Hidden Battles on Unseen Fronts

by Patricia Driscoll

  The firefight in “House B” in Baghdad left six Army SpecOps personnel wounded, two severely. As the Medevac helicopters were landing, Bryan’s friend Scott, the medic, worked diligently on his shattered arm. “He saved it by stopping the bleeding and cleaning out all the debris.” Once he was on the operating table in Baghdad, Bryan fought with the hospital staff who wanted to cut off his body armor. “When they started to cut off my vest, I screamed’ Don’t touch it!’ I made my vest myself, and it took me over a month to sew it up. No way were they going to chop it up.”

  His route to recovery went from Baghdad to the Air Force Theater Hospital (AFTH) at Balad Air Base, to Landstuhl Medical Center, Germany, where he had two more surgeries on his arm, and finally the Womack Army Medical Center at Fort Bragg. He had over a year of surgeries and intensive rehabilitation.

  Bryan was at the Fort Bragg hospital all day, but lived off base in a two-man apartment. Soon after he moved in, the soldier he roomed with deployed back to Iraq. “I got very depressed—my version of PTSD. I had insomnia from all the medications. I lost my appetite. I basically withdrew from the world. Wouldn’t let my parents or my girlfriend come and see me. Wouldn’t get help; I felt like it was a lot easier to deal with everything by myself. At first I thought I was going back to my unit, but then I found out that wasn’t going to happen because of my injuries.” Even though his arm had been saved, it was a new left-handed world.

  The next nine months were tough. Then he met Patricia Driscoll, president of the Armed Forces Foundation. “She was playing golf with my boss, and she asked him if he knew of any wounded soldiers who were getting out and he said, “Yeah, I know someone.” We met at a Barnes and Noble in Fayetteville. She wanted me to work for AFF at Fort Bragg, but I told her nothing would keep me in North Carolina. I was getting out of there and moving to the West Coast.” Two months later Patricia called him to ask if he would head up the Armed Forces Foundation Career Counseling program for wounded warriors out of Las Vegas. She’d found someone else to partner with him in Fayetteville. Bryan took the job immediately.

  Today Bryan lives in Las Vegas and works full-time for the Armed Forces Foundation, managing the Career Counseling and Family Assistance programs as well as doing occasional security consulting. He is currently remodeling a house with his girlfriend, Danyel. He has also gathered together five of his friends from Army Special Operations units, wounded warriors all, to run together in the Las Vegas marathon in December 2008 to raise money for other wounded veterans. “After that we’re conditioning for other marathons and triathlons, and eventually we want to climb Mount Everest,” he says.

  Bryan joined the Army and initially became a Ranger assigned to the 2nd Ranger Battalion in Fort Lewis WA. He was deployed to Afghanistan as a sniper, then moved to US Army Special Operations in Fort Bragg. He deployed to Iraq twice before being wounded in combat.

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  REALIZING THE PROMISE OF EVIDENCE-BASED PSYCHOTHERAPIES IN THE VHA

  By Bradley Karlin, PhD, Josef Ruzek, PhD, and Kathleen Chard, PhD

  These are both challenging and exciting times in mental health care, particularly for veterans and active-duty personnel. Many service members when they return home face significant challenges readjusting to civilian life and reclaiming their lives of old. Even veterans who have been home for decades and have been able to “get by” can have increased difficulty coping that may suddenly appear or be worsened by changes in their lives, such as illness and loss. These difficulties, for some, may develop into full mental disorders, such as Major Depressive Disorder, a substance use disorder, Post-Traumatic Stress Disorder (PTSD), or other mental health conditions.

  For years, mental health experts had limited options to treat some of the most complex mental illnesses, such as PTSD. This was the case following the Vietnam War, where despite best intentions, effective treatments were limited because the science was still in its in fancy. Following the Vietnam conflict, we knew little about PTSD and its causes; in fact, we did not even have a consistent name for the condition.

