Evidence-Based Treatment Approaches for Troops with PTSD
Nearly 20% of the 2.6 million troops deployed to Afghanistan and Iraq report symptoms of posttraumatic stress disorder (PTSD). PTSD is associated with hyperarousal, avoidance, and disturbing or reoccurring flashbacks, all of which affect mental and physical health.
The Department of Defense (DoD) and Veterans Affairs (VA) have recommend four treatment approaches for PTSD: Prolonged Exposure (PE) Therapy, Cognitive Processing Therapy (CPT), Stress Inoculation Therapy (SIT), and Eye-Movement Desensitization and Reprocessing (EMDR) Therapy. While there has been little empirical research indicating that EMDR and SIT are effective for PTSD, there is considerable research supporting the effectiveness of both PE and CPT. As a result, the VA has mandated that PE and CPT be available to all patients with PTSD. PE uses imagined and in vivo exposure to help patients confront trauma-related stimuli and extinguish fear responses. CPT targets trauma-related maladaptive cognitions by exposing patients to their own thoughts as they write about their traumas. According to the current review, four randomized control trials (RCTs) support the efficacy of PE for military-related PTSD and one RCT and one uncontrolled effectiveness study provide initial support for the efficacy of CPT in treating military-related PTSD.
Even though the VA has mandated PE and CPT for veterans and military service men and women with PTSD, it is important for clinicians who work with this population (both within and outside the VA) to educate their clients about evidenced based treatment to promote retention and recovery.
Steenkamp, M. M., & Litz, B. T. (February 01, 2013). Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clinical Psychology Review, 33, 1, 45-53.
(Posted July 22, 2013)
Announcing: Roadmap to Resilience
A message from the author: “In Roadmap to Resilience, I discuss the differences between individuals (some 70% of military and civilian populations) who evidence resilience and the 30% who manifest persistent adjustment difficulties following traumatic events. This practical, user-friendly guide provides “How To” evidence-based ways to bolster resilience in six domains (physical, interpersonal, emotional, cognitive, behavioral and spiritual). I have also included numerous narrative examples, 101 Self-improvement Action Plans, and a comprehensive Resource Guide.” -Don Meichenbaum, Ph.D.
For more information, or to purchase this book, click here.
(Posted November 12, 2012)
Long Term Effects of CBT for PTSD
According to a recent study published in the Journal of Consulting and Clinical Psychology, cognitive-behavior treatments (CBT) may provide long-term improvements for PTSD and related symptoms. CBTs such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) have already been shown to be effective and are considered some of the “first line treatments” for PTSD. However, the important question of CBT’s long term efficacy for PTSD has not been explored as deeply, as follow ups typically occur only three to six months after treatment.
The current study compares the long term outcomes of CPT and PE for PTSD in female rape survivors. The original study measured symptoms of women suffering from PTSD (n=171), before and after receiving either CPT or PE. This long term follow up, from 4.5 to 10 years later (M = 6.15), includes 73.7% of the original sample following initial treatments (n= 126) of CPT (n= 63) or PE (n=63). Researchers used the PTSD Symptom Scale (PSS), the Beck Depression Inventory (BDI), and the Clinician-Administered PTSD Scale (CAPS) to measure PTSD symptoms. Of those allocated to CPT, 46 completed the therapy, 10 received some therapy, and 7 did not start. Of those allocated to PE, 44 completed the therapy, 13 received some therapy, and 6 did not start.
Participants who received both cognitive therapies (CPT and PE) showed significant improvements in PTSD and related symptoms from pre- to post-treatment. There was no marked significance in the difference between the two samples receiving treatment. During the long term follow up, there was an impressive amount of maintenance of these improvements in symptoms. At pre-treatment assessment, 100% of participants had met criteria for PTSD; however, at the long term follow up only 22.2% of participants in the CPT group and 17.5% in the PE group met criteria for PTSD. In addition, there was no further psychotherapy or medication use reported which could have otherwise accounted for the long term efficacy of these treatments.
