Therapy in Theater: The Last Frontier

Rocky Liesman, PsyD, ABPP

On that warm summer evening, six soldiers from the small forward operating base (FOB) where I was working as the Clinical/Survival, Evasion, Resistance, and Escape (SERE) psychologist were killed by an IED. Their deaths were personal, gruesome, and tragic. They were part of a convoy returning to FOB Airborne where they were scheduled to stay for one week before returning home for an early redeployment. Increasing the impact of this event was members of the fallen soldiers’ unit were made responsible for attempting to save the life of the one surviving soldier, sifting through the wreckage, and identifying remains of the six fallen soldiers. The fragments they helped to identify were not nameless soldiers; the tangled and twisted remains were friends, brothers and sisters in arms.  Each one had a story and background, making distancing one’s emotions from such a task impossible. I also knew each of the victims, either having talked with them during our regular visits to each of the combat outposts (COPs), worked out with them in the gym, or sat across from them as their treatment provider. This fact also made distancing myself from the task extremely difficult. I too had to fight against the urge to push away from it all, but the treatment required that the patients and I go towards what we all wanted so badly to avoid.

I used a modified, exposure-based CBT protocol to treat those soldiers most affected by the incident. The treatment was a four-session model developed by Foa, Hearst-Ikeda, and Perry (1995) and has empirical support for treating ASD and preventing the development of PTSD in civilian populations (Bryant, Harvey, & Dang, 1998; Rothbaum, Kearns, Price, Malcoun, Davis, Ressler, Lang, & Houry, 2013). A similar treatment protocol was implemented with active duty personnel presenting with PTSD in primary care (Cigrang, Rauch, Avila, Bryan, Goodie, & Hryshko-Mullen, 2011), with positive results in the form of symptom reduction. Cigrang, Peterson, & Schobitz (2005) have only study to date demonstrating the use of this treatment in among actively deployed personnel. The article was a case study of three individuals treated using the shortened CBT, exposure-based protocol for treatment of PTSD. In the article all three individuals treated showed improved symptoms and were returned to duty. In addition to research supporting the use of this treatment protocol for ASD and prevention of PTSD, it was also listed as the recommended course of treatment by the 2010 VA/DOD Guidelines for the Treatment of PTSD.  

Despite a firm empirical foundation supporting my decision to engage in this treatment, I could not help but question myself as soldiers sat across from me shaking, eyes closed, mimicking movements performed on that day; walking the fine line between dissociating and staying present. I also wondered if it was the right treatment for me given that I was struggling at times to maintain focus on the task at hand while I fought against the images of the dead soldiers’ faces filling my head. Yet, I was able to find comfort in the notable improvements seen in the soldiers I was treating. The five soldiers who completed at least four sessions of the brief, exposure-based treatment evidenced improvements on both subjective rating scales (i.e., lower scores on the ASD scale) and objective behaviors (i.e., returning to mission, increased use of the gym, etc.). Unfortunately, I cannot say with certainty how the soldiers fared for the remainder of the deployment nor how they are doing now. I cannot say for sure if the treatment was the right choice given the non-empirical nature of my observations of these individuals and the outcomes it produced. 

The war in Iraq is over, draw-down of troops in Afghanistan has begun, and all combat troops are projected to be out of Afghanistan by 2014. In over 11 years of active combat the DoD has made strides in nearly every area of combat medicine, except in the area of PTSD prevention and treatment in theatre. Researchers and practitioners are no closer to understanding how best to treat Combat Operational Stress Reactions (COSR), Acute Stress Disorder (ASD), and PTSD in active duty personnel then they were at the start of the war in 2001. Research has focused instead on identifying the etiology and epidemiology of PTSD in active duty personnel returning from war, but there is a dearth of RCTs examining the treatment and prevention of these symptoms in theater. In arriving in Afghanistan I had agreed to write about the absence of research on the use of empirically supported treatments for PTSD in theater. In my writings I hypothesized the following factors have influenced the lack of available research on the treatment of ASD and PTSD in theater.

