Combat-Related Trauma Assessment and Treatment

Military personnel and their families are exposed to diverse stressors that challenge their psychological wellbeing.  These stressors include frequent relocations, deployments, separations from their families for extended periods of time, and subsequent reintegration, as well as physical and psychological traumas experienced in combat.  The common mental health issues associated with military trauma include posttraumatic stress disorder, suicide, depression, grief, substance use disorder, and intimate partner violence or child abuse.  Identifying the major tasks that military families face during reintegration of a returning service member allows the therapist a broader comprehension of its implications for all members of the family.  Therefore, the therapist can determine effective interventions to enable the family to navigate each task successfully and to become resilient when facing adversities.

Suicide assessment

Center for Deployment Psychology (n.d.) assert that suicide is the second leading cause of death in the U.S. military with suicide rate of 20.2 per 100,000 for the Active component, 24.7 per 100,000 for the Selected Reserves component, and 27.1 per 100,000 for the National Guard.  Veterans account for approximately 22% of the deaths from suicide in the United States, demonstrating higher rates than the general population (Department of Veterans Affairs Department of Defense, 2013 p. 2).  Various studies indicate that suicide rate in the US military rose drastically since the beginning of the Iraq and Afghanistan conflicts (Center for Deployment Psychology, n.d.; Nock, et al., 2013 p. 2; Schoenbaum, et al., 2014 p. 494).

Combination of complex factors including psychological, social, neurobiological, and demographic factors, are associated with increased risk of suicide.  In addition, military personnel face further stressors, including both combat and peacetime challenges, that can increase their risk for suicide.  Without treatment or proper support, stressors can become overwhelming making military personnel more vulnerable to substance use disorders and mood disorders.  Both disorders are associated with military suicide (Realwarriors.net, n.d.).  Early identification of suicidal ideation increases the opportunity to reduce the risk of suicide attempt and death.  Recognition of warning signs leads to early assessment and intervention.  According to VA/DOD (2013 pp. 10, 22), three direct warning signs indicative of suicide risk are: “communicating suicidal thought verbally or in writing; seeking access to lethal means such as firearms or medications; and demonstrating preparatory behaviors such as putting affairs in order.”  Further assessment is needed with the presence of one or more of these warning signs.

SAMHSA (n.d.) and Zero Suicide (n.d.) provide procedures and screening tools such as Patient Health Questionnaire (PHQ), Columbia-Suicide Severity Rating Scale (C-SSRS), and SAFE-T (Suicide Assessment Five-Step Evaluation and Triage), which allow mental health professional to identify at-risk individuals early and appropriately provide early care.  Intervention recommended for suicide risk include suicide-focused psychotherapy, psychotherapy for co-occurring psychological disorders, and pharmacotherapy (this would have to be referred to psychiatrist); and follow-up and monitoring of the patient at risk for suicide, including adherence to treatment and follow-up care strategies and continuity of care (Meisnere & Warner, 2014 p. 69)

Trauma screening

Various studies have shown a link between combat and combat-related trauma service members’ increased risk for PTSD, depression, substance use problems, and violent behavior (Brockman, et al., 2016 p. 2).  Ruglass & Kendall-Tackett (2014 p. 4) define a traumatic event as an occurrence that causes an individual physical, emotional, or psychological distress.  The experience may feel threatening, disturbing or frightening to the individual.  These feelings can overwhelm a person’s capacity to cope and leave him/her with feelings of helplessness.  Traumatic events can lead to PTSD, depression, substance abuse, sleep problems, and potentially chronic health problems, such as heart disease, diabetes, and cancer.  DSM-5 (APA, 2013 p. 271) describes a traumatic event as exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence.  This may be direct exposure to traumatic event; witnessing, in person, the event as it occurred to others; learning that a family member or a close friend was exposed to a trauma; or repeated experience and indirect exposure to aversive details of traumatic events.  Ruglass (2014 p. 14) explains combat trauma as “direct or indirect exposures to extremely stressful events in a war zone including situations such as experiencing serious injuries, witnessing the serious injury or death of a friend, exposure to hostile enemy or friendly fire, and exposure to rocket attacks, bombs, and the grotesque (e.g., seeing and smelling decomposing dead bodies).”