Female rape survivors in this study benefitted significantly from a lasting improvement in PTSD symptoms. Although further research and replication studies are needed, these findings suggest that CBT may be effective for years following initial treatment.
Resick, Patricia A., Williams, Lauren F., Suvak, Michael K., Monson, Candice M., & Gradus, Jaimie L. (2012). Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80(2) 201-210.
Beck Institute will offer a 3-day workshop on CBT for PTSD on September 10-12, 2012, in Philadelphia. A limited number of spaces remain.
(Posted September 4, 2012)
Healing PTSD: Emotional Processing with Cognitive Behavioral Therapy
Elizabeth A. Hembree, PhD
Department of Psychiatry, Perelman School of Medicine
University of Pennsylvania
Traumatic experiences are quite common, and survivors must in some way emotionally process and integrate these unwanted and painful events. Successful processing yields a realistic perspective in which the traumatic experience is in the past, reducing the person’s sense of current threat. Many trauma survivors accomplish this over time via natural mechanisms of recovery and do not require treatment. When this process is impeded or the natural processing is insufficient, posttraumatic stress disorder (PTSD), depression, and other problems frequently result.
Studies continue to show that PTSD is a common condition, with prevalence in the general US population of about 8%. Prevalence of PTSD in the active military and veteran population is even higher: Among US active duty service men and women returning from current military deployments, PTSD is estimated as high as 14-16% and among US veterans of the wars in Iraq and Afghanistan, estimates range from 4% to 17% (see Hoge et al., 2004; Richardson et al., 2010).
Given the impact of PTSD on individuals and families affected by this condition, dissemination and implementation of effective treatments is a very high priority.
Psychological treatments are aimed at helping the PTSD sufferer to process and integrate traumatic experiences. Cognitive behavioral therapies have extensive and strong empirical support and often result in remission or a decrease in the severity of PTSD, and decreased severity of depression and anxiety. All effective CBT interventions, which commonly include exposure (imaginal and in vivo), cognitive therapy, or skills training (e.g., stress inoculation; affect regulation and interpersonal effectiveness training), help the survivor to become less afraid of or threatened by trauma memories and reminders and of PTSD symptoms themselves, and to feel more competent and better able to cope. Theorists of exposure and cognitive approaches agree that treatment must in some way access or activate trauma memories, thoughts, and feelings, while providing corrective information that serves to modify the person’s unrealistic expectations of harm and danger and to reduce excessive negative emotion.
Prolonged exposure (PE; Foa, Hembree, Rothbaum, 2007) for PTSD has amassed considerable empirical support and is one of the primary treatments being rolled out by the U.S. Department of Veteran’s Affairs and the Department of Defense. While PE is a highly effective treatment, clinicians are sometimes concerned about whether it is an appropriate treatment for individuals with PTSD resulting from certain types of trauma or for those clients whose trauma narratives and current experience are dominated by emotions other than or in addition to fear: guilt, shame, anger, grief, and sadness. This is understandable – exposure-based treatments were designed for amelioration of excessive and/or unrealistic fear, not excessive guilt or anger. Experienced trauma therapists know that fear is but one of the emotional responses to trauma that are important to address in treatment. And most likely all would agree that facing trauma memories and reminders, and dealing with the feelings that result, are of prime importance.
Clinicians are also sometimes concerned that repeated revisiting of some trauma memories, particularly those associated with guilt or shame or anger about what occurred or what one did or did not do during the trauma, will be ineffective or will result in increased negative emotion. Many years of using and studying PE have yielded a rich understanding of emotional processing of traumatic memories via imaginal and in vivo exposure. Imaginal exposure – repeatedly revisiting trauma memories in imagination – and discussing and processing this experience with the therapist is a potent and efficient means of helping the PTSD sufferer to 1) fully access all of the salient information – facts, emotions, thoughts, behaviors, environment – within the trauma memory, 2) contextualize and understand his or her reactions and experience of the trauma and its aftermath, and 3) achieve a realistic perspective on the traumatic event and one’s behavior during it, as well as the impact it has had and will have in the future.
