LANDSTUHL REGIONAL MEDICAL CENTER, Germany - Symptoms of combat stress and post-traumatic stress disorder include continual nightmares, avoidance behaviors, denial, grief, anger and fear.
Some Soldiers, battling these and other symptoms, can be treated successfully as an outpatient while assuming their normal duties. For others, however, returning to work and becoming their old selves again were challenges recognized by several mental health professionals across the European theater.
"We were looking at how we can best meet the needs of our clientele, and we were identifying that a lot of the Soldiers needed more than once-a-week outpatient, individual therapy and probably needed more than once- or twice-a-week group therapy," said Joseph Pehm, chief of Medical Social Work at Landstuhl Regional Medical Center.
The solution came in the creation of an intensive eight-week therapeutic Post-Traumatic Stress Disorder Day Treatment Program called "evolution" that began in March 2009 at LRMC. During the eight-hour days, patients enrolled in the program participate in multiple disciplines and interests, including art therapy, yoga and meditation classes, substance abuse groups, anger and grief management, tobacco cessation, pain management and multiple PTSD evidence-based practice protocols.
"I am a great believer in the kitchen sink, meaning I throw everything, including the kitchen sink, and something will stick," said Dr. Daphne Brown, chief of the Division of Behavioral Health at LRMC. "And so we've come with all the evidence-based treatment for PTSD that we know about ... We've taken everything that we can think of that will be of use in redirecting symptoms for these folks and put it into an eight-week program."
Brown, Pehm and Sharon Stewart, a Red Cross volunteer who recently received a doctorate in psychology, said the program is designed from research into the effects of traumatic experience and mirrors successful PTSD programs at Walter Reed Army Medical Center and the Department of Veterans Affairs, as well as programs run by psychologists in the U.S.
"We are building on the groundbreaking work that some of our peers and colleagues have done and just expanding it out," said Brown.
During treatment, patients begin the day with a community meeting where they discuss how well they feel and any additional issues or concerns since their last meeting. The remainder of the day depends on the curriculum scheduled for that week.
The first few weeks focus on learning basic coping skills such as how to reduce anxiety and fight fear, as well as yoga and meditation for relaxation. Eye Movement Desensitization and Reprocessing, or EMDR, an evidence-based practice for treating PTSD, is also conducted during the early phases of the treatment program.
"The concept behind EMDR is that, essentially, memories become fixed in one part of our brain and they maintain their power and control over our emotions as long as they are fixed there," said Brown. "And if we can activate a different part of the brain while we're experiencing that memory, we can help to remove some of that emotional valence from it. So we use physiological maneuvers to activate both sides of the brain."
The goal at the beginning of the PTSD program is to provide patients with a number of tools they can use to help them calm down when feeling overwhelmed, especially before more intense therapy begins in the latter weeks. Cognitive processing therapy is used throughout the program. EMDR and prolonged exposure therapy are also available on an individual basis at the Soldier's request. All three techniques are research-based treatments.
When life-changing events occur, Brown said perceptions about the world may change. For example, before Soldiers experience combat trauma they may think the world is safe. Following combat, a Soldier's perceptions may change - a majority of the world may now seem unsafe. Cognitive processing therapy attempts to re-address experiences and reshift a Soldier's perceptions.
Prolonged exposure therapy is behaviorally based and addresses a Soldier's fears, which are seen as reflex reactions to a stimulus. To decondition the reactions, a patient is continually exposed to the stimulus by retelling the story repeatedly, minus the negative outcome. Brown compared it to riding a roller coaster over and over again to overcome a fear of roller coasters.
"So they're getting EMDR, they're getting cognitive processing therapy, they're getting individual therapy, they're getting group therapy, they're getting education, anger management, self-esteem, relationship issues, grief and loss, yoga, meditation exercise, skill building -- a little bit of everything across the board," said Brown. "Not everything's going to resonate with everyone who comes through, but something's going to resonate for everyone who comes through."
In addition to the overall core curriculum, Brown and her staff have programs such as pain management, relationship enrichment and tobacco cessation to help individualize treatment.
"The core of the group and individual education is consistent for everyone," said Brown. "But we recognize that every patient is different, and we have to tailor-make it to give an individualized treatment plan. We don't keep people in pain management if they're not in pain. We don't give them tobacco cessation if they're not smoking. So we do try and tailor as much of it as we can."
Spirituality, relationship enrichment and gender-specific issues are also areas of focus.
"The program is holistic," said Pehm. "It looks at people from different spheres, not just the medical model, because everything is impacted when someone has combat stress or PTSD - not just the individual Soldier, but everybody who comes in contact with them."
The intensity, length and "kitchen sink" qualities are not the only aspects that make this program unique, said Brown. It is a joint military and civilian effort accomplished entirely by volunteers. The staff is as diverse as the therapy options, and includes chaplains, social workers, Red Cross volunteers, psychiatrists, a nurse practitioner, enlisted psychiatric technicians, and graduate students. Brown said having a sundry of personnel keeps the program fresh and the staff excited.
"The patients get perspectives from people from a number of different backgrounds," said Brown.
Thus far, the staff outnumbers the program's participants.
"By design we started out small, and we were able to establish a really good working relationship with the local Warrior Transition Unit people ... It's been a wonderful working relationship with them," said Pehm.
Evolution is currently on it second eight-week course, with five patients enrolled. The first class had four. The goal is to keep the class size small in order to benefit from the program's intensity. Thinking small also helps keep the impact large by successfully returning Soldiers to their units, while also expanding access outside the WTUs. However, Pehm said they would like to expand the program to include patients from throughout the European Command.
"Ideally, we'd like to max it at about 10 because it is so intensive," said Brown. "These are folks we hope to remediate and return to the Army to be functional members again. Also, if they go back to their communities and their providers or spouses see the changes that have come about, that will increase the willingness or desire of more people to be here."
Though few have completed this young program, signs of success have already started to surface.
"With the last group, the shift from 'I have to be here' to 'I'm so glad I came' was really phenomenal," said Pehm.
"One of them said that he didn't think he was getting anything out of the program," Brown said. "It was about week six until he saw himself react differently to a situation that came up, and watched himself do it differently using skills that he didn't know he learned. He went 'Wow,' maybe I am getting something out of this."
It is too early, and the numbers are too small, to generalize the early trends, but self-completed PTSD checklists showed a significant decrease in reported symptoms for three of the four patients in the first cohort. Additionally, anxiety and depression symptom measures decreased.
"The whole idea is that we know all the changes aren't going to take place here," said Brown. "But we hope we give them enough learning to send them in a different direction. My hope is that we can build a program to provide valid, effective treatment to folks who have put themselves in harm's way at the request of their country, and help them live happier and better lives."