Cognitive Behavioral Therapy CBT Techniques for Combat Veterans With Posttraumatic Stress Disorder PTSD

Cognitive Behavioral Therapy for Combat Veterans With Post Traumatic Stress Disorder

Although not limited to veterans, Post Traumatic Stress Disorder (PTSD) may be the single most significant mental health risk to veterans, particularly to those veterans that have seen combat. PTSD is an anxiety disorder, which occurs after a person has seen or experienced a traumatic event including, but not limited to: assault, domestic abuse, prison stay, rape, terrorism, war, or natural disaster (Vorvick et al., 2011). In fact, PTSD is unique among psychiatric diagnosis in that it "requires a specific type of event to occur from which the person affected does not recover" (Resick et al., 2008). Veterans are at high risk of PTSD because they experience war, but they also experience many of the other traumatic events that can trigger PTSD in the course of the war. PTSD can have serious lifelong effects for veterans. It can impair their ability to hold down a steady job, interfere with interpersonal relationships, and, in the most extreme cases, even lead to an increased risk of violence that makes veterans a danger to themselves and others. Therefore, it is critical for PTSD to be identified and successfully treated in order to ensure the best possible quality of life for veterans.

While trauma is a triggering event for PTSD, it is not appropriate to say that trauma causes PTSD. This is clear because not all persons experiencing trauma develop PTSD, even when the trauma is extreme, such as experiencing combat. On the contrary, "The cause of PTSD is unknown. Psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters). It is not known why traumatic events cause PTSD in some people but not others" (Vorvick et al., 2011). What is known is that a history of trauma can increase the individual risk of developing PTSD after a traumatic event, which might help explain why veterans, who have almost certainly experienced a series of traumas, are at such high risk for the disorder. Furthermore, there are risk factors that are associated with the development of PTSD, including the nature, severity, and duration of the trauma exposure, prior history of trauma exposure, lack of social support, and additional life stressors (The Management of Post-Traumatic Stress Working Group, 2010). What these factors make clear is that it might be possible to predict those soldiers who are most at risk of developing PTSD before ever sending them into combat, and, with careful post-combat monitoring, it might even be possible to prevent the development of PTSD.

PTSD can manifest in various different ways, which fall into three main categories: reliving the event, avoidance, and arousal. Reliving the event can include flashbacks, nightmares, and upsetting memories of the event (Vorvick et al., 2011). Avoidance includes feelings of detachment, difficulty remembering parts of the trauma, emotional numbing, flat affect, a lack of interest in normal activities, and avoiding things that might trigger memories of the event (Vorvick et al., 2011). Arousal might be the element of PTSD that is most frequently associated in the minds of people when thinking about how PTSD manifests in veterans and includes: difficulty concentrating, startling easily, an exaggerated startle reflex, hypervigilance, irritability, angry outbursts, and difficulty sleeping (Vorvick et al., 2011). In addition to those three main categories, PTSD sufferers might suffer a general range of anxiety symptoms including: agitation, excitability, dizziness, fainting, racing heartbeat, and headache (Vorvick et al., 2011). As clear by the symptoms, there is no one definitive element that differentiates PTSD from other anxiety disorders and its symptoms can overlap with other disorders, such as depression. Therefore, a diagnosis has to be based upon symptoms, how long symptoms have lasted, and whether the presence of any other disorder can explain the symptoms (Vorvick et al., 2011).