These outcomes are clearly illustrated in the case of a veteran treated with PE whose traumatic experience involved a deadly engagement with the enemy in which several of the men under his command were killed, despite his considerable and courageous efforts to lead this mission successfully and to save lives. The veteran presented for treatment about 5 years after this event with severe PTSD and depression, and he was suffering from extreme guilt and self-blame for the death of his men. In imaginal exposure he revisited the memory of that painful day in which these men under his command were killed and he was shot at while trying to render them aid. He was given a recording of this first imaginal exposure to take home and asked to listen to it daily before the next session, which he did.
During the review of his homework in the following session, the veteran reported that he had listened to the recording of his imaginal exposure frequently, as requested, and that he had done much ‘soul-searching’. He realized that he had done his job as best he could, and that if he had not done his job well, even more people would have died. Moreover, the veteran reported that thinking this over and listening to the session repeatedly had led him to accept that there was probably nothing that he could have done differently, and that he was beginning to feel a lessening of the “guilt and shame and the blame” he held on to for years after the death of his men. The veteran seemed relieved as he told his therapist that even though he had done everything in his power to bring everybody home, it was just not possible, and not up to him. He ended by saying that he was realizing through this process that he needed to try to let this go and to forgive himself.
This case is a good reminder that our powers of recovery are strong, and that when these powers have stalled or been impeded, they can be unleashed or facilitated by good, trauma-focused psychotherapy so that healing can proceed. Prolonged exposure and cognitive therapy, often primed by imaginal revisiting of the trauma memory as suggested by Ehlers and Clark (2000), are powerful and effective procedures that activate these forces and promote a reorganization of the trauma-related information that is more accurate and whole, an acceptance of what has happened, and a reduction of anxiety, guilt, anger, sadness, and other emotions that have dominated the person’s current experience, and result in reduction of PTSD and other trauma-related disorders.
Ehlers, A., & Clark, D.M. (2000). A Cognitive Model of Persistent Posttraumatic Stress Disorder. Behaviour Research and Therapy, 38, 319-345.
Foa, E. B., Hembree, E. A. & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. New York: Oxford University Press.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.
Richardson, L. K., Frueh, B. C., & Acierno, R. (2010). Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry, 44, 4-19.
(Posted July 10, 2012)
Identifying patterns of symptom change during a randomized controlled trial of cognitive processing therapy for military-related posttraumatic stress disorder
A recent study published in the Journal of Traumatic Stress demonstrated that cognitive processing therapy (CPT), a form of cognitive behavioral therapy (CBT), may quickly reduce symptoms of posttraumatic stress disorder (PTSD) and maintain improvements among veterans. Previous research on psychotherapeutic change indicates that, when treated, symptoms of PTSD tend to decline rapidly, initially, followed by a slower decline and plateau. The same was reported in the current study.
Participants included 60 male and female veterans referred by a Veterans Administration (VA) Medical Center who were assigned to either a CPT group who received CPT immediately or were assigned to a wait-list (WL) group who received treatment following a 10-week wait. Participants received 12-sessions of manualized CPT, twice weekly when possible, from doctoral level clinicians with experience treating PTSD. Self-report measures were administered at baseline, mid-treatment, at the end of treatment, and one month following treatment.
The results showed an overall and maintained decrease in PTSD symptoms among participants in the CPT group who received treatment immediately compared to those who did not (WL group). This suggests that CPT can produce quick, lasting results for PTSD within the military population. These results are consistent with the bulk of previous research which has found PTSD symptoms to decrease rapidly, at first, before plateauing, though there have been some studies which found PTSD symptoms to first plateau before declining (see Nishith et al., 2002). Recommendations for future research include replication studies with other PTSD populations (e.g., sexual assault victims) to determine if these results can be generalized across treatment groups.
