Clinical Conversation on PTSD Related to Military Combat

by APA Practice Organization


February 14, 2008 — This "Clinical Conversation" was stimulated by the documented mental health needs of active duty military, National Guard, Reservists and veterans who served in Operation Iraqi Freedom and in Operation Enduring Freedom in Afghanistan.

Terence M. Keane, PhD, is Director of the Behavioral Science Division of the National Center for PTSD at VA Boston Healthcare System. He is also Professor and Vice Chairman of the Division of Psychiatry at Boston University School of Medicine and Professor of Psychology.

The author of more than 200 publications, Dr. Keane has also edited nine volumes on post-traumatic stress disorder (PTSD), while developing many of the most widely used measures of psychological trauma and PTSD. He is recognized internationally as one of the leading authorities on trauma and PTSD.

Randy Phelps, PhD, is Deputy Director of the American Psychological Association (APA) Practice Directorate and has worked for many years on veterans issues as an advocate of professional psychology. Dr. Phelps is serving as the Practice Directorate interim executive director until April 2008.

The online "Clinical Conversations" in this PracticeUpdate e-newsletter generally focus on clinical information and developments of interest to practicing psychologists. The psychologists featured in these conversations offer their own professional perspective on a particular topic.

This conversation is intended to stimulate feedback from APA members.

Dr. Phelps: Where do individuals who have returned from combat get treated for their mental health needs?

Dr. Keane: The Department of Veterans Affairs (VA) operates an integrated health care system dedicated to providing comprehensive health care and mental health care to military veterans. The VA health care system's mental health programs comprise a wide range of services including inpatient care, outpatient care, the Vet Center (psychological and social services in storefront settings), residential treatment programs, vocational rehabilitation programs, substance abuse treatment programs, sexual trauma treatment programs and homeless domiciliary programs, among other services. This care is provided to eligible men and women veterans.

Typically, VA provides health care to those who were injured during their military service or who developed a disease/disorder during the time of their service. Additional eligibility is conferred on those whose annual income is below a certain level and who do not have alternative sources of health care available to them. Elderly veterans over the age of 65 can also receive care at VA.

Historically, VA provided care to approximately 20 percent of all veterans. Eighty percent of veterans received their health care elsewhere. Veterans from the current conflicts in Iraq and Afghanistan are accessing VA health care at a higher level. Approximately one-third of eligible veterans have been to a VA setting for some type of care. Generally, the problems driving this care are musculoskeletal complaints, dental needs and, naturally, mental health problems. Of course, combat-related PTSD is the most common psychological problem, but veterans also present with depression, substance abuse, chronic pain, traumatic brain injury (TBI) and other anxiety disorders.

The vast majority of veterans and their family members receive their mental health care from the private sector. For this reason, it's important for mental health practitioners of all types to assess for veteran status. Making this determination may provide important information for case formulation and treatment planning. Practitioners who feel the need for additional training in the assessment and treatment of military veterans (male and female) may find helpful information through APA and state, provincial and territorial psychological associations and through a wide range of Web training initiatives.

Dr. Phelps: How do various subgroups such as active duty military and National Guard/Reserve members access treatment?

Dr. Keane: Active duty military have their own health care system provided by the Department of Defense (DoD). For active duty military, mental health services can be provided by the DoD directly or through a mechanism known as One Source. Providers affiliated with One Source consist of psychologists and other mental health professionals who contract with the DoD to provide a limited number of assessment/therapy sessions to individuals and their families.

National Guard and Reservists are not ordinarily eligible for VA health care, nor are they typically eligible for DoD health care when they are inactive. However, an act of Congress created time-limited eligibility for these military members to utilize VA services. This legislative action has been a great source of mental health care for the returning Reservists and National Guard personnel.

The VA provides care largely to individual veterans themselves. Family members, and especially family members of those activated and serving in the war zones, are not deemed eligible for VA services. With a wide range of psychiatric and psychological services available in diverse settings, VA is a living example of the goals of the President's New Freedom Commission on Mental Health. It may well be the model system that the rest of the country could emulate.

Dr. Phelps: What is important for psychologists to know about the demographics of returning service members?

Dr. Keane: Several key demographic features of the current military force are important to appreciate. First, it is a decidedly diverse, multicultural military. More than 40 percent of active duty military personnel is a racial or ethnic minority. This figure represents greater diversity than in the U.S. population at large.

