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    Post-traumatic Stress Disorder and War Veterans

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    The United States is home to American veterans from every military conflict since World War II. The United States defines a veteran as any individual who has served in military under active duty status and was released from such duty under any condition other than dishonorable (Veteran’s Benefits, 2014). Narrowing our focus down to veterans who served in combat operations post 9-11, these men and women were deployed to Iraq and Afghanistan and were confronted with a unique set of challenges including longer, more rapid deployments. These challenges combined with the increased stress of asymmetric warfare has left these combat veteran with not just physical but invisible, psychological scars including posttraumatic stress disorder (PTSD) (Caforio, 2014).

    PTSD can be defined as a psychiatric disorder caused by experiencing or witnessing a traumatic event such as natural disasters, serious accidents, terrorist acts, war/combat, rape or other violent personal assaults (Parekh, 2017). The American Psychiatric Association (2013) characterizes PTSD by the following symptom clusters; intrusion, avoidance, negative alterations in mood or cognition, and increased arousal. Intrusion or re-experiencing can be described as having recurring dreams that cause distress, intrusive memories, flashbacks, and physical reactions to cues that resemble the traumatic event. Avoidant symptoms include the purposeful avoidance of people, places, thoughts, feelings, or activities closely associated with the traumatic event. Negative alterations in mood or cognition represent exaggerated negative beliefs and self-blame for the traumatic event, detachment from others, loss of interest, persistent negative emotional state, or reduced ability to feel positive emotions.

    Finally, increased arousal symptoms include hypervigilance, being easily startled, acting irritable or aggressive, recklessness, sleep disturbances, and difficulty concentrating. PTSD has proven to be a considerable health risk for our country’s military veterans. Between 2006 and 2007, veterans seeking treatment for PTSD has increased nearly 70% (Stuart, 2014). Of the soldiers who have been deployed in the past six years, one in every five military personnel returning from Iraq and Afghanistan has PTSD; over 300,000 (Rand Corporation, 2008). Furthermore, in the past year alone diagnosed cases in the military jumped 50% – and that is just diagnosed cases (“Dramatic Rise in Ex-Soldiers Reporting PTSD,” 2017). Health disparities based on sociocultural factors like gender, race and ethnicity, socioeconomic status, culture, and access to health care can potentially complicate the early diagnosis and effective management of PTSD among combat veterans (Nayback, 2008).

    Female veterans with symptoms of PTSD are twice as likely to seek help than their male veteran counterparts. Compared to Caucasian veterans, African American veterans were significantly less likely to receive a diagnosis of PTSD (Murdoch, Nelson, & Fortier, 2003). Brewin, Andrews, and Valentine (2000) showed that lower military rank, lower educational level, and lower socioeconomic status correlated with higher rates of PTSD. In this paper, the theoretical approaches related to PTSD will be examined first. Next, the best practices for both PTSD and combat veterans will be discussed. Finally, theoretical approaches and best practices will be applied to the intervention strategies. Theoretical Approaches History of Treatment Approaches to Posttraumatic Stress Disorder From the beginning of time, exposure to traumatic events have been a part of human life. Early literature from Homer, Shakespeare, and Dickens offer accounts of what we know now as PTSD.

    These authors penned literary tales detailing traumatic events which included the symptoms that followed these experiences (Friedman, Resick, Bryant, & Brewin, 2011). Accounts of psychological symptoms following military trauma date back to the American Civil War and marks the start of formal medical attempts to address the problems of military Veterans exposed to combat (Jones, 2006). In 1870, PTSD was most commonly seen in soldiers during times of stress and was suggested to be a result of physical injury (Jones, 2006). It was referred to as ‘Soldier’s heart’ due to the physical symptoms of rapid pulse, anxiety, and trouble breathing; Soldiers were given medications to control symptoms and sent right back to the front lines (Jones, 2006). During the early 1900’s, “shell shock” was the term given to the symptoms associated with the present-day PTSD due to being seen in soldiers after experiencing explosions from artillery shells (Jones, 2006).

    These symptoms described were among panic and sleep problem and treatment varied (Jones, 2006). Oftentimes soldiers were granted only a few days’ rest before returning to the war zone (Jones, 2006). Those who were experiencing more severe or chronic symptoms, endured more intense treatment which focused on increasing functioning in everyday life with the hope of returning home to their normal, productive lives (Jones, 2006). As World War II progressed, the diagnosis of Combat Stress Reaction (CSR), also known as ‘battle fatigue’ soon replaced shell shock. World War II saw long fighting surges resulting in soldiers frequently becoming battle weary and exhausted. The most common treatment used for CSR was Proximity, Immediacy, Expectancy (PIE) principles. Under the PIE principles, casualties were treated immediately and without delay to ensure quick and complete recovery so that they could return to combat after rest (Jones, Thomas, & Ironside, 2007). It was not until the Vietnam war that principles of treating psychiatric casualties in the forward area were successfully applied (Jones & Wessely, 2003).

