Rehabilitation of Combat-Related Injuries in the Veterans Administration: A Web of Support.

The Department of Veterans Affairs provides acute, subacute, and continuing rehabilitation for veterans using a hub-and-spoke system of hospitals and outpatient facilities. Using traumatic brain injury as an example, this commentary illustrates how this system provides interdisciplinary rehabilitative care to veterans throughout North Carolina.

[Rehabilitation and reintegration of soldiers injured on deployment]. / Réadaptation et réinsertion des militaires blessés en operation.

The participation of the French army in the Afghan conflict has highlighted the need for discussion and action regarding the pathway, rehabilitation and reintegration of soldiers who have been physically or psychologically injured. Clinical experience demonstrates that difficulties are less likely to appear during the initial treatment phase than later on, when there is less group support and there are fewer visible effects of the recognition on the part of the institution. It is important to strengthen the links between healthcare personnel and institutional players, in order to optimise the medical and social care of these war casualties.

[The "Écoute Défense" helpline, a new care tool within the military health service]. / La ligne Écoute Défense, un nouveau dispositif de soin du Service de santé des armées.

The "Écoute Défense" helpline was launched on 23rd January 2013. This freephone number, available 24/7, is aimed at soldiers, former soldiers and their families. The main objective of the service is to listen, provide information and guide those suffering from psychological traumas which have arisen during service. Carried out by clinical psychologists from the military health service, the mission raises discussion around the challenges of this new channel for accessing care for soldiers.

Mindful attention increases and mediates psychological outcomes following mantram repetition practice in veterans with posttraumatic stress disorder.

BACKGROUND: Several evidence-based treatments are available to veterans diagnosed with posttraumatic stress disorder (PTSD). However, not all veterans benefit from these treatments or prefer to engage in them. OBJECTIVES: The current study explored whether (1) a mantram repetition program (MRP) increased mindful attention among veterans with PTSD, (2) mindful attention mediated reduced PTSD symptom severity and enhanced psychological well-being, and (3) improvement in mindful attention was due to the frequency of mantram repetition practice. RESEARCH DESIGN: Data from a randomized controlled trial comparing MRP plus treatment as usual (MRP+TAU) or TAU were analyzed using hierarchical linear models. SUBJECTS: A total of 146 veterans with PTSD from military-related trauma were recruited from a Veterans Affairs outpatient PTSD clinic (71 MRP+TAU; 75 TAU). MEASURES: The Clinician Administered PTSD Scale (CAPS), PTSD Checklist (PCL), the Brief Symptom Inventory-18 depression subscale, Health Survey SF-12v2, and Mindfulness Attention Awareness Scale (MAAS) were used. Frequency of mantram repetition practice was measured using wrist-worn counters and daily logs. RESULTS: Intent-to-treat analyses indicated greater increases in mindful attention, as measured by the MAAS, for MRP+TAU as compared with TAU participants (P<0.01). Mindful attention gains mediated previously reported treatment effects on reduced PTSD symptoms (using both CAPS and PCL), reduced depression, and improved psychological well-being. Frequency of mantram repetition practice in turn mediated increased mindful attention. CONCLUSIONS: The MRP intervention and specifically, mantram practice, improved mindful attention in veterans with PTSD, yielding improved overall psychological well-being. MRP may be a beneficial adjunct to usual care in veterans with PTSD.

Loving-kindness meditation and the broaden-and-build theory of positive emotions among veterans with posttraumatic stress disorder.

BACKGROUND: Loving-kindness meditation (LKM) is a practice intended to enhance feelings of kindness and compassion for self and others. OBJECTIVES: To assess whether participation in a 12-week course of LKM for veterans with posttraumatic stress disorder (PTSD) is associated with improved positive emotions, decentering, and personal resources. RESEARCH DESIGN: In an open-pilot trial, veterans were assessed at baseline, after the course, and 3 months later. Effect sizes were calculated from baseline to each follow-up point for each construct of interest. Measures were chosen as an initial investigation of the broaden-and-build theory of positive emotions. SUBJECTS: A total of 42 veterans with active PTSD (40% female) participated. MEASURES: Emotions, decentering, psychological wellbeing including autonomy, environmental mastery, personal growth, positive relations, purpose in life, self-acceptance, and sense of social support were measured at each time point. RESULTS: Significant increases in unactivated pleasant (d=0.73), but not activated pleasant, emotions were found over time. Activated and unactivated unpleasant emotions decreased over time (d=-0.69 and -0.53, respectively). There were also increases in environmental mastery (d=0.61), personal growth (d=0.54), purpose in life (d=0.71), self-acceptance (d=0.68), and decentering (d=0.96) at 3-month follow-up. CONCLUSIONS: Overall, positive emotions increased, and enhancement of personal resources occurred over time. Further investigation of LKM for PTSD is warranted.