• Conflicting guidelines received by clinicians during pre-deployment training and those provided by the 2010 VA/DOD Guidelines, which supports the use of brief-exposure based treatments. The focus of pre-deployment training for mental health providers centers on a non-pathologizing view of mental health symptoms in both language (i.e., using combat operational stress reaction to refer to presenting problems) and treatment approach (i.e., psychoeducation, normalizing symptoms, psychological first aid). In fact, the combat operational stress control (COSC) pre-deployment training for providers warns against treating behavioral health disorders in theater.
• Research demonstrating high probability of recovery without treatment for most individuals exposed to potentially traumatic events.
• Clinicians’ personal beliefs that people with ASD or PTSD should not be treated in theatre and, instead should be medically evacuated from theater, due to the limitations (i.e., time available for sessions, mission demands, etc.) of the treatment environment in deployed settings.
• Clinicians’ fear that treating ASD or PTSD in theater could result in a worsening of symptoms due to the treatment itself and the potential for continued exposure to stressors.

These hypothesized concerns are understandable and I can say with certainty that each of these concerns arose in me while conducting the treatment. Yet, these concerns have prevented any growth or advancement in knowledge about what works for the treatment of ASD and PTSD in theater. I believe in the effectiveness of the treatment I utilized for those three weeks in Eastern Afghanistan and sincerely hope that I played some small part in either preventing the development of PTSD in the soldiers I treated or at least opening the door for future treatment. Yet, without further research we will never know with certainty what works, there will be significant variability regarding the treatment soldiers receive in theatre, and deployed clinicians will be left to second-guess decisions about how best to treat a population in desperate need of our services. 

This article is dedicated to all of the soldiers that have paid the ultimate sacrifice for their service and for the six soldiers I was lucky enough to serve alongside that lost their lives on that July 8, 2012 evening.

• Army Staff Sgt. Ricardo Seija, 31, of Tampa, FL
• Army Spc. Erica P. Alecksen, 21, of Eatonton, GA
• Army Spc. Clarence Williams III, 23, of Brooksville, FL
• Army Pfc. Trevor B. Adkins, 21, of Spring Lake, NC
• Army Pfc. Alejandro J. Pardo, 21, of Porterville, CA
• Army Pfc. Cameron J. Stambaugh, 20, of Spring Grove, PA

References

Bryant, R.A., Harvey, A. G., & Dang, S. T. (1998).  Treatment of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66, 862-866.

Cigrang, J. A., Peterson, A. L., & Schobitz, R. P. (2005). Three American troops in Iraq: Evaluation of a brief exposure therapy treatment for the secondary prevention of combat-related PTSD. Pragmatic Case Studies in Psychotherapy, 1 (2), 1-25.

Cigrang, J. A., Rauch, S. A., Avila, L. L., Craig, J. B., Goodie, J. L., Hryshko-Mullen, A., Peterson, A. L. (2011). Treatment of Active-duty military with PTSD in primary care: Early findings. Psychological Services, 8 (2), 104-113.

Foa, E.B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive behavioral program for the prevention of chronic PTSD in recent assault victims.  Journal of Consulting and Clinical Psychology, 63, 948-955.

Peterson, A. L., Luethcke, C. A., Borah, E. V., Borah, A. M., Young-McCaughan, S. (2011). Assessment and treatment of combat-related PTSD in returning war veterans. Journal of Clinical Psychology in Medical Settings, 18,164-175.

About the Author

Rocky Liesman, PsyD, ABPP is a primary care psychologist at the St. Louis VA. He received his doctorate from Wright State University and was awarded the HPSP Scholarship through the United States Air Force. He served in Afghanistan as the Survival, Evasion, Escape, and Resistance (SERE)/Clinical Psychologist for the Warkak Province. Dr. Liesman is board certified in clinical psychology and trained in use of empirically supported treatments (i.e., ACT, CBT, DBT) for a variety of mental health conditions. He is certified as a Master's level provider in the administration and supervision of prolonged exposure and is a VA certified provider of motivational interviewing.