Post Traumatic Stress Disorder Treatment

Post Traumatic Stress Disorder

Treatment Modalities for Post Traumatic Stress Disorder

Being a combat veteran of the Iraq war, I am interested in treatment modalities for Post Traumatic Stress Disorder or PTSD.

[Personal Statement..

This research paper shall discuss and critically analyze PTSD intervention theories and methods. There are a number of models of acute post trauma intervention that are in current use. These will be reviewed below. It should be noted that while some of these share similarities with interventions for the treatment of established and even chronic PTSD, their focus is different in that they primarily aim for the fullest possible recovery, although this may not be clearly articulated. The chronicity of longer-established disorder means that the focus of interventions is usually on the maintenance of function and the diminution of symptoms.

The term Psychological First Aid arose in the disaster context (Schubert & Lee, 2009) and is increasingly used in these and other situations of trauma. It involves a number of models including those of Foss (1994), a semi-structured support process (Craine, 2008), a model linking to the culture of physical first aid, and more recently a similar approach from the World Health Organization (WHO) (Defense and Veterans Brain Injury Center, 2007). While these are intended to be generic and supportive, they have not been subjected to research and evaluation, so that the usefulness and validity of their application needs to be established. Their general supportive nature and non-active intervention suggest that they are unlikely to do harm.

II: Literature Review

There is a range of literature on debriefing models that have arisen, generally from the military psychiatry approach to deal with combat stress reactions, one pattern of acute post trauma reaction. While Degeneffe, C.E. (2001) has critically reviewed models and placed these in educational and psycho educational contexts, the popularity of the ?Mitchell model? (Craine, 2008) means that this is usually equated to debriefing. This model has been widely used across the world, and extensive presentation and training concerning its use has occurred. Debriefing was originally suggested as an intervention for emergency service workers such as police, rescue, fire services, and other emergency personnel. It was situated in an occupational health context with aims of diminishing adverse consequences of critical incidents experienced in the course of work, such as job turnover, stress, and sick leave. As the model evolved it became situated in a critical incident stress management (CISM) framework and became known as CISD (critical incident stress debriefing). It was seen as on a continuum with other acute interventions, including defusing, peer support, crisis intervention and possibly counseling (Army News Service, 2007; CBS News, 2007).

This debriefing model has a number of stages and is intended to be carried out in the earliest days posttraumatization. It provides a structured group process in which the incident is reviewed, knowledge shared, feelings expressed, and education provided about symptoms that may occur. While it is frequently perceived as helpful by those who receive it, this helpfulness does not appear to correlate with improved outcomes. Nevertheless, DePalma, et al. (2005), following a range of reviews of their own and others work, conclude there is ample evidence of its effectiveness in reducing symptoms of stress in the posttraumatic period, of increasing workers' capacity to function, and of lessening levels of sick leave and job turnover in the emergency professions. Thus it can be seen, if this proves to be the case, as a form of stress management relevant to 'critical incident stress' (Army News Service, 2007).

The authors carefully delineate this from traumatic stress and do not claim that it lessens risk for or levels of PTSD, although this possibility is frequently inferred by those who use this debriefing model. Furthermore, the extensive spread of CISD and the social demand generated have occurred alongside a reluctance to evaluate it, and to systematically examine any negative effects, while claiming its undoubted benefit. Recent studies such as those of Sontag & Alvarez, (2008) and Kennedy et al. (2007) contest the benefits of debriefing. They have not found it to be beneficial in their studies of disaster-affected populations or, for those workers using a CISD model for support. This leads to considerable debate between those supportive of the Mitchell model specifically or debriefing generally, on one side, and those who do not find benefit and even suggest that there is the potential for those provided with this type of acute intervention to fare worse, on the other.

Furthermore, studies using the model as an acute one-off intervention in other settings such as acute intervention for psychological traumatization following serious burn injuries (Martenyi, 2005) and following the trauma of motor vehicle accidents (Sontag & Alvarez, 2008) have found it to be of no benefit in reported trials. A recent Cochrane review came to the same conclusion (Caplan, 1964). Thus there must be a call for caution in the broad use of the model, concern about the potential to ?make worse,' perhaps through mechanisms suggested by Degeneffe, (2001). Moreover, some of these studies have suggested that those who have had several debriefings were worse. Many research criticisms can be placed on the findings of both groups of protagonists, but there is certainly a growing body of negative findings which must challenge any universal application of de- briefing as an acute posttraumatic intervention (Schubert & Lee, 2009).