Reductions in cortisol associated with primary care brief mindfulness program for veterans with PTSD.

BACKGROUND: Patients with posttraumatic stress disorder (PTSD) have significant medical morbidity, which may be mediated by hypothalamic pituitary axis (HPA) dysfunction and reflected in cortisol output. Many veterans with PTSD are hesitant to engage in trauma-focused exposure treatments; therefore briefer, non-exposure-based treatments are needed; one such promising approach is an abbreviated Primary Care brief Mindfulness Program (PCbMP). OBJECTIVE: This study investigated the relationship between dose-response to participation in a veterans PCbMP program and diurnal cortisol. Cortisol reflects HPA function and PTSD is associated with HPA dysregulation. RESEARCH DESIGN: Veterans with PTSD were identified in PC and randomly assigned to treatment as usual (TAU, n=21) or participation in brief 4-week Mindfulness Based Stress Reduction program (n=19). SUBJECTS: Veterans (n=40) (mean age, 48±16 y; 90% men) with PTSD referred through their VA PC provider and randomly assigned to PCbMP or TAU. MEASURE: As an objective indicator of HPA function, salivary diurnal cortisol was measured from samples collected across 2 consecutive days at baseline and follow-up. RESULTS: Analyses revealed that significant changes in cortisol were associated with PCbMP treatment engagement and dosing (number of mindfulness program sessions completed). Veterans completing 4 mindfulness-based meditation sessions significantly reduced their cortisol awakening response (P≤0.05); and had significant changes in cortisol area under the curve increase compared with TAU participants (P≤0.05). Results indicate that PCbMP has a beneficial physiological impact on veterans with PTSD with a minimum of 4 weeks of practice.

Screening for postdeployment conditions: development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory.

OBJECTIVE: To develop and cross-validate internal validity scales for the Neurobehavioral Symptom Inventory (NSI). PARTICIPANTS: Four existing data sets were used: (1) outpatient clinical traumatic brain injury (TBI)/neurorehabilitation database from a military site (n = 403), (2) National Department of Veterans Affairs TBI evaluation database (n = 48 175), (3) Florida National Guard nonclinical TBI survey database (n = 3098), and (4) a cross-validation outpatient clinical TBI/neurorehabilitation database combined across 2 military medical centers (n = 206). RESEARCH DESIGN: Secondary analysis of existing cohort data to develop (study 1) and cross-validate (study 2) internal validity scales for the NSI. MAIN MEASURES: The NSI, Mild Brain Injury Atypical Symptoms, and Personality Assessment Inventory scores. RESULTS: Study 1: Three NSI validity scales were developed, composed of 5 unusual items (Negative Impression Management [NIM5]), 6 low-frequency items (LOW6), and the combination of 10 nonoverlapping items (Validity-10). Cut scores maximizing sensitivity and specificity on these measures were determined, using a Mild Brain Injury Atypical Symptoms score of 8 or more as the criterion for invalidity. Study 2: The same validity scale cut scores again resulted in the highest classification accuracy and optimal balance between sensitivity and specificity in the cross-validation sample, using a Personality Assessment Inventory Negative Impression Management scale with a T score of 75 or higher as the criterion for invalidity. CONCLUSIONS: The NSI is widely used in the Department of Defense and Veterans Affairs as a symptom-severity assessment following TBI, but is subject to symptom overreporting or exaggeration. This study developed embedded NSI validity scales to facilitate the detection of invalid response styles. The NSI Validity-10 scale appears to hold considerable promise for validity assessment when the NSI is used as a population-screening tool.

Narrative transformation among military personnel on an adventurous training and sport course.