Macdonald, A. Mason, C.M. Doron-Lamarca,S. Resick, P. A. Pailfai, T.P. (2011). Identifying patterns of symptom change during a randomized controlled trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Traumatic Stress. 24(3), 268-276 doi: 10.1002/jts.20642
(Posted November 21, 2011)
Therapist adherence to manualized cognitive-behavioral therapy for anger management delivered to veterans with PTSD via videoconferencing
It is important that veterans with Posttraumatic Stress Disorder (PTSD) have access to evidence-based treatment (EBT). A significant number (40%) of military service members leaving active duty return to rural or remote areas where access to EBT and specialized PTSD treatment is often limited or unavailable. To overcome this obstacle, the use of video conferencing is becoming a more widespread and acceptable method of providing therapy to those living in areas with limited access to EBT.
While research indicates that cognitive behavior therapy (CBT) is an effective treatment for PTSD, there are few studies that examine outcomes of group CBT with veterans. In the current study, Morland et al. compared therapist adherence to manualized cognitive-behavioral anger management group treatment (AMT) between therapy delivered via video conference (VC) and the traditional in-person modality. The researchers also compared the equivalency of cognitive-behavioral anger management group therapy delivered via VC and the same therapy delivered in-person.
The results of this study indicate that utilizing video conferencing did not affect therapists’ adherence to CBT anger management group therapy. This study provides support for the utility of video conferencing as a method for delivering effective therapy to veterans. It also identifies video-conferencing as a potential gateway to evidence-based CBT for veterans and service members returning to remote areas following deployment. These findings encourage future research on the effectiveness of video conferencing among different populations and EBTs.
Morland, L.A., Greene, C.J., Grubbs, K., Kloezeman, K., Mackintosh, M., Rosen, C., et al. (2011). Therapist Adherence to Manualized Cognitive-Behavioral Therapy for Anger Management Delivered to Veterans with PTSD via Videoconferencing. Journal of Clinical Psychology, 67, 629-638.
(Posted October 13, 2011)
Beck Spotlight on Antonette Zeiss
At a 90th birthday party for Dr. Aaron Beck, given by Pearson Assessment at the American Psychological Association annual conference in Washington, D.C., we had the opportunity to catch up with our colleague, Dr. Antonette Zeiss, Ph.D., whom we have known for many years. We are so pleased that she, a very prominent cognitive behavior therapist, has been appointed to be Chief Consultant for the Office of Mental Health Services, in the Veterans Health Administration at the Department of Veterans Affairs (VA). Dr. Zeiss was already the highest ranking psychologist in the VA, and is now the first psychologist, and first woman, to hold the role of Chief Consultant.
In 2007, Dr. Zeiss received an American Psychological Association (APA) Presidential Citation recognizing her leadership contributions both in APA and the VA. And last year, Dr. Zeiss won a Distinguished Career Award from the Association of VA Psychologist Leaders for her continued efforts to improve mental health services.
We applaud Dr. Zeiss’s accomplishments in the field of psychology and cognitive behavior therapy, and we appreciate the efforts of the tens of thousands of health and mental health professionals who treat active duty and veteran military service members and their families. To learn more about a scholarship initiative to help train these professionals in cognitive behavior therapy please visit our CBT Scholarships page.
(Posted October 6, 2011)
An Intervention to Increase Mental Health Treatment Engagement among OIF Veterans: A Pilot Trial
In a recent study, researchers evaluated an intervention designed to modify personal or attitudinal barriers to mental health treatment-seeking among returning veterans. Previous research has documented that a stigma associated with mental health problems interferes with an individual’s decision to seek treatment. Only one-fourth of military service members who acknowledge mental health problems actually seek treatment.
Personal factors, such as the preference to solve problems on one’s own, the belief that problems will just go away on their own, and the view that treatment is ineffective, are some of the barriers that impede the decision to seek mental health treatment. Among the female veteran population, the process of initiating care at the Veteran’s Administration, as well as the lack of women-specific services have been identified as the most prominent barriers.