    Still, the rate of delayed and chronic PTSD symptoms among veterans returning from Vietnam drastically rose and was a shocking reminder of the casualties of warfare (Crocq, M. & Crocq, L., 2000). Current Theoretical Approaches to PTSD Today, there are many theoretical approaches represented in the literature for treating PTSD. Psychotherapy, specifically cognitive behavioral therapy (CBT), is a common approach used in treating PTSD. In cognitive behavioral therapy, the relationship among thoughts, feelings, and behaviors, are the primary focus and how positive change in anyone can improve functioning. Prolonged exposure therapy (PE) is one of the most prevalent forms of CBT for treating PTSD (Rauch, et al., 2009). The two core components of PE are imaginal exposures and in vivo exposures.

    PE teaches individuals how to gain control by facing your negative feelings. It involves talking about your trauma with a provider and doing things you have avoided since the trauma (Ford, Grasso, Greene, Slivinsky, & DeViva, 2018). Cognitive Processing Therapy (CPT) is another empirically supported treatment for PTSD. CPT targets irrational thinking and cognitive distortions in therapy to help patients process their trauma memories while teaching them to reframe negative thoughts about the trauma. It involves talking with your provider about your negative thoughts and doing short writing assignments to uncover cognitive distortions regarding their trauma narrative (Kaczkurkin & Foa, 2015). Eye-movement desensitization and reprocessing (EMDR) helps process and make sense of your trauma. EMDR involves 8 phases where the client focuses on image or belief while simultaneously paying attention to a back-and-forth movement of a finger waving, light, or sound (Shapiro & Maxfield, 2002). Our chosen theoretical approach for combat veterans with PTSD is CBT in conjunction with exposure component.

    CBT’s role in the treatment of PTSD is evident; it is one of the most effective methods for treating PTSD among combat veterans (Martin, 2016). CBT is a form of psychotherapy short-term and goal-oriented taking a hands-on, practical approach to problem solving (Martin, 2016). Additionally, CBT attempts to change the attitudes and behaviors by focusing on the thoughts, images, beliefs and attitudes held by the individual (Martin, 2016). Because the goal of CBT is to change patterns of thinking or behavior that contribute to difficulties one may experience, the changing of behavior will allow the PTSD sufferer to better handle the feelings they are experiencing.

    Current Best Practices Group Treatment for PTSD PTSD negatively impacts one’s mental health, physical health, work, and relationships. With the rise in PTSD diagnoses over the past decade, it is crucial an evidenced based approach be used to provide long term symptom management. The most common form of evidence based treatment used in a group setting is CBT. Other group approaches include psychodynamic/interpersonal groups, support groups, and psychoeducation groups (Sloan, Bovin, & Schnurr, 2012). Psychodynamic and interpersonal groups focus on increasing awareness about internal conflicts (Sloan, Bovin, & Schnurr, 2012).

    Specifically, psychodynamic groups attempt to increase insight on how the trauma influences self-perception, world view, interpersonal functioning, and emotion regulation (Sloan, Bovin, & Schnurr, 2012). Interpersonal groups focus on helping members identify how the trauma has influenced their relationships. These types of groups, including CBT, are typically closed with all members joining and completing simultaneously. Supportive groups are open format groups offering a safe space for members to discuss ongoing stressors, share successes, problem-solve, and provide emotional support for each other. The focal point of supportive groups is strengthening and maintaining interpersonal connections (Sloan, Bovin, & Schnurr, 2012). This interpersonal enrichment combined with normalizing and universality allows for deeper reflection and healing for members. Psychoeducational groups focus on symptom management by explaining common symptoms of PTSD and helping members develop effective coping skills. These groups are ideal as introductory groups for members especially those transitioning out of intensive inpatient care.

    Psychoeducational groups tend to have fewer sessions compared to other types of groups, unless following a specific curriculum (Sloan, Bovin, & Schnurr, 2012). Beyond the specific type of groups, there are also techniques for group work including skills training, exposure, and cognitive PTSD group treatment restructuring (Sloan, Bovin, & Schnurr, 2012). Skills-based techniques target specific problem areas common for patients with PTSD like emotion regulation (Sloan, Bovin, & Schnurr, 2012). Exposure components may include imaginal, virtual, and real life exposure to the feared stimulus or memory associated with the traumatic event (Tielman, Neerincx, Bidarra, Kybartas, & Brinkman, 2017). These components are usually assigned homework which members then reflect upon during group sessions.

    Additionally, cognitive restructuring is a popular and effective component used in CBT and CPT. Cognitive restructuring focuses on adjusting how members experience their symptomatic thoughts to alter their internal actions and core beliefs. Therapists can integrate these various techniques with their group practice based on the purpose and demographic makeup of the group. Group Treatment for Combat Veterans The VA is the number one provider of physical and mental health care needs for veterans. While most of their services are provided in a one-on-one setting, group settings can be used with veterans to manage PTSD symptoms, integration problems, depression, substance use, cognitive disorders, and traumatic brain injuries (Sayer et al., 2010).