Not all military personnel develop PTSD, however, factors prior, during, and after deployment such as history of childhood trauma, intensity and duration of combat exposure, and military, family, social, and political support on return home contribute to the extent and severity of psychological distress of those that do (Ruglass, 2014 p. 14).  Moreover, studies have confirmed an association between Complicated Grief (CG) and greater PTSD severity, functional impairment, trauma-related guilt, higher rates of depression, and lifetime suicide attempts.  CG has been found to be prevalent and associated with adverse psychosocial outcomes in veterans and service members with combat-related PTSD (Khoshaba, 2013; Shear, 2010 p. 3; Simon et al., 2017 p. 12).  Piver (n.d.) explains that balancing traumatic experiences with the intensity of grief may feel overwhelming for military personnel. Therefore, it is important to assess and respect the individual ‘s ability to cope and manage these feelings at any time.  Ruglass (2014 p. 31) suggests that to ensure the validity of the diagnosis, information must be obtained from multiple measures and multiple sources such as gathering collateral information from the client’s family members and friends and from clinical records.

U.S. Department of Veterans Affairs (2017) and American Psychological Association (2017) provide a list of PTSD screening interview and self-report instruments that are used for detection of trauma history and identification of trauma related symptoms.  Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is a structured interview tool to make a diagnosis, determine lifetime diagnosis, or assess PTSD symptoms over the previous week.  PTSD Symptom Scale Interview (PSS-I-5) is semi-structured or brief interview to assess the presence and severity of symptoms over the past month, and to assess distress and interference in daily life as well as symptom onset and duration.  Structured Clinical Interview; PTSD Module (SCID PTSD Module or SCID-5) is a semi-structured interview for making the major DSM-5 diagnoses.  Structured Interview for PTSD (SIP or SI-PTSD) is a clinical interview to assess symptoms of PTSD corresponding to DSM-IV criteria along with survival and behavioral guilt. Treatment-Outcome Posttraumatic Stress Disorder Scale (TOP-8), developed from a SI-PTSD scale, is a brief interview-based assessment of the DSM-IV version of PTSD.  Self-Report Instruments include Davidson Trauma Scale (DTS), Impact of Event Scale – Revised (IES-R), Mississippi Scale for Combat-related PTSD (MISS or M-PTSD), Modified PTSD Symptom Scale (MPSS-SR), PTSD Checklist for DSM-5 (PCL-5), PTSD Symptom Scale Self-Report Version (PSS-SR), Short PTSD Rating Interview (SPRINT).

Suggested useful assessment tools with military personnel to identify symptoms of CG are The Inventory of Complicated Grief-Revised, most widely used, which reflects current bereavement research; and the Texas Revised Inventory of Grief, which has been used in a variety of populations and has been well validated (Piver, n.d. p. 77).

Relationship assessment

Studies show service members’ risk for posttraumatic stress disorder (PTSD), depression, substance use problems, and violent behavior are increased by combat and combat related trauma.  Bovin, et al. (2018 p. 217) state that “in addition to the direct negative emotional and cognitive symptoms of PTSD, individuals with PTSD often experience clinically significant psychosocial functional impairment across a range of domains,” including poorer work performance, high levels of verbal and physical abuse and violence in romantic relationships, and many with PTSD reporting that their partners and/or children are afraid of them.  Martin’s experiences of combat-related trauma and loss are evident stressors that seem to have greatly affected not only Martin but also the family system.  Reintegration seems to have been a difficult process for the family.  Though, Martin’s wife and children are relieved to have him home, they are overwhelmed by his psychological and physical impairments, and unable to help him.  These challenges greatly impact family dynamics and functioning which can negatively affect all members of the family.  Stressors can put spouses/intimate partners at increased risk for depression and anxiety problems due to the postdeployment adjustment, and children at increased risk for internalizing and externalizing problems (Brockman, et al. 2016 p. 2; Carroll, et al. 2013 p. 559; Sensiba & Franklin, 2015 p. 48).