Once diagnosed, there are several different ways to treat PTSD. Each of these methods has various strengths and weaknesses, and there is no single approach that has been proven effective in all cases of PTSD. Instead, PTSD treatment must be somewhat individualized, with the realization that a treatment that is effective for some people may not prove effective in other patients. Despite that caveat, there is substantial support for the most widely-utilized PTSD treatments. "The evidence-based psychotherapeutic interventions for PTSD that are most strongly supported by RCTs can be considered broadly within in the trauma-focused psychotherapy category or stress inoculation training" (The Management of Post-Traumatic Stress Working Group, 2010). These trauma-focused therapies center on helping the patient deal with the trauma and are based on "learning theory, cognitive theory, emotional processing theory, fear-conditioning models, and other theories. They include a variety of techniques most commonly involving exposure and/or cognitive restructuring (e.g. Prolonged Exposure, Cognitive Processing Therapy and Eye movement Desensitization and Reprocessing). They are often combined with anxiety management/stress reduction skills focused specifically on alleviating the symptoms of PTSD" (The Management of Post-Traumatic Stress Working Group, 2010). While these CBT techniques have proven very effective, non-trauma focused CBT interventions are not as effective. The most commonly used approach is desensitization, which involves controlled exposure to the traumatic event with the goal of making the memories of the event less frightening. Another approach is cognitive therapy. It is important to note that PTSD may manifest in veterans in similar ways as in the rest of the population, but, given the training and experiences of veterans, may be a potentially more dangerous disease in that subpopulation than in the rest of people suffering from PTSD. The reality is that combat veterans have not only been trained to kill, but, in many ways, may be desensitized to the real impact of violence in a non-combat scenario. Therefore, their PTSD-influenced reactions, which might be entirely rational in a combat scenario, could have dire consequences outside of the context of war. Moreover, the potential negative impact is not limited to peacetime environments. Attacks on civilians in wartime environments can, in some cases, be triggering incidents for PTSD, but might also be evidence of PTSD in the perpetrators.

Furthermore, because wartime scenarios are so different from peacetime scenarios, dealing with PTSD in veterans can present special issues. Another issue that can complicate the treatment of PTSD in veterans is the impact that military sexual trauma (MST) can have on the prevalence of PTSD in veterans (Kimmerling et al., 2010). It seems like there is an ever-increasing awareness of sexual assault in the military, and one must be cognizant of the possibility when treating any veteran presenting with PTSD symptoms. There are two main approaches to treating PTSD in combat veterans: cognitive processing therapy (CPT) and prolonged exposure therapy (PE). In addition, mindfulness-based cognitive behavioral therapy techniques have shown promise in treating PTSD in veterans.

Discussion

It is important to understand that while PTSD may be an illness, it is also a reflection of a normal processing system that has gone wrong. The body is supposed to feel anxiety in the face of a scary or traumatic situation; anxiety is the way the body processes the production of those hormones necessary to respond in high-danger scenarios. However, this heightened anxiety existing when there is no actual danger can present real problems for the person suffering from any anxiety disorder, including PTSD. In patients with PTSD, the underlying traumatic event has caused fear and this fear is then inappropriately generalized outside of the context of the initial trauma. Emotional processing theory (EPT), which is used to explain many anxiety disorders, helps explain PTSD and inform treatment structures for PTSD. EPT "posits that the fear structures of trauma survivors with PTSD include two basic dysfunctional cognitions that underlie the development and maintenance of PTSD. First, the world if completely dangerous…Second, one's self is totally incompetent" (Rauch & Foa, 2006). The combination of these two beliefs means that the patient not only feels constantly in a state of danger, but also feels as if he or she is unequipped to deal with that danger in an appropriate manner. In other words, the patient feels helpless. Therefore, most believe that treating PTSD means modifying the fear structure so that it is not responding in an irrational manner to stimuli that should not create fear. CBT seeks to do this by confronting the patient with the trauma and having them associate rational responses to triggers, rather than rely upon the trauma-induced irrational responses.

Myths about trauma-focused therapy continue to create a barrier to effective PTSD treatment; both because these myths make some practitioners reluctant to engage in trauma-focused therapy and it can even lead some patients to fear the impact of trauma-focused therapy. Some practitioners feel that encouraging trauma survivors to relive the trauma is cruel or revictimizing, but this reflects faulty reasoning on the part of the practitioner. "The therapist is not creating new pain, but must access the emotions to assist the patient in emotionally processing the memory so it can become less painful" (Rothbaum & Schwartz, 2002). Moreover, contrary to myth, patients are not generally unwilling or reluctant to undergo exposure therapy, but are able to recognize that exposure may be necessary to help them move past the traumatic event. The whole thought process behind trauma focused therapy is that by changing thoughts, the therapist can help achieve symptom reduction, and this hypothesis has been verified in a number of studies (Sobel et al., 2009).

