Pivoting from a community based, free program using EMDR to treat trauma in veterans, to treating trauma in the LGBTQIA Community

After 20+ years working with the LGBTQIA population dealing with HIV/AIDS, it is striking to note the number of similarities to the younger veteran population. In both cases, young people who were unprepared for the traumas they were to encounter experienced extreme loss, physical and emotional trauma and PTSD, only to be further marginalized and experience shame as a result of their experiences. A large number of both populations have had their mental health needs go untreated, and have addressed their untreated trauma with alcohol, substance use, and process addictions. The good news is that trauma is fixable. Weill Cornell Medicine has developed a trauma treatment program that eliminates symptoms of PTSD and related trauma symptoms, and this program can and should be utilized to treat trauma nationally in the LGBTQIA community.

Weill Cornell Headstrong’s trauma treatment model history: Weill Cornell Headstrong was a community based treatment program providing free mental health treatment for Veterans with PTSD. It was founded in 2012, the year the Pentagon reported that “The suicide rate among the nation’s active-duty military personnel has eclipsed the number of troops dying in battle.” (Williams, 2012, June 8) Weill Cornell Headstrong's mission was “to heal the hidden wounds of war and save lives on the path to ending Veteran suicide by providing cost-free, bureaucracy-free, stigma-free, confidential and effective mental health treatment for post-9/11 Veterans and their families.”

PTSD, a significant risk factor for suicidal ideation among post-9/11 Veterans became Headstrong’s diagnostic focus. The odds of endorsing suicidal ideation was four times higher among Veterans screening positive for PTSD relative to Veterans with negative PTSD screens. (Jakupcak et al., 2009) PTSD occurs at a higher rate among Veterans and military service members, 23%, than representative samples of U.S. civilian adults, 7-8%. (Fulton et al., 2015) Most Veterans diagnosed with PTSD related to traumas sustained during military service, also had non-military related trauma. (Clancy et al., 2006) Evidence-based treatment of PTSD can improve suicidal ideation. (Cox et al., 2016)(Gradus, Suvak, Wisco, Marx, & Resick, 2013)

The Weill Cornell Headstrong model was designed to overcome Veterans’ stated barriers to seeking mental health care. (Hoge et al., 2004) (Schell & Marshall, 2008)

Prominent among the barriers to care were the high dropout rates (Imel, Laska, Jakupcak, & Simpson, 2013) (Garcia, Kelley, Rentz, & Lee, 2011) (Eftekhari, Crowley, Mackintosh, & Rosen, 2020) and low remission rates of the only two PTSD evidence based treatments (EBT) offered at the VA at that time, cognitive processing therapy (CPT) and prolonged exposure (PE). (Karlin & Cross, 2014) A review of nine randomized controlled trials in the treatment of military-related PTSD (Steenkamp, Litz, Hoge, & Marmar, 2015), found that, although 49-70% of patients receiving CPT and PE showed improvement, 60-72% retained their PTSD diagnosis after treatment (mean post treatment scores remained at or above clinical criteria for PTSD). Only two randomized control trials testing adequate doses of EMDR for military PTSD are available, and both were conducted before 9/11. (Boudewyns & Hyer, 1996) (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998) In the 2 trials, there was minimal to no dropout, large symptom reductions, and 78% of completers no longer met criteria for PTSD, with results maintained at 9-month follow-up.

Influenced by the clear need to offer alternatives to CPT and PE to Veterans and the compelling work of other PTSD treatment perspectives (van der Kolk, 2014) (Porges, 2007) (Levine, 1997) (Siegel, 2012), EMDR became Weill Cornell Headstrong’s core treatment modality.

EMDR therapy is an eight-phase treatment. Eye movements (or other bilateral stimulation) are used during one part of the session. After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision. As this happens, for reasons believed by a Harvard researcher to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level.

All the treatment providers from Weill Cornell Medicine were trained by the Parnell Institute. 90% of Headstrong patients were treated with EMDR. When applicable, other treatment modalities (e.g. Neurofeedback, Internal Family Systems, Motivational Interviewing, Somatic Experiencing) were integrated with EMDR, and are available for Veterans who were not appropriate candidates for EMDR.

Headstrong treats any post 9/11 Veteran with PTSD and Veterans from all eras with Military Sexual Trauma. Veterans who are too sick to be managed in an outpatient, private practice model are referred to a more acute level of care.