In the wake of recent wars, some military personnel face considerable physical and mental health problems. In this article I explore the effects of an adapted sport and inclusive adventurous training course for military personnel who have experienced physical injury and/or psychological trauma. Using a dialogical narrative approach, I analyzed stories shared by six soldiers during the course to explore the effects of involvement. Participation in the course seemed to facilitate a narrative transformation or opening corresponding to a broadening identity and sense of self. Story plots progressed from a failing monological narrative, through a chaos narrative, toward a dialogical quest narrative prioritizing immersion in an intense present, a developing self, and a relational orientation. On the basis of narrative theory, I suggest this transformation holds positive consequences for the health and well-being of military personnel who have experienced injury and/or trauma.

Nonprofit Charity Impacts Wounded Combat Veterans And Children Facing Adversity.

Mental and physical health challenges, especially for returning war veterans and their families, is a growing national concern. A grassroots program featuring equine therapy for these patients and their families shows promise in increasing self-esteem and self-confidence, reducing isolation and depression, and improving speaking and writing skills.

Post-traumatic stress symptoms among former child soldiers in Sierra Leone: follow-up study.

BACKGROUND: Former child soldiers are at risk of developing post-traumatic stress disorder (PTSD); however, the trajectory of symptoms has yet to be examined. AIMS: The risk and protective factors associated with PTSD symptom change among former child soldiers in Sierra Leone were investigated. METHOD: Data from 243 former child soldiers (mean age 16.6 years, 30% female) were analysed. RESULTS: Self-reported rates of possible PTSD using standard cut-off points declined from 32% to 16% 4 years later (P<0.05). Symptoms of PTSD at baseline were significantly associated with war experiences (P<0.01) and post-conflict family abuse (P<0.001). Reliable improvement in symptoms was reported by 30%. In growth models examining symptom change, worsening of symptoms was associated with death of a parent (P<0.05) and post-conflict stigma (P<0.001). Protective effects were observed for increases in family acceptance (P<0.001). CONCLUSIONS: The findings indicated improvement in PTSD symptoms among former child soldiers despite limited access to care. Family and community support played a vital part in promoting psychological adjustment.

Readiness for change predicts VA Mental Healthcare utilization among Iraq and Afghanistan war veterans.

Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment-seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care.

Alcohol and drug abuse among U.S. veterans: comparing associations with intimate partner substance abuse and veteran psychopathology.

This study examined the relative influences of posttraumatic stress disorder (PTSD), other psychopathology, and intimate partner alcohol and drug use on substance-related problems in U.S. veterans (242 couples, N = 484). Hierarchical regression analyses revealed that partner alcohol and drug use severity explained more variance in veteran alcohol use and drug use (20% and 13%, respectively) than did veteran PTSD, adult antisocial behavior, or depression symptoms combined (6% for veteran alcohol use; 7% for veteran drug use). Findings shed new light on the influence of relationship factors on veteran alcohol and drug use and underscore the importance of couples-oriented approaches to treating veterans with comorbid PTSD and substance abuse.

With Doug: an Eastern Orthodox--Gestalt framework for pastoral psychotherapy in the armed forces.

In military behavioral healthcare, a short-term, solutions-focused system often privileges cognitive techniques over existential, affective, or psychodynamic approaches to care. Pastoral psychotherapy, which often privileges existential and person-centered care, has the potential to prove a pivotal complement in treating the whole person. This article offers an existential approach to pastoral psychotherapy in the military using integrated concepts and applications from Gestalt Therapy and Eastern Orthodox pastoral care.

A scoping study of one-to-one peer mentorship interventions and recommendations for application with Veterans with postdeployment syndrome.

BACKGROUND: We employ the term postdeployment syndrome (PDS) to characterize the combinations of physical, psychological, and social difficulties frequently encountered by Veterans returning from combat. OBJECTIVES: To conduct a scoping review to identify and describe one-to-one peer mentorship (PM) interventions, identify elements associated with positive outcome and of relevance to Veterans with PDS, and summarize current practice in a way that informs the development of such interventions for this population. METHODS: Scoping review methodology was used to identify and summarize key practices and concepts in the one-to-one PM literature between 1980 and 2012. Of 196 articles initially identified, 33 were retained for further examination. Eighteen met full-study criteria and were retained in the analyses. Three reviewers reached consensus on articles to include, and 2 coders independently extracted information from each article. RESULTS: A range of populations was targeted in the interventions. Most identified the provision of support as the primary goal, although some also included other educational and behavioral goals. Most employed selection and training strategies for their mentors and offered ongoing supervision and consultation. Most studies indicated that participants found PM to be beneficial. CONCLUSIONS: This review supports the application in this population and proposes next steps for the development and systematic evaluation of PM interventions.