Despite the fact that some therapists have lingering, erroneous concerns about trauma-centered therapy, it has long been the preferred approach for treating PTSD. In fact, CPT, a form of trauma-centered therapy is considered the go-to treatment for PTSD. CPT is a counseling-based intervention that generally involves meeting with a therapist on a weekly basis in an effort to move the person suffering from PTSD, who is seen as stuck in the time of the event, past the event (National Center for PTSD, 2011). It is believed to work because the goal of CPT is to give the patient the skills he or she needs to handle the distressing thoughts that accompany PTSD. By changing how the person thinks about the traumatic event, the belief is that one can change how they feel about the event (National Center for PTSD, 2011). There are four main components to CPT: learning about the PTSD symptoms and how treatment can help; increasing awareness of thoughts and feelings; cognitive restructuring, which is learning skills to challenge thoughts and feelings; and understanding changes in beliefs that are common after a trauma (National Center for PTSD, 2011). Finally, patients undergoing CPT will be given practice assignments to use their new skills outside of a therapeutic setting (National Center for PTSD, 2011).

PE therapy is another type of cognitive therapy, and it involves focusing on the traumatic event. The belief is that repeated exposure to the thoughts, feelings, and situations that the patient has been avoiding can demonstrate that those things do not have to be avoided. It begins with an identification of what scenarios the patients has been avoiding, and then involves confronting those situations until the patient feels a decrease in distress (National Center for PTSD, 2011). PE has four different components: education about symptoms and how treatment can help; breathing retraining to promote relaxation and stress management; real world practice in previously avoided scenarios; and imagination exposure (National Center for PTSD, 2011). The idea is that exposure to the traumatic event will eventually lead to desensitization, so that the patient can respond normally to the trauma or things that remind him or her of the trauma, instead of responding in a heightened or sensitized manner.

One of the more interesting and controversial research conclusions is that cognitive interventions may not be necessary given how effective behavioral interventions have been for anxiety and depression, and this outcome flies in the face of those who believe that behavioral changes are the result of cognitive changes achieved in CPT. If those studies are correct, then cognitive behavioral interventions may not be the appropriate way to treat PTSD; instead purely behavior interventions may be more appropriate than cognitive-behavioral approaches. Hassija and Gray investigated the relative efficacy of cognitive and exposure treatment to PTSD, focusing on whether the addition of cognitive restructuring to exposure therapy enhanced the cognitive changes one receives from the exposure therapy (2010). What they discovered was that cognitive restructuring could be beneficial for some symptoms of PTSD, specifically for guilt symptoms and detachment, and could enhance cognitive change (Hassija & Gray, 2010). Moreover, they discovered something somewhat unexpected, which is that restructuring, alone, can be as effective as restructuring with exposure-based behavior therapy (Hassija & Gray, 2010). They came to the conclusion that both cognitive therapy and exposure can be effective for patients with PTSD (Hassija & Gray, 2010).

This conclusion bolsters existing practices that suggest some cognitive component as part of EP. In fact, when one looks at the basic format of standard EP, one sees several cognitive components to the therapy. The patients are not simply exposed to the aversive stimuli or trauma and expected to acclimate non-trauma responses into their response repertoire. Instead, EP involves significant thoughts about the underlying trauma and how to deal with the symptoms they produce in the sufferer. This leads one to the conclusion that EP cannot be labeled a strictly behavioral therapy; it might not focus on cognition, but it certainly contains a number of cognitive elements.

