traumatic brain injury (TBI) is the signature wound of Veterans returning from Operations Iraqi Freedom, Operation Enduring Freedom and Operation New Dawn (OIF/OEF/OND), with up to 20 percent exposed to a mild TBI (mTBI) and experiencing persistent post-concussive symptoms. Among those with a mTBI diagnosis, the majority also suffers from stress-based psychopathology (e.g., depression, post-traumatic stress disorder, generalized anxiety disorder), as well as chronic pain. To cope with distress, pain, and other difficulties, Veterans often turn to maladaptive avoidant coping strategies which offer short term relief but exacerbate/maintain mental health problems and have detrimental long-term effects on social, occupational, and community reintegration. Unfortunately, Veterans face significant barriers to engaging in mental health treatment, including stigma, the belief that one should overcome psychological difficulties on his/her own, and concern that receiving such care would negatively impact their careers. Practical barriers, including time constraints, distance from a treatment facility, and competing priorities (e.g., work and family demands), are also barriers to care. Even among Veterans who start mental health treatment, only a small minority complete a recommended course of evidence-based therapy. Acceptance and Commitment Therapy (ACT) is a trans-diagnostic treatment model that helps patients to overcome avoidance by promoting acceptance-based coping and engagement in meaningful life activities. In this context, Veterans are asked to think about their “new mission(s)” after leaving the military and the importance of engaging in actions that fulfill their mission even when it may be difficult. ACT has established efficacy in the treatment of depression, anxiety, and chronic pain, and has been effectively implemented in various treatment-delivery formats, including 1-day group workshops. A 1-day ACT workshop addresses specific needs of Veterans with mTBI, stress-based psychopathology, and chronic pain (polytrauma triad) and important barriers to treatment. It 1) is trans-diagnostic (i.e., applies to more than one condition); 2) targets avoidance-based coping; 3) cultivates acceptance-based coping and builds on Veteran’s values and goals to motivate them to make difficult decisions; 4) is delivered efficiently and thus more accessible; 5) is less stigmatizing and thus acceptable; and 6) address problems with treatment adherence and completion. With the support of an RR&D SPiRE pilot grant, the PIs developed a 1-day ‘ACT on Life’ workshop tailored specifically for the needs of Veterans with mTBI, stress-based psychopathology, and chronic pain. Veterans with this polytrauma were then randomly assigned to the ‘ACT on Life’ workshop (N=20) or to Treatment as Usual (TAU; N=12). All Veterans attending the 1-day ACT workshop completed it, and relative to TAU, exhibited greater improvements in distress and reintegration at the 3-month follow-up (effect sizes .68 and .47, respectively). Building on these promising preliminary findings, we now propose to conduct a more rigorous randomized controlled trial with 212 Veterans to compare the efficacy of the 1-day ACT workshop to an active treatment comparison (Education, Resources, and Support; ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response to identify which ACT components are directly responsible for treatment effectiveness and whether treatment benefits are constrained by various personal factors. Establishing the efficacy of a 1-day ACT workshop for OEF/OEF/OND Veterans with mTBI and multiple coexistent conditions addresses key priorities of VHA RR&D: 1. developing interventions which will improve the psychological health status of Veterans who have specific needs; and 2. enhancing the community, social, and occupational reintegration and functioning of post-deployment Veterans so that they may function more fully in society.