Second, women constitute more than 10 percent of the military serving in Afghanistan and Iraq, and they perform a wide range of professional roles and combat roles. This situation is different than Vietnam, for example, when women were disproportionately represented in nursing and administrative positions and served in the war zone in far lower percentages of the total military force.

Third, there is a bifurcated distribution of age among service members. Some members serving in their first enlistment might be in their late teens or early twenties. Others are Reservists and National Guard members who might be in their later thirties or forties. Accordingly, their backgrounds and issues are very different and reflect their age, vocational and family structures.

Dr. Phelps: How do family members — spouses, children, parents and other family members — factor into treatment for returning service members?

Dr. Keane: Veterans themselves are the ones deemed eligible for VA care. The VA's statutory authority to treat family members is limited.

Family members are treated to the extent to which they are directly involved in the veteran's care. For example, if a veteran develops depression or PTSD as a consequence of his or her service, the veteran's spouse could be actively involved in a marital treatment program for these conditions. If a veteran is injured by an improvised explosive device (IED) and his/her cognitive processes are compromised, the parents could be involved in a psycho-educational rehabilitative program in conjunction with the veteran. This treatment would be fully provided by VA to the veteran and their family members.

Dr. Phelps: How generalizable are skills in treating trauma to treating people exposed to combat? How likely is someone with a practice focused generally on trauma, such as helping victims of abuse, to be well skilled in meeting the needs of returning service personnel?

Dr. Keane: I'd like to think that the specific skills and conceptual models for understanding and treating one type of trauma are directly generalizable to another form of trauma exposure. This notion is fundamental to much of the work accomplished by our group at the National Center for PTSD over the past 30 years.

Yet, specific contextual factors are important to consider if one is to succeed in navigating the transition from working with one group of trauma-exposed people to another group. In the instance of combat trauma, it is critical to understand general military contextual variables and the specific details associated with the war itself, and to have an appreciation of the stressors and pressures under which the individual served. Even understanding the political climate in Afghanistan or Iraq during the time of service may communicate to your patient important things about your competence. Learning about the contextual factors associated with a particular type of trauma exposure would, in my view, be far easier and quicker to master than the acquisition of new therapy skills.

The principles for treating trauma survivors are far better understood today than 30 years ago when we first started to treat combatants. Importantly, the models and techniques that guide psychological assessment and psychological treatment of PTSD now possess reliability and validity data that transcend the various types of trauma to which people are exposed. These same principles appear to be effective across racial, ethnic and cultural boundaries. These facts are enormously encouraging to me.

Dr. Phelps: What is important for practitioners to know about the combat-related experience that today's returning soldiers may bring to treatment that's different from other trauma-related life experiences?

Dr. Keane: Fundamentally, trauma is about exposure to life-and-death situations. Trauma may also be secondary to exposure to events that challenge one's personal integrity or may inculcate shame or humiliation. For combatants, their experience in a war zone may transcend all of these experiences and exposure to these experiences often happens multiple times over the period of service.

Combat is not exposure to a uniform, single traumatic event. Rather, it often involves multiple types of life-and-death experiences associated with strong and wide-ranging emotional reactions in the context of a malevolent living environment that is estranged from the usual forms of family and social support. As a result, it's vital to conduct a comprehensive assessment of exposures both in the war zone and prior to service in the war zone.

My experience is that veterans can be extraordinarily open in describing the devastation of war but may be reluctant to express details of events in which they might have had an active role. Patience is needed to understand the precise role of the individual in certain war events, their immediate reactions to those events and the long-term impact of this participation. Combatants are often actively and passively involved in acts of violence; understanding the boundary conditions of war is pivotal in making progress in the psychological treatment of war veterans regardless of their rank at the time of service.

Dr. Phelps: What specific treatments show the greatest promise for successful treatment of combat-related PTSD?

Dr. Keane: The general principles that guide treatment of PTSD are derived from several different models of care. First, the development of a strong therapeutic alliance is pivotal for all future work. It may determine the extent to which particular patients might even share with you the details of their military experiences. Conflict about one's participation in combat is a function of what one does in the war zone and what happens to that person in the war zone. The complex emotions that emerge can be fear, anxiety, dread, horror, shame, guilt and disgust — the strongest and most aversive of human emotions.