Headstrong clinicians are licensed in: Psychiatry, Clinical Nurse Specialty, Psychology, Social Work, or Marital and Family Therapy. Headstrong psychologists, social workers, and marital/family therapists are sought who have a minimum of ten years of experience utilizing trauma focused treatment modalities. Clinicians are identified through a variety of means, including the EMDRIA website. Within a given region, Headstrong seeks to find a variety of providers to meet geographic diversity, ethnic diversity, and treatment modality diversity, e.g, Neurofeedback, addiction expertise, family therapy and group skills. The clinicians are promptly paid market rate for their services and complete a minimum of paperwork. Veterans are seen in the private offices of the clinicians.

As of May 2020, Headstrong had treatment programs in 26 cities. From 2012 to May 31, 2020, Headstrong provided 52,534 clinical sessions to 1704 clients, and partnered with 245 clinician (200 active clinicians) across the US. As of May 2020, Headstrong served 865 active clients.

Weill Cornell Headstrong employs three methods to assure clinical quality and treatment fidelity: review of patient notes, bi-monthly case conference, and treatment outcome measures. Clinicians who do not have access to their own EMDR clinical supervision and consultation are eligible to participate in free clinical supervision and consultation provided via video conference by Headstrong EMDR consultants.

Symptom severity and treatment progress were measured by three scales: PCL-5, ReQol, and a PTSD symptom checklist consisting of ten core PTSD symptoms.

The PTSD symptom checklist was completed by the therapist every eight sessions up twenty four sessions, and every twenty four sessions after that. Based on the PTSD checklist completed by the therapists, the percentage of Headstrong clients who report improved PTSD symptoms ranges from 77% who report improvement in at least two symptom categories to 60% who report improvement in all ten PTSD symptom categories. See Table 2. This data reflects the 310 Headstrong clients treated from December 2015 to December 10, 2019 for whom the checklist was acquired for the first and last sessions (for completed treatments) or first and most recent session (for active clients who have completed at least twenty sessions).

PCL-5 (Weathers & Palmieri, 2013) is a 20 question validated self-report instrument (Blevins, Weathers, Davis, Witte, & Domino, 2015) developed as a PTSD checklist for DSM-5 (American Psychiatric Association Diagnostic and Statistical Manual, Fifth Edition). The questionnaire is administered by the therapist and filled out by Veteran during the first and sixth months of treatment. ReQol (Recovering Quality of Life) is a 20 question validated self-report outcome measure for people experiencing mental health difficulties. (Keetharuth et al., 2018) The questionnaire is administered by the therapist and filled out by Veteran during the first, last, and sixth months of treatment, a total of two to three times, dependent on the length of treatment. Outcome data from these two instruments are in the process of being tabulated.

Weill Cornell Headstrong achieved its goals of overcoming barriers to care. A licensed mental health worker responded to the Veteran within 48 hours of their registration on the Headstrong website. Treatment retention was robust; the average number of sessions was 29, and median number of sessions is 18. Client satisfaction was very high. A satisfaction survey distributed in February 2017 to 138 active clients and in May 2019 to 520 active clients, (response rates were 30% and 26% respectively) showed, among other results, 92% of respondents, said they would recommend Headstrong to a friend or family member. Far more compelling than the satisfaction survey are the numerous unsolicited testimonials of gratitude from our clients.

EMDR has distinct benefits over CPT and PE for the treatment of PTSD in the Veteran population. Specifically, it does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework. Weill Cornell Headstrong was a community based program for the treatment of PTSD and military sexual trauma in a Veteran population; it is the only such program that utilizes EMDR as its primary treatment modality. The success of Headstrong, demonstrated by its high treatment retention, remission rates, and client satisfaction, are due, in large part, to the utilization of EMDR as the primary modality to treat PTSD in this population.

PIVOTING TO THE LGBTQIA POPULATION

A quick review of the literature on the treatment of trauma in the LGBTQIA population yields very little in terms of a systematic approach to identifying qualified trauma therapists, and utilizing a model aimed at reducing trauma symptoms in the LGBTQIA population. The LGBTQIA population experiences trauma on a number of levels including community wide trauma, familial trauma, and individual trauma. As in the veteran population, where more than half of veterans suffering from PTSD report adverse childhood events including physical and sexual abuse in the home, and domestic violence, members of the LGBTQIA population have a greater likelihood of having endured childhood trauma. As adults, members of the LGBTQIA population are more at risk for violence and discrimination, and studies indicate a higher rate of suicide risk among LGB youth, 5 times that of the heterosexual population, and 40% of transgender adults reported having made a suicide attempt, 92% of them before the age of 25. A majority of LGBTQ+ people say that they or an LGBTQ+ friend or family member have been threatened or non-sexually harassed (57 percent), been sexually harassed (51 percent), or experienced violence (51 percent) because of their sexuality or gender identity. [4]