  The exciting news is we have come a long way in the treatment of mental illness since 1975 when the Vietnam War ended. Over the last three decades, there have been significant strides made within the scientific community to better understand mental disorders and to develop effective treatments. A variety of new medications have been developed for various mental health conditions. Several new psychotherapies, or “talk therapies,” that are not as well known have been developed for specific mental health problems, and are showing great potential.

  Over the last few decades there has been increasing interest in scientifically evaluating the effectiveness of psychotherapies in much the same way we evaluate treatments for medical disorders, such as high blood pressure or diabetes. This research has clearly shown that psychotherapy is a very effective treatment for a variety of mental disorders. This research has also shown that certain psychotherapies are more effective than others. Psychotherapies that have consistently been shown in controlled research to be effective for a particular condition or conditions are referred to as “evidence-based.”

  One condition for which research has shown evidence-based psychotherapies to be the most effective available treatment is PTSD, according to a 2007 Institute of Medicine report. In recent years, research has shown that two psychotherapies, known as Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE) have been developed for PTSD and consistently shown to be very effective. In fact, these treatments are recommended in the Department of Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guidelines for PTSD at the highest level, indicating “a strong recommendation that the intervention is always indicated and acceptable.” Both psychotherapies are fairly structured and consist of approximately twelve weekly sessions, lasting for an hour to an hour and a half each. These psychotherapies are based on a well established evidence-based set of psychotherapeutic interventions known as Cognitive Behavioral Therapy.

  Cognitive Processing Therapy, or CPT, is based on years of research that has shown a strong connection between thoughts and emotions. Although it is often believed that events or situations produce emotions, it is usually one’s interpretation of an event or the meaning one attributes to a situation or oneself that directly makes a person feel the way they feel. When thoughts or interpretations of events or oneself are not balanced or do not consider the “complete picture,” but rather overly focus on specific details at the exclusion of others, individuals are prone to negative emotions; when this happens repeatedly it may lead to significant psychological distress or mental illness. In PTSD, disruptive thoughts or beliefs focus around a traumatic experience and oneself as a result of the traumatic event. CPT refers to these disruptive beliefs as “stuck points,” which are an important focus of the treatment.

  The first stage of CPT consists of educating the patient, having them write a statement about the meaning of the trauma, and helping them begin to make the connection between thoughts and feelings. In the second stage, the patient is typically asked to write a detailed account of the trauma to access the natural emotions related to the event and to identify specific stuck points. The therapist helps the patient evaluate and challenge extreme thinking, particularly thoughts related to blame, guilt and hindsight bias, in which only part of an event is recalled, leaving out information that may be inconsistent with self-blame or guilt.

  In the third part of the treatment, the therapist guides the patient in challenging their thoughts in three areas: the self, others and the world. CPT further focuses on stuck points in the areas of safety, trust, power/control, esteem and intimacy within each of the three areas. Through practice, patients learn to replace or change their extreme thoughts related to the traumatic event with more realistic beliefs.

  The process of the therapy is outlined in the following case description of Mr. C, a 26-year-old Operation Iraqi Freedom veteran who was honorably discharged from the Army after five years and
two tours in Iraq. He stated he was a sniper and enjoyed being in the Army and was “good” at what he did. Mr. C received 100 percent service connection for PTSD, and was referred for PTSD treatment due to symptoms related to his combat experiences, including explosions, seeing friends die, and causing the death of someone else.

  He had frequent feelings of guilt, as well as thoughts about the traumatic event and about himself in relation to it. He was treated for PTSD in a seven-week residential PTSD treatment program that uses CPT in a combined group and individual format. When Mr. C was admitted to the program he obtained a Clinician Administered PTSD Scale (CAPS) score of 70 (a score of 45 on the CAPS is usually indicative of a diagnosis of PTSD). Mr. C also met criteria for Major Depressive Disorder and Alcohol Dependence in full remission.