The above information is particularly relevant when one considers that the Veterans Administration actively promotes two particular and distinct treatments for PTSD: CPT and PE. The vast majority of VA facilities currently offer either CPT or PE, with many of them (72%) offering both types of therapy (Karlin et al., 2010). The results from the different types of therapies are comparable and both therapies have been proven to be effective in treating veterans with PTSD. Recent studies have shown that CPT was effective in reducing PTSD severity by 30% or more in 28% of cases, while PE was effective in reducing PTSD severity by 30% or more in 30% of cases (Karlin et al., 2010). However, there is a lingering treatment problem that is not necessarily related to the type of treatment offered, but does impact treatment offered and possibility long-term prognosis. That is the belief among both patients and practitioners that PTSD is a chronic life-long disorder that is treatment resistant (Karlin et al., 2010). As a result, future research may want to focus on patient and therapist beliefs about the disorder and how those beliefs impact treatment outcomes. Furthermore, this study did not examine the overlap between the two treatment protocols; it seems unlikely that any form of PE would not have a cognitive element.

With the realm of CBT, PE, which some refer to as desensitization, has been the primary way to treat veterans with PTSD. While PE can be effective, recent studies suggest that there may be advantages to alternative therapies, particularly CPT, which includes cognitive and exposure components (Monson et al., 2006). "Although originally developed for women suffering sexual assault-related PTSD, CPT seems well suited to the veteran population and VA treatment setting. CPT focuses on the range of emotions, in addition to anxiety, that may result from traumatization (e.g., shame, sadness, anger), can be generalized to comorbid mental health conditions and day-to-day problems, is in a manualized format amenable to widespread dissemination, and can be delivered in a group format" (Monson et al., 2006). Moreover, when looking at specific subcomponents of PTSD such as trauma-related guilt, CPT is frequently more effective than PE (Monson et al., 2006). This evidence suggests that CPT might be the more effective of the two approaches.

Because treatments are relatively successful, one of the problems that might occur is when a patient is treatment resistant. Prior thinking about the condition may lead both patient and therapist to give up on treatment options under the erroneous belief that nonresponsive PTSD cannot be cured. In fact, for many years, PTSD was considered a chronic condition and the prognosis for individual patients was not very good. New research not only suggests that is false, but also that treatment for PTSD can be successful after a relatively short duration. Examining combat veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who exhibited PTSD, researchers found that patients responded rapidly to PE treatments. In fact, after as few as six sessions, patients showed significant improvements in both depression and PTSD symptoms (Tuerk et al., "Prolonged" 2010). The most significant declines in symptoms were noted in the first five sessions, which may suggest that the impact of PE levels off after an initial success period. The results suggest that PE should be used as part of the standard treatment for combat veterans with PTSD. However, the research also suggests that a therapist should be able to determine the efficacy of PE alone in a patient within a relatively short period of time. If PE has not demonstrated a significant impact within the first six sessions, it might be appropriate for a therapist to introduce other interventions. This is an important development, because the standard PE intervention is far greater than six weeks. For those veterans who are responding to treatment, this extended treatment period may be beneficial and is almost certainly non-harmful. However, if a patient is not responding to traditional PE, one has to consider the possibility that extended PE is simply reinforcing the existing anxiety that is linked to the trauma. Therefore, future researchers should certainly consider moving non-responsive patients from PE only groups to CPT groups after six weeks of treatment and then comparing their response rates to a control groups left in PE for the standard duration of treatment. One would assume better results in the CPT group of treatment resistant soldiers than the PE alone group.

Moreover, it is important to keep in mind that therapy can exist in a variety of different contexts and modalities. For example, exposure therapy does not have to be done on an individual basis. While the basic structure of PE is one-on-one clinical intervention, other modalities have proven effective. Ready et al. field tested group-based exposure therapy (GBET) with a group of 102 veterans suffering from war-related PTSD. The therapy was more frequent and more intensive than traditional one-on-one PE; it was groups of 9 to 11 patients attending 3 hours of group therapy per day twice a week for 16 to 18 weeks (Ready et al., 2008). What they found was that GBET produced significant and lasting reductions in PTSD for most patients in the groups (Ready et al., 2008). While the therapy was more intensive and involved greater participation than traditional one-on-one PE, the success rates were also higher. Moreover, it is important to differentiate GBET from a simple support group scenario, because support groups do not necessarily feature the trauma exposure that seems to be a significant component of GBET's success.