    Cognitive Strategy Training (CST) has been found to be one of the more effective group treatments not only for psychiatric illnesses but also memory and integration problems (Huckans, Pavawalla, Demadura, Kolessar, Seelye, Roost, Twamley, 2010). Heckans et al. (2010) report the combination of CST based compensatory and internal cognitive strategies with external cognitive aids is particularly effective in symptom reduction (p. 11). Additionally, support groups and addiction treatment groups are used to help veterans manage their stressors, emotions, and substance use. Regarding mental health and emotion regulation, Kracen, Mastnak, Loaiza and Matthieu (2013) found a majority of veterans prefer individual therapy over group therapy due to fear of being part of a crowd (p. 146). Additionally, not wanting to discuss or express emotions was found to be the second highest reported barrier to group therapy from veterans (Kracen, Mastnak, Karen & Matthieu, 2013).

    However, more recent studies are showing increased openness to group treatment by veterans due to its proven efficacy in PTSD symptom management (Kracen, Mastnak, Karen & Matthieu, 2013: Sloan, Bovin, & Schnurr, 2012). Group Treatment for Combat Veterans with PTSD Research suggests most veterans experience mental illness symptoms, including substance use, within the first year of returning from deployment. Additionally, PTSD is the most prevalent psychiatric disorder among returning combat veterans (Sayer et al., 2010). Special attention is being paid to PTSD not only due to its prevalence but also its extensive impact on all quality-of-life outcomes (Sayer et al., 2010). Previously, PTSD treatment has been provided through use of CBT in individual therapy.

    CBT has been proven time and time again to be overwhelming effective in assisting veterans with symptom management. However, it is lacking enrichment of additional biopsychosocial aspects which are key to daily functioning. These include interpersonal connection, normalization, and comradery. Even Yalom notes the social component of group work is one of the driving mechanisms for making change, in this case changing member’s cognitions. Combining the CBT approach with the interpersonal enrichment of a group setting allows for multi-dimensional progress and healing. Beyond the clinic benefits of group treatment there are business benefits. Outpatient treatment facilities are frequently understaffed and unable to meet all patient needs.

    Group treatment allows them to maximize employee and billing resources. Utilization in Practice To effectively utilize CBT in our designed intervention, we will incorporate the principles of CBT as our primary theoretical approach. Because the goal of CBT is to change attitudes and behaviors by encouraging individuals to reevaluate their thinking patterns, our interventions will aim at identifying negative cognitive distortions and turning them into more balanced and effective thinking patterns. Additional components of CBT, including dealing with anger, understanding triggers, coping with stress will be incorporated into the intervention sessions. There is extensive empirical evidence to support CBT as one of the most effective, evidence-based forms of treatment for PTSD. We utilize this evidence in our practice through the structure and progression of our curriculum. Sessions are designed to encourage reflection, challenge perceptions, and provide feasible ways to restructure cognitions.

    Furthermore, PE has proved to be a crucial component of CBT and is used both in session and as assigned homework as members progress through our group. Group cognitive behavioral therapy (GCBT) is designed with a focus on building and maintaining group cohesion, while introducing cognitive-behavioral interventions. In an effort to master fundamental skills, there is a considerable emphasis placed on between session homework in our curriculum.

    Additionally, there are mindfulness, grounding, and educational components to session layouts. It is important we tailor our sessions to meet the needs of the population we are working with. PTSD is the most prevalent psychiatric disorder experienced by veterans. Additionally, substance use, depression, and emotion regulation problems are high in those returning from deployment. Providing opportunities for social enrichment while also acknowledging the uncomfortableness some feel in a group setting allows for further normalization and lays the foundation for group cohesion. Our session are created specifically for veterans as we recognize the struggles only veterans experience.

    Conversely, even if created for this specific population, we are aware no two veterans are the same and allow for individual interpretation and application of our practices. Conclusion There is no question the sacrifices veterans make while serving our country in combat operations are immeasurable. The deep, mental scars including posttraumatic stress disorder among combat veterans has become increasingly prevalent throughout the years. It is imperative that only highly effective, empirically based treatment modalities are used to provide the most highly effective treatment outcomes.

    Theoretical approaches, best practices, and utilization of both were examined for treating PTSD among combat veterans. Due to the goal-oriented, hands-on, practical approach to problem solving, CBT was determined to be the most utilized and effective theoretical approach to use with this population. Additionally, the best practices for treating PTSD in a group setting was determined to be CBT. When treating combat veterans, the VA medical model was found to be the best practice. By utilizing the key components of CBT when treating combat veterans with PTSD in a group setting, we provide the greatest chance of a successful outcomes.

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