Treatment of these emotional responses initially involves a quieting of the strong emotions often employing relaxation or meditational strategies, accompanied by psycho-educational efforts to inform the patient of the psychological, physiological and interpersonal consequences of trauma exposure. Reframing the experiences using cognitive restructuring models that focus upon realistic appraisals of the situation and the circumstances found in a war zone by combatants also is an important component of psychological care. Finally, emotional processing of the details associated with difficult combat events is also demonstrably effective in helping patients to overcome their reactions. Emotional processing can take many forms, including prolonged exposure therapy, systematic desensitization, eye movement desensitization and reprocessing (EMDR) and other approaches that focus directly upon the emotional reactions precipitated by the traumatic events per se.

Dr. Phelps: Of course psychologists are trained to pay attention to countertransference. But are there potential blind spots for certain practitioners, such as those unfamiliar with military service or opposed to war, that they should be mindful of in working with returning service members?

Dr. Keane: Yes, I think so. The therapeutic alliance can be a challenge in any setting and with any type of patient, but there are some key features that will determine whether veteran patients will return for continuing care. Listening attentively to the description of service, while asking informed questions about location, duties and training, can communicate to the veteran an understanding of their experience in important ways.

Most people who join the military do so for the honor and defense of their country. Their belief system is such that they respect those who join the military and they consider the work of the military among the most worthwhile things possible. Challenging this belief or even demonstrating a political position on the value and merits of a particular war may inadvertently damage the therapeutic alliance in ways that aren't remediable.

For many war veterans, even those in their eighties today, the work they did for their country in the military was among the most rewarding life experiences they've had. Supporting this belief is important to moving to the next stage of treatment.

Dr. Phelps: What is the Department of Veterans Affairs doing to help psychologists — both VA psychologists and non-VA psychologists — become better informed? What's the role for non-DoD and non-VA psychologists in helping with PTSD treatment?

Dr. Keane: The National Center for PTSD has an award-winning website that is a national resource on the topic of PTSD broadly, but with a special emphasis on combat-related PTSD. The PILOTS (Published International Literature on Traumatic Stress) literature search engine, one of the most widely used facets of our website, contains both published and unpublished works on the topic of trauma — including chapters in books from across the world. PILOTS can be accessed directly from our website.

At the moment there are two fantastic initiatives within VA to bring effective treatments to all corners of the VA mental health system. Several treatments appear to help veterans and others to overcome symptoms of PTSD: Exposure Therapy, Cognitive Therapy, Anxiety Management (for example, Stress Inoculation, Stress Management) Treatments, EMDR, combinations of the above treatments and psychopharmacological treatment using serotonin-acting medications. These treatments are identified and described in the most recent edition (in press; Guilford Press) of the International Society for Traumatic Stress Studies (ISTSS) Best Practice Guidelines for PTSD. My colleagues in Boston, Patricia Resick, PhD, and Candice Monson, PhD, are involved in a national VA-based dissemination of Cognitive Processing Therapy, a treatment developed by Patti some 20 years ago. Joe Ruzek, PhD, also from the National Center for PTSD, is engaged in a dissemination project for Exposure Therapy and works closely with Edna Foa, PhD, and her colleagues at the University of Pennsylvania. These projects are the first efforts to bring evidence-based psychotherapy to the clinicians working in VA.

Secondly, Brian Marx, PhD, Paula Schnurr, PhD, Matthew Friedman, MD, PhD, and I are involved in a project that will disseminate evidence-based approaches to the assessment of PTSD nationwide. We've developed a Best Practice Guideline for the assessment of PTSD. Following a recommendation from the Institute of Medicine, the VA will disseminate these best practices nationwide to bring uniformity to the process of evaluating veterans seeking compensation for psychological war injuries.

Dr. Phelps: What widely accessible resources, especially online resources, are helpful for psychologists who want to become better informed about spotting signs and symptoms of PTSD and treating individuals who have returned from recent combat for PTSD?

Dr. Keane: Surely, the National Center for PTSD's Web site is a wonderful resource, but there are others. The APA has resources for evaluating and treating psychological trauma, as does the International Society for Traumatic Stress Studies and the the Anxiety Disorders Association of America. The American Psychiatric Association also has much information on the assessment and treatment of PTSD.

For texts on the topic, following are recent publications from Guilford Press:

Friedman, M.J., Keane, T.M., & Resick, P.A. (2007) Handbook of PTSD: Science and Practice.

Wilson, J. P. & Keane, T.M. (2004) Assessing Trauma and PTSD. (2nd Edition).