For relationship assessment, Bovin, et al. (2018 p. 218) suggest Inventory of Psychosocial Functioning (IPF), a self-report measure designed to capture PTSD-related psychosocial functional impairment.  IPF includes seven domain scales: romantic relationship with a spouse or partner, family relationships, work, friendships and socializing, parenting, education, and self-care.

Reintegration being challenging for service members and their families, Sandoz et al. (2015 p. 496) suggest that developing and strengthening family-coping skills that focus on prevention and intervention strategies must be an ongoing process throughout the deployment cycle.  Recommended evidence-based interventions including resiliency-based strategies, parent skills training, and cognitive and behavioral strategies such as psycho-education, behavior management, and relaxation training.  Additionally, trauma-related interventions such as mindfulness-based strategies incorporate several behaviors including acting with awareness of the present environment, observing experiences nonjudgmentally, and accepting experiences nonreactively.  These interventions will enable the family to attain psychological flexibility which refers one’s ability to fully experience the present moment while engaging in behavior that is consistent with chosen values even when the present moment includes difficult emotions, thoughts, memories, or body sensations (Sandoz et al., 2015 p. 497).

Family therapy interventions

With high prevalence of PTSD (U.S. Department of Veterans Affairs, 2017), clients must be assessed and treated for PTSD since many returning personnel struggle with PTSD symptoms (Sandoz et al., 2015 p. 496).  Reisman (2016 p. 625) states that the best treatment approach for PTSD is psychological interventions.  Cognitive Behavioral Therapy (CBT) is considered to have the strongest evidence for reducing the symptoms of PTSD in veterans and has been shown to be more effective than any other nondrug treatment.  Specifically, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy are recommended by the VA and the Department of Defense as first-line treatments in PTSD practice guidelines.

Family interventions listed by Sandoz et al. (2015 p. 497) are cognitive behavior therapies (CBTs) focusing on building psychological skills that promote psychological flexibility in the presence of distress.  CBTs include Dialectical Behavior Therapy (DBT), Functional Analytic Psychotherapy (FAP), Integrative Behavioral Couples Therapy (IBCT), and Mindfulness-Based Cognitive Therapy (MBCT).  These CBTs emphasize the ability to accept ongoing experiences as they occur while continuing to pursue meaningful goals.  Moreover, Sandoz et al. (2015 p. 498-503) states that psychological flexibility is an important aspect of couples’ relationship functioning, effective parenting behavior, and one’s ability to cope with traumatic experiences.  Thus, Acceptance and Commitment Therapy (ACT) is recommended which focuses on aspects of psychological flexibility including Being Present, Cognitive Defusion, Experiential Acceptance, Perspective-Taking or transcendent sense of self, Valued Living, and Committed Action.  These skills are key to psychological well-being and functioning of the family as a system.

Likewise, Sensiba (2015) provides various family interventions for combat-related PTSD which can be helpful.  Cognitive Behavioral Conjoint Therapy (CBCT) provides techniques that focus on conflict management, minimize avoidance behavior, improve communication, and modify maladaptive thinking patterns (p. 49).  Strategic approach therapy (SAT) helps individuals develop new skills to help them cope with previous and current stressful experiences with the aim of generalizing the skills to future stressful situations (p. 51).  Family Systems Therapy (FST) focuses on interventions which include correcting problematic thinking patterns, renegotiating family roles and patterns, and creating a common narrative about the deployment experience (p. 51).  Multifamily Group (MFG) Psychoeducation focuses to create a social support network for families that decreases social isolation and caretaker burden often associated with caring for someone with a mental illness (p. 52).  Parent Management Training helps parents learn effective techniques to establish limits, effectively problem solve, and interact positively with their children. Parents also learn to manage their emotions, which promotes a supportive home environment (p. 52).  Furthermore, a strengths-based approach that builds on family resiliency, considers the family’s current stage in the deployment cycle, and helps parents learn to effectively manage their emotions is recommended (Sensiba, 2015 p. 52).

Interventions for clients and their families must be part of a comprehensive treatment plan that includes, assessments, individual therapy interventions, family therapy interventions for the family unit, group therapy, and psychoeducation.  Based the goals and needs of each family member, treatment must include a combination of therapy modalities. Thus, all members of the family will benefit and be empowered to develop resiliency and stronger relationships within the family and their community.

Reference

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