The authors of the current study developed an intervention based on cognitive behavior therapy (CBT) which has been widely demonstrated as an effective method of treating a variety of disorders, including anxiety and depression. The intervention in this study targeted a change in beliefs that would influence a participant’s willingness to engage in mental health treatment. It included a 45-60 minute session in which participants were informed that CBT is based on the theory that thoughts, feelings, and behaviors interact with each other. Participants were trained on constructive versus destructive thinking and informed about types of thinking styles that often predict behavior.
This intervention, a structured and brief session, focused primarily on individual beliefs about mental health treatment. Results indicated that the intention to enter treatment significantly increased three months post-intervention. This suggests that, given the high rates of mental health symptoms among newly returning veterans and the low likelihood of treatment-seeking among this population, interventions designed to increase treatment-seeking behavior are paramount and may be effective.
Stecker, T., Fortney, J.C., Sherbourne, C.D. (2011). An Intervention to Increase Mental Health Treatment Engagement Among OIF Veterans: A Pilot Trial. Military Medicine, 176, 613-619.
(Posted September 29, 2011)
Cognitive Behavioral Therapy for PTSD in Women
A recent study assessed PTSD treatment for female active-duty and veteran military. Events such as the attacks on September 11, 2001, and the ongoing war in Iraq have increased attention on posttraumatic stress disorder (PTSD). Lifetime prevalence of PTSD among women who have served in the military is especially high.
Although there have been many studies conducted on PTSD treatment in veterans, many of them focus on men. In general, cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are recommended as the primary treatments for PTSD. Previous studies have indicated that CBT is particularly effective. This study utilized prolonged exposure, a form of CBT that encourages patients to re-experience traumatic events repeatedly in an attempt to decrease their emotional response and to gradually confront safe but fear-evoking traumatic reminders. Prolonged exposure is used to improve emotional and cognitive processing of traumatic events by helping patients “face their fears.” The Department of Veterans Affairs (VA) typically uses a present-centered approach. Present-centered therapy focuses on existing life problems as manifestations of PTSD. Schnurr et al. compared the efficacy of prolonged exposure therapy to that of present-centered therapy in active-duty and veteran women with PTSD.
The results of this study demonstrated that the women who experienced prolonged-exposure therapy were more likely to achieve total remission. In both groups, self- reported PTSD, depression, and overall mental health improved. With prolonged exposure therapy, participants indicated a decrease in anxiety and enhanced quality of life. Prolonged exposure was found to be more effective than present-centered therapy at posttreatment as well as 3 months following treatment.
While present-centered therapy addresses the problems that have manifested as a result of PTSD, prolonged exposure requires patients to confront and emotionally process the root causes of their PTSD. The results of this randomized controlled trial suggest that while both therapies are beneficial, prolonged exposure therapy provides more effective and longer-lasting treatment.
Schnurr, P.P, Friedman, M.J., Engel, C.C., Foa, E.B., Shea, T.M., Chow, B.K., et al. (2007). Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women: A Randomized Controlled Trial. Journal of the American Medical Association, 297, 820-830.
(Posted September 11, 2011)
Managing Stress in Military Personnel with a Web-Enhanced Behavioral Self-Management Program
A large number of active duty military personnel spend every day stressed over deployment, war experiences, or anticipation of conflict.Such stress can lead to medical and mental health problems. Providing all of these service members with therapy would be too costly and difficult to arrange due to soldiers’ schedules and the distances they travel.A potential solution, the “Stress Gym,” is currently being developed and studied. The Stress Gym is an online program designed to provide people with CBT interventions.The program is tailored to the individual; it can be used by a large number of people; it is flexible to their schedules; and it is relatively low cost.
The present study looks at the feasibility of using the Stress Gym in military settings and how well the program is received by military personnel.Researchers invited all active duty members of the Naval Medical Center in Portsmouth, Virginia, to participate in the study using the Stress Gym.142 individuals joined the study and fully completed it.An initial screen suggested which of the nine stress modules were most relevant to them.In the end, participants were asked to complete a feasibility questionnaire and an open-ended qualitative evaluation.In addition, the participants filled out a Numeric Rating Scale of Stress (NRS) before and after the stress gym, giving researchers an idea of the participants’ perceived stress levels.