Military Interventions

These interventions evolved with the recognition of combat stress and its detrimental effects on soldiers, in the immediate period of the battle, when their ability to continue fighting was critical to the achievement of military goals, and subsequently when long-term disability brought a burden of personal damage and social cost. Two types of intervention which have been utilized in this setting sit in the acute posttraumatic framework.

These are forward ppehiatg based on the principles of proximity, immediacy, and expectancy (PIE), and debriefing. The former intervention is a specific treatment format for soldiers who develop combat stress reactions and are unable to continue to fight effectively. They are taken from their unit but kept close to the front (proximity), treated immediately with supportive measures including rest and possibly medication (immediacy), and with an orientation to return them rapidly to their unit where they will continue to function as soldiers (expectancy). This treatment modality has been studied and validated (Defense Link, 2008; Degeneffe, 2001). It has been found to be very effective in achieving its goals, with the soldier usually reengaging with his unit and returning to combat (Martenyi, 2005).

Thus it is effective in diminishing symptoms and supporting function. Whether or not it can prevent PTSD has not been established, however. Solomon and associates' work and longer-term follow-up of these men in the Israeli army and subsequently have shown that those with repeated combat stress reaction, even though continuing to function as soldiers at the time, were in many instances later more vulnerable to developing chronic and disabling PTSD (Army News Service, 2007).

Whether keeping people functional but in so doing keeping them in a situation where they may be traumatized again (and again) is ultimately helpful to outcomes is a critical question for future research. Here as elsewhere findings need to be extended to better encompass the role of pre-trauma factors such as the following: previous experience and mastery or vulnerability; vulnerable personal styles such as those of obsessive rumination; resilience characteristics such as those of hardiness and personal hopefulness; and background preparation and training. Post trauma interventions cannot be really evaluated without taking these things into account.

Debriefing in military contexts has evolved somewhat differently Atwater, (2009), a U.S. military historian, undertook to interview soldiers in groups to get a full and clear picture of what had happened in combat in particular battles.

All were treated as equal, every soldier's story was encouraged, and no interpretations were made. These narratives appeared to help the soldiers (as well as the interviewer) to gain a coherent or "whole" picture of what had gone on and appeared to be helpful to them psychologically, although no specific research was done to formally establish this. While debriefing has been widely used in the military since that time, it has, with the recent uptake of interest in debriefing models, usually been in the CISD format. More recent concerns about debriefing have called this into question, and this review suggests that it may be more appropriate to return to the use of the earlier type of model. Degeneffe, (2001) describes the effectiveness of this ?historical group debriefing in decreasing arousal in soldiers and suggests that, as this is a crucial pathway to PTSD, this intervention may help to prevent it.

DePalma, et al. (2005), again talking of the military context, suggests that debriefing is of most use when it is for those who have been briefed for an incident and that the leaders of groups of soldiers or emergency workers, for instance, should be trained and supported to provide this type of debriefing as part of their leadership roles. DePalma, et al. (2005), add that other debriefing formats should only be used for incidents where stresses are so severe as to disrupt the unit's functioning (e.g., when there are deaths of several soldiers or emergency workers of a unit). Combat is a stressor that is associated with a relatively high risk of PTSD, and those interventions that can potentially diminish this risk are very important. But what is not clear in the above is how much the debriefing provided is more a form of stress management for the ?critical incidents? that are very much part of warfare, as opposed to interventions for those psycho- logically traumatized and at risk of PTSD. People in the military are exposed to stressors other than combat, and these may be traumatic (Atwater, 2009). Reports of soldiers who were involved in body recovery in the Gulf War provide important insights. This is a high-stress situation, linked to vulnerability to posttraumatic morbidity.