Assessment of co-occurring disorders in veterans diagnosed with traumatic brain injury.

AIMS: The co-occurrence of psychiatric disorders and other somatic disorders poses a significant challenge for the individual clinician working with veterans who report a history of mild traumatic brain injury (mTBI). In this article, common co-occurring symptoms and disorders will be described in relation to the population of veterans with mTBI, using a retrospective analysis of data from initial screening and secondary level evaluation for traumatic brain injury (TBI) in an urban Veteran's Affairs Medical Center. PARTICIPANTS: Four hundred two veterans of the recent conflicts who received secondary level evaluation for TBI following positive TBI screening. OUTCOMES: Significant differences were detected in symptom reporting between those who screened positive and those who screened negative on psychiatric screening. Those with positive posttraumatic stress disorder and depression screens endorsed more cognitive and affective symptoms; individuals screening positive for alcohol abuse did not report significantly more symptoms. Individuals without positive psychiatric screens reported fewer symptoms than those with positive screens. Consideration of these data in the context of a clinical case will be used to elucidate the challenge this presents to the clinical team. CONCLUSION: The presence of co-occurring disorders should be considered in the etiology of a veteran's continued symptomatic complaints following TBI.

Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic.

Exposure therapy is an evidence-based treatment for posttraumatic stress disorder (PTSD), but research evaluating its effectiveness with active duty service members is limited. This report examines the effectiveness of virtual reality exposure therapy (VRE) for active duty soldiers (N = 24) seeking treatment following a deployment to Iraq or Afghanistan. Relative to their pretreatment self-reported symptoms on the PTSD Checklist, Military Version (M = 60.92; SD = 11.03), patients reported a significant reduction at posttreatment (M = 47.08; SD = 12.70; p < .001). Sixty-two percent of patients (n = 15) reported a reliable change of 11 points or more. This study supports the effectiveness of exposure therapy for active duty soldiers and extends previous research on VRE to this population.

Insomnia as predictor versus outcome of PTSD and depression among Iraq combat veterans.

OBJECTIVES: The study conducted a longitudinal assessment of insomnia as an antecedent versus consequence of posttraumatic stress disorder (PTSD) and depression symptoms among combat veterans. DESIGN: Two postdeployment time points were used in combination with structural equation modeling to examine the relative strength of two possible directions of prediction: insomnia as a predictor of psychological symptoms, and psychological symptoms as a predictor of insomnia. Participants were active duty soldiers (N = 659) in a brigade combat team who were assessed 4 months after their return from a 12-month deployment to Iraq, and then again eight months later. RESULTS: Although both insomnia and psychological symptoms were associated at both time periods and across time periods, insomnia at 4 months postdeployment was a significant predictor of change in depression and PTSD symptoms at 12 months postdeployment, whereas depression and PTSD symptoms at 4 months postdeployment were not significant predictors of change in insomnia at 12 months postdeployment. CONCLUSIONS: Results support the role of insomnia in the development of additional psychological problems and highlight the clinical implications for combat veterans, to include the importance of longitudinal assessment and monitoring of sleep disturbances, and the need for early intervention.

Posttraumatic growth in combat veterans.

Combat veterans and their families face significant challenges not only to their abilities to cope, but often to their fundamental belief systems. Traumatic events represent assaults on core beliefs, yet at times, produce cognitive processing that can ultimately result in personal transformations called posttraumatic growth (PTG). Clinicians can utilize a systematic therapeutic approach to facilitate PTG as they carry out a relationship of expert companionship. PTG in service members is described in this article, as well as the approach to facilitation of PTG.

Assessment and treatment of combat-related PTSD in returning war veterans.

Over the past 9 years approximately 2 million U.S. military personnel have deployed in support of Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in and around Afghanistan. It has been estimated that 5-17% of service members returning from these deployments are at significant risk for combat-related posttraumatic stress disorder (PTSD). Many of these returning war veterans will seek medical and mental health care in academic health centers. This paper reviews the unique stressors that are related to the development of combat-related PTSD. It also reviews evidence-based approaches to the assessment and treatment of PTSD, research needed to evaluate treatments for combat-related PTSD, and opportunities and challenges for clinical psychologists working in academic health centers.