Results showed a generally positive reception of the Stress Gym among personnel.There was a significant decline in stress after use of the program and the more modules that were completed, the greater the decrease in stress scores.The results also showed that the effects were the same regardless of rank, gender, or status of deployment.The study suggests that the use of the Stress Gym can be highly beneficial in military settings at reducing stress and the risk of depression, and improving coping strategies in active personnel.
William, A., Hagerty, B. M., Brasington, S. J., Clem, J. B., & Williams, D. A. (2010).Stress gym: Feasibility of deploying a web-enhanced behavioral self-management program for stress in a military setting.Military Medicine, 175(7), 487-493.
(Posted June 8, 2011)
CBT for Soldiers: Workshop Announcement
Dr. Judith Beck will present a Cognitive Behavior Therapy workshop at the Combat Stress Intervention Program’s 2nd Annual Conference at Washington & Jefferson College on Friday, March 26, 2010. The theme of this year’s conference is Combat Stress: Working Effectively with Military Clients.
If you’re a mental health professional working with soldiers, vets, or their families, you might be eligible to receive a partial scholarship program for participation in our Cognitive Therapy Workshops at Beck Institute. For more information, visit our training page.
(Posted February 24, 2010)
Veterans with TBI and Suicidality
Previous research has shown that, in recent years, there has been an increased rate of suicide in soldiers returning from war. In addition, as many as 15-23% of returning soldiers have incurred traumatic brain injuries (TBI). A new study published in Rehabilitation Psychology aimed to identify risk and protective factors for suicide ideation or suicidal behavior among veterans who have experienced TBI.
Thirteen suicidal veterans in a TBI clinic completed 30 to 60 minute interviews that included structured questionnaires regarding suicidality, methods of coping/seeking support, and military service. Researchers identified a post-injury loss of sense of self, cognitive deficits secondary to TBI, and psychiatric and emotional difficulties as precipitating factors for suicide ideation or suicidal behavior. Social support, a sense of purpose and hopefulness, religion or spirituality, and mental health treatment were identified as protective factors.
This study helps to identify those precipitating factors that practitioners should target when working with a similar population. The authors note that concepts associated with perceived burdensomeness and thwarted belonging can be targeted using cognitive and behavioral strategies along with techniques that encourage the client to re-conceptualize his or her worth and meaning to others.
Brenner, L. A., Homaifar, B. Y., Adler, L. E., Wolfman, J. H., & Kemp, J. (2009). Suicidality and veterans with a history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies. Rehabilitation Psychology, 54, 390-397.
(Posted February 23, 2010)
Lecture at U explores role of hope in preventing suicide
On October 7th, David Rudd, a clinical suicidology expert and co-author of The Interpersonal Theory of Suicide delivered a lecture at the University of Utah addressing the role of hope in suicide prevention. Rudd’s talk focused on new technology that has allowed doctors to pinpoint specific regions of the brain that respond to cognitive therapy geared toward generating hope, as well as what we know about hope that builds resiliency and saves lives.
(Posted October 22, 2009)
New York Times reports: After Combat, Victims of an Inner War
The rising toll of suicides in the military has hit a National Guard unit particularly hard: four soldiers, out of roughly 175 members, have committed suicide.
(Posted August 3, 2009)
Repeat suicide attempts reduced by CBT
A randomized control study in the Journal of the American Medical Association found cognitive behavioral therapy (CBT) to be effective in reducing the number of repeat suicide attempts in adults.
Past research had focused on intensive follow-up treatment or intensive case management, interpersonal psychotherapy, or cognitive behavioral therapy for the preventative treatment of suicide attempts, but empirical evidence for the efficacy of these therapies has been limited. The current study aimed to examine the efficacy of cognitive behavioral therapy as a preventative therapy for suicide, by performing a randomized control study adequate in power to detect treatment differences.