Asnis, et al. (2004) reported that soldiers of one group who had been debriefed were compared with another, which, for operational reasons, had not. The debriefed group was no better at longer-term follow-up: no benefits could be demonstrated for the debriefing in groups that appeared to be equivalent in experience and vulnerability to these stressors. PTSD was not prevented by this intervention. Peacekeepers also suffer experiences which may be psychologically traumatic-for instance, witnessing genocide, violence, bombing, or deaths from famine, without being able to intervene. Fairweather & Garcia, (2007) have demonstrated significant psychological morbidity in a group of peacekeepers, and cases of PTSD have also been reported in such groups. Yet these groups have had extensive briefing and debriefing in recent times. For many, however, their experiences in the developing countries where they had these peacekeeping roles were overwhelming and may well have added to their vulnerability. Soldiers, like emergency workers and others in structured crisis response services, may have their own informal "debriefing" mechanisms in socially sanctioned modalities and in more secure settings (Caplan, 1964).

III: Proposed Project Method

A proposed modality developed from Caplan's (1964) original ideas of preventive intervention following stressful life events. It has been applied as a brief intervention in association with bereavement (Seal, et al. 2007), motor vehicle accidents (Bordow & Porritt, 1979), and acute injury and illness (Martenyi, 2005). When provided in accordance with this theoretical modality, it has been shown to be effective in high-risk populations in lessening the likelihood of morbidity. Although potentially "traumatic" stressors could have been identified in each of these studies, the traumatic stress model did not inform them. While it is now known that traumatic bereavements can be associated with PTSD, that motor vehicle accidents may lead to the development of PTSD, and that life-threatening illness and injury may be associated with vulnerability to PTSD, further research in crisis intervention is needed to test this model as an acute posttraumatic intervention. Nevertheless, it is potentially so. The recontextualizing of debriefing in the crisis intervention frame- work is not really helpful, as its format, intervention, timing, and hypothesized mode of action are quite different.

IV. Proposed Project Evaluation/Data Analysis

This modality has become a subject of research in recent times, with studies showing that specific focused counseling can lessen the risk of PTSD after acute rape trauma (Asnis, et al. 2004). Trauma counseling has often been provided as a nonspecific general counseling aimed at both making better the psychological hurt and preventing the development of PTSD. Unfortunately, the marketplace demand for trauma counseling and the belief in its value have far outstripped the knowledge base of what is effective and the skills of many would-be providers. The effectiveness of focused interventions which are provided over a number of sessions in the later (2 weeks or more) acute post trauma period appears to be established (Bergfeld, 2006). These interventions are chiefly in cognitive behavioral formats which focus on the specific trauma and support reconfrontation and working through. Fairweather & Garcia, (2007) carried out a pilot study of a brief preventive intervention program for female sexual assault survivors.

The intervention built on what was known to be effective in the treatment of some chronic PTSD in such circumstances (Kennedy et al. (2007) and included exposure, relaxation training, and cognitive restructuring. The authors compared intervention and nonintervention subjects, both groups having an intervention, of four weekly 2-hour sessions which began within a month of the assault. Although numbers were small and it was not a controlled trial, those who would have met criteria for PTSD diminished significantly in the intervention group and did not in the control group. Symptoms were far less severe for the intervention group. These benefits were sustained. The authors note that intervention did not start until 2 weeks later.

While they initially believed this might contribute a difficulty, they subsequently considered that those affected may have been better able to benefit from these interventions at this later time. This would fit with findings of bereavement counseling. With these findings in mind, and the comparative effectiveness of cognitive behavioral interventions for treatment of some cases of established PTSD, there is a sound framework for using this modality of trauma-focused cognitive behavioral therapy in short-term counseling as the basis for an acute post trauma intervention provided in the early weeks but not immediately post trauma.

Some debriefing and other acute posttraumatic interventions are provided in a structured and integrated framework which seems to have been associated with some positive results. This is exemplified in Kennedy et al.'s (2007) rotation and support for officers working after the Lockerbie plane crash in Scotland and Alexander's structural support of police body recovery workers after the North Sea oil rig disaster. In the latter case, a support system was provided by briefing workers. This consisted of pairing a younger with an older, more experienced officer and providing informal debriefing merged with support by a psychiatrist known to and trusted by these men (Bergfeld, 2006).