  Mr. C was very reserved during his early therapy sessions, rarely participating in group while hesitant to share information in his individual sessions. Mr. C wrote an Impact Statement about the trauma for his first session homework, and he was able to identify key stuck points, including “I am weak for having PTSD” and “I no longer fit in society.” Using worksheets to connect thoughts and feelings, Mr. C began to see that his primary emotion was anger, and it was fueled by what he was thinking.

  In the middle phase of treatment, Mr. C wrote about two traumatic experiences, one outlining the death of a friend and one about a mission when he killed his first enemy. He identified additional stuck points, including “I could have prevented my friend’s death” and “No one respects me unless I get angry.” In the third phase of treatment, Mr. C was able to challenge his disruptive thoughts, and he began to see how he was not looking at all of the details of the events when he was blaming himself. He also noted that since he returned from Iraq he was not trusting of others and did not give them a chance before he pushed them away.

  Upon completion of the program, Mr. C obtained a CAPS score of 22, and he was in remission for his Major Depression. Realizing that he still wanted to pursue a military career, Mr. C petitioned for and was granted a waiver to return to the military. In addition, he asked his fiancé to attend couples counseling to discuss the impact his being in the military again would have on their family.

  In Prolonged Exposure Therapy, or PE, the emphasis is on helping the patient confront feared memories and situations. The emphasis on confrontation, or exposure, is due to the fact that individuals with PTSD frequently avoid emotionally processing trauma-related memories, and also avoid situations (e.g., crowded areas, social situations) that remind them of the traumatic experience. These avoidance tendencies actually serve to maintain and even strengthen PTSD symptoms in the long run and, as noted, prevent needed emotional processing from occurring.

  PE helps patients emotionally process traumatic events by providing education about PTSD, repeated and prolonged imaginary exposure to trauma-related memories, repeated real-world confrontation with feared, but safe, situations the patient is avoiding, and discussion of thoughts and feelings related to exposure exercises.

  The PE treatment is typically delivered in nine to twelve 90-minute sessions administered once or twice weekly. The first session consists of an overview of the treatment, rationale for exposure, information gathering, treatment planning, and breathing relaxation techniques. In the second session, patients are asked to talk in detail about their reactions to the trauma and its effect on them. Patients also begin to engage in real-world exposure to safe situations (e.g., public places) that they have avoided.

  In the third session, the first imaginary revisiting of the trauma memory takes place, followed by discussion aimed at helping to process associated thoughts and feelings. During sessions four to nine (or more, as needed), imaginary exposure, post-exposure processing of thoughts and feelings, and discussion of real-world homework assignments are continued.

  The following is a course of PE treatment with Mr. B, a 32-yearold, married, African-American veteran of Iraq, employed as an office worker. He sought care after his wife pressured him to deal with his combat experiences, and, during assessment reported concerns about distressing memories, nightmares, sleep problems, hypervigilance, difficulties with concentration and sexual problems. Mr. B scored a 68 on the CAPS questionnaire and met criteria for a PTSD diagnosis. His symptoms were present for three years and caused moderate distress and severe impairment in work and social functioning. He also met criteria for Major Depressive Disorder.

  Mr. B had been in treatment focused on providing education about PTSD, coping skills, and group support for several months before initiating PE. While he perceived these elements of treatment as helpful, his symptoms diminished only slightly. Initially, Mr. B was apprehensive about starting PE. He was praised for his commitment to recovery and engaged in a discussion of the rationale for PE treatment, and the therapy was acknowledged to be “difficult but not dangerous.”

  Mr. B considered his direct exposure to an IED blast to be most distressing among a range of stressful experiences. His leg was injured during the explosion and was bleeding badly. During the next few minutes, the situation was chaotic and Mr. B experienced great anxiety. His attention darted from his leg, to his duty to the individuals in his command, to his dizziness. He blamed himself for not protecting his men more effectively. This experience was associated with his intrusive thoughts and other PTSD symptoms.