Participants consisted of patients who had attempted suicide and received a medical or psychological evaluation within 48 hours of the attempt. Participants were randomly assigned to follow-up care of either CBT or usual care (UC). Those placed in the CBT group received outpatient CBT sessions that were specifically designed for preventing future suicide attempts. The CBT aimed to address and identify the thoughts, images, and core beliefs that activated the previous suicide attempt, and to teach cognitive and behavioral strategies as better ways of coping with these thoughts and stressors.
The authors found that participants in the CBT group were 50% less likely to reattempt suicide than the participants in the UC group. In addition, the CBT group measured significantly lower for depression as well as hopelessness than the UC group. The authors concluded that “the short-term feature of cognitive therapy would make it particularly applicable for the treatment of suicide attempters at community mental health centers, which typically provide relatively short-term therapy.”
Reference: Brown, G. K, Have, T. T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294, 563-570
Journal of the American Medical Association article
National Institute of Mental Health report
Cognitive Therapy Is Helping Veterans
Guest Blogger: John Milwee, Psy.D., Veterans Administration therapist and Beck Institute alumnus
Veterans returning from the conflicts in Afghanistan and Iraq may face many challenges as they begin to reintegrate into their roles as parents, employees, friends, and neighbors. In recent months a great deal of media attention has been focused on those returning Veterans who suffer with symptoms of Post-Traumatic Stress Disorder (PTSD) associated with their combat experience. Alarming statistics are frequently reported that describe the number of these Veterans who, when untreated, commit suicide.
Heightened awareness within the civilian population of PTSD has served as an important catalyst for changing public perceptions of our Veterans’ experience while in theater and, within the VA, for development of new outreach programs to help them once they are back home. The application of empirically-based cognitive behavioral therapies to a growing number of disorders, PTSD among them, is one of the most important and effective tools for addressing our Veterans’ needs and, in some cases, saving lives.
The violence and chaos of war sometimes (but not always) leave some of our Veterans with a second battle to fight once they have gotten back home. As a clinical psychologist in a VA hospital for the past three and a half years, I have learned that the challenges of reintegrating into civilian life do not stop with those Veterans who have been in combat. Simply joining the military requires sacrifices that most of us in the civilian population will never be required to make. Long absences from family and friends, unexpected changes in station and living situation, an unwavering commitment to duty and service, and an obligation to follow the orders of an unquestioned chain of command set the average soldier’s experience apart from most civilian lifestyles.
Cognitive Therapy (CT) has been a very useful means of helping Veterans learn to function effectively in civilian life after they have left the service. The term “military training” refers to much more than education about combat tactics, equipment maintenance and drills. Joining the military requires that the individual learn how to live within a culture that is distinct from that of their previous experience. The structure, rules, and expectations that the military provides our service men and women shape them psychologically in profound ways. This is precisely the kind of learning that contributes to the development of the conditional assumptions and beliefs and the behavioral compensatory strategies that frequently constitute the therapeutic targets of CT.
Cognitive restructuring of dysfunctional, sometimes negative thinking, behavioral activation, and a spirit of collaborative empiricism are excellent helpmeets for veterans who are learning to live in a less structured social environment where success is not always rewarded, failure not always punished, and expectations are not always clear. I have found that Veterans are quite comfortable with the structure of a good Cognitive Therapy session, setting clear goals for treatment and criteria for success, and the collaborative development and testing of hypotheses.
As our Veterans return from the current conflicts and others leave the service because they have fulfilled the obligations of their commitment, it is our duty to ensure that they receive the very best care our medical and psychiatric systems can provide. At the VA, new initiatives in training and service are being rolled out regularly. As the number of new providers being trained in CT increases we can be more confident that our Veterans will be given state-of-the-art treatment that is empirically derived and validated and which truly addresses their most urgent needs and concerns.