There are adjuncts to CBT that can be helpful for PTSD. "Regular mindfulness practice can lead to a greater present-centered awareness and nonjudgmental acceptance of potentially distressing cognitive and emotional states as well as trauma-related internal and external triggers" (Vujanovic, et al., 2010). This mindfulness is, in and of itself, a form of PE, as it can serve "as an indirect mechanism of cognitive-affective exposure" that can "decrease experiential avoidance, reduce arousal, and foster emotion regulation (Vujanovic et al., 2010). Mindfulness, especially when used in combination with other CBT for PTSD is thought to increase engagement, preparation, and compliance, as well as reduce rumination (Vujanovic et al., 2010).

One of the promising advances in treatment of PTSD in military primary care patients has been the use of internet interventions to treat PTSD. In a study of 22 Australian Veterans, researchers found that therapist-assisted internet interventions can be highly successful. A 10-week online PTSD treatment showed comparable results to face-to-face interventions (Klein et al., 2010). Moreover, the therapeutic alliance ratings were high, which has been a consistent concern that critics have mentioned when examining the possibilities of treatments delivered via the internet (Klein et al., 2010). This is critical because therapeutic alliance has shown to have an impact on how likely a patient is to complete the homework assignments that are seen as a critical component to successful PE therapy (Keller et al., 2010). The internet is not the only means of remote therapeutic interventions. Telehealth technology, which refers to various methods of telecommunication technology including the internet, teleconferencing, and other forms of telecommunication to provide health services, has also proven an effective means of therapeutic intervention for PTSD patients (Tuerk et al., "Pilot," 2010).

One of the important things to realize is that, regardless of the modality chosen to treat PTSD, other approaches may be used to treat symptoms. For example, sleep problems are a common symptom in veterans suffering from PTSD. As a result, many of them are prescribed drugs. Two medications that are used to treat sleep problems, though they are not specifically sleep aids, are quetiapine and prazosin. Quetiapine is an antipsychotic and prazosin is an alpha 1-adrenergic receptor antagonist (Byers et al., 2010). In addition to those two drugs, it is not uncommon for PTSD patients to be treated with selective serotonin reuptake inhibitors (SSRIs), benzodiazipines, and specific sleep agents (Byers et al., 2010). What is interesting is that prazosin seemed to be more effective than quietiapine in treating sleeping problems, but quietapine is still more frequently the initial option for drug treatment (Byers et al., 2010). As one must anticipate that drug therapies will impact other therapeutic interventions, it behooves the counselor to understand the drugs being used to treat the patient.

One concern with treating veterans suffering from PTSD is that symptoms are self-described and self-reported, but there are substantial reasons to believe that veterans may not be completely honest about the symptoms they are suffering:

Patients themselves may have a number of incentives to minimize their distress: to hasten discharge, to accelerate a return to the family, to avoid compromising their military career or retirement. Fears about possible impact on career prospects are based in reality; indeed, some will be judged medically unfit to return to duty. Veterans may be concerned that a diagnosis of PTSD, or even Acute Stress Disorder, in their medical record may harm their chances of future promotion, lead to a decision to not be retained, or affect type of discharge received. Some may think that the information obtained if they receive mental health treatment will be shared with their unit commanders, as is sometimes the case in the military (Ruzek et al., 2010).

These are all important considerations when evaluating the efficacy of a treatment, not just in general, but for a specific patient. Therefore, the therapist must be cognizant of the possibility that the patient is not being honest, not due to a desire to deceive, but because of a real desire to continue to work or to be considered functioning in mainstream society.