LGBT Adults: Approximately 40 percent of LGBTQ+ adults had a mental illness in the past year, in comparison to the 18 percent of total adults who faced a mental illness in the past year.2 LGBTQ+ individuals also are more likely to abuse substances at an estimated percentage of 20-30% due to factors such as prejudice and discrimination, in comparison to the 9% substance abuse of the general population (NAMI, LGBTQI). LGB adults are more than twice as likely as heterosexual adults to experience a mental health condition. According to a 2013 survey, 40% of LGBT adults have experienced rejection from a family member or a close friend. Fifty-nine percent of LGBTQ+ people feel that they have fewer employment opportunities and 50 percent believe they are paid less than non-LGBTQ+ people. (NPR, RWJF, Harvard TH Chan School of Public Health).

Transgender Thirty-eight percent of transgender people say they have experienced slurs and 28 percent have insensitive or offensive comments because of their gender identity or sexual orientation. Twenty-two percent of transgender individuals say they have avoided doctors or health care our of concern they would be discriminated against. Forty-eight percent of transgender adults report that they have considered suicide in the last year, compared to 4 percent of the overall US population. Transgender individuals are nearly four times as likely as cisgender (a person whose sense of gender identity corresponds with their birth sex) individuals to experience a mental health condition 40% of transgender adults have attempted suicide in their lifetime, compared to less than 5% of the general U.S. population, 92% of them before the age of 25. (NPR, RWJF, Harvard TH Chan School of Public Health).

LGBT youth: LGBTQ+ teens are six times more likely to experience symptoms of depression than non-LGBTQ+ identifying teens. (Anxiety and Depression Association of America, 2018) LG BTQ+ youth are more than twice as likely to feel suicidal and over four times as likely to attempt suicide compared to heterosexual youth. (HRCF 2017). High school students who identify as lesbian, gay or bisexual are almost five times as likely to attempt suicide compared to their heterosexual peers.

According to The Trevor Project’s 2020 National Survey on LGBTQ Youth Mental Health, 40% of LGBTQ respondents seriously considered attempting suicide in the past twelve months, with more than half of transgender and nonbinary youth having seriously considered suicide.

68% of LGBTQ youth reported symptoms of generalized anxiety disorder in the past two weeks, including more than 3 in 4 transgender and nonbinary youth.

48% of LGBTQ youth reported engaging in self-harm in the past twelve months, including over 60% of transgender and nonbinary youth.

46% of LGBTQ youth report they wanted psychological or emotional counseling from a mental health professional but were unable to receive it in the past 12 months.

10% of LGBTQ youth reported undergoing conversion therapy, with 78% reporting it occurred when they were under age 18.

29% of LGBTQ youth have experienced homelessness, been kicked out, or run away.

1 in 3 LGBTQ youth reported that they had been physically threatened or harmed in their lifetime due to their LGBTQ identity.

61% of transgender and nonbinary youth reported being prevented or discouraged from using a bathroom that corresponds with their gender identity.

86% of LGBTQ youth said that recent politics have negatively impacted their well-being.

It is estimated that LGBTQ youth and young adults have a 120% higher risk of experiencing homelessness.

The Weill Cornell Headstrong solution: Weill Cornell Headstrong’s national network of 245 trauma therapists in 26 cities are well placed to make a significant impact on a largely untreated population. A quick look at mental health services for uninsured LGBTQIA folks in NYC reveals a few programs offering groups or short term crisis counseling, but there are no programs dedicated to healing the hidden wounds of the LGBTQIA population through tailored, expert, tri-phasic trauma treatment.

Headstrong is poised to pivot to assist in treating trauma in the LGBTQIA populations using an existing network of therapists with some additional recruiting. We would like to address untreated trauma in the LGBTQIA population, and with the necessary resources we are set up to demonstrate the same type of excellent outcomes that we have demonstrated in the veteran population.

AUTHOR INFORMATION: Carol J. Weiss, M.D. is a psychiatrist and Associate Medical Director of Headstrong. Gerard Ilaria, LCSW, is Clinical Director and Co-founder of Headstrong. Ann B. Beeder, M.D., a psychiatrist, is Medical Director and Co-founder of Headstrong. All completed their EMDR training with Laurel Parnell.

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