  After introductory sessions focusing on the rationale for PE, information collection, and education and discussion about reactions to trauma, Mr. B was started on real-world exposure homework assignments. He was avoiding many situations that reminded him of the attack, and reported high levels of distress in situations involving driving, crowds and loud noises. He reported performing errands during off-hour times, avoiding roads where traffic congestion might occur, and driving very fast. He developed a list, ranking these from least to most distressing, that would be used for progressive exposure tasks.

  Following the first imaginary exposure during session three, Mr. B had several disturbing memories and some difficulty sleeping. He reported that he was skeptical of the treatment. His concerns were discussed and described as very common once emotional avoidance was no longer taking place, and he was encouraged to continue with the treatment. He decided to remain in treatment. Repeated exposures during sessions three through nine, coupled with in-vivo exposure homework tasks, led to diminishing levels of distress. As the exposure activities became more routine, he gained confidence in the treatment and in his ability to recover.

  During the emotional processing that took place after his imaginary exposure sessions, Mr. B was able to see that he didn’t abandon his duties or his men during the blast experience. When he revisited his memories of the event in detail, he realized that, despite his injury, he continued to lead his team and take appropriate defensive actions until he lost consciousness. In the ninth session, during emotional processing, he stated, “I did, in fact, do the best that I could.” Through this process, his troubling feelings of guilt were resolved.

  Mr. B appeared for his last session wearing his finest suit. He was proud of what he had accomplished, and showed a genuine respect for himself that had not been present at the beginning of treatment. Mr. B no longer met diagnostic criteria for PTSD or Major Depressive Disorder.

  How do we “achieve the promise” by bridging the gap between research and practice? Despite the clear effectiveness of evidence based psychotherapies and their recommendation in numerous practice guidelines and other reports, research has consistently revealed that mental health providers deliver evidence-based psychological treatments at low rates. Why are these “gold standard” treatments not frequently delivered? Primary reasons identified for this include limited systematic training and lack of administrative support.

  The Department of Veterans Affairs sees a tremendous opportunity to realize the potential of evidence-based psychotherapies and bridge the gap between research and practice so that veterans have access to the most effective treatments. According
ly, the VA is embarking on a major national effort to disseminate several evidence-based psychotherapies throughout the VA health care system, as part of the implementation of the VHA Mental Health Strategic Plan and the transformation of its mental health care delivery system.

  Specifically, the VA has developed national training programs to train VA mental health providers in the delivery of CPT and PE for PTSD, CBT and Acceptance and Commitment Therapy for depression and co-occurring anxiety, and Social Skills Training for serious mental illness. In these training programs, VA mental health clinicians attend intensive clinical workshops, usually three to four days in length, followed by ongoing clinical consultation and feedback by an expert clinician and program training consultant. The VA has developed specific evidence-based psychotherapy protocols, manuals, and other materials tailored to veterans. The VA is also working closely with DoD to make these trainings and materials available to active duty military personnel. As of the end of Fiscal Year 2008, the VA has trained over 1,200 VA mental health providers and over 600 DoD mental health clinicians in the delivery of CPT or PE for PTSD.

  Beyond intensive clinical training, there are numerous efforts in place at multiple levels of the VA health care system to provide administrative structures and procedures to successfully implement the delivery of evidence-based psychotherapies. This includes mechanisms for tracking the delivery of the treatments, ensuring appropriate clinical capacity, evaluating training and clinical outcomes, and providing ongoing support and education broadly in the field.

  Mental health treatment has come a long way in a relatively short period of time. We now have proven treatments that work for many of the most challenging and, at one point, seemingly untreatable mental illnesses. These treatments offer great promise to individuals returning from Iraq and Afghanistan, as well as to those who have been home for 30 or more years. Moreover, they provide an opportunity to move beyond symptom reduction toward promoting true recovery in multiple aspects of life.