Post Traumatic Stress Disorder Treatment Research Proposal

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g., when there are deaths of several soldiers or emergency workers of a unit). Combat is a stressor that is associated with a relatively high risk of PTSD, and those interventions that can potentially diminish this risk are very important. But what is not clear in the above is how much the debriefing provided is more a form of stress management for the ?critical incidents? that are very much part of warfare, as opposed to interventions for those psycho- logically traumatized and at risk of PTSD. People in the military are exposed to stressors other than combat, and these may be traumatic (Atwater, 2009). Reports of soldiers who were involved in body recovery in the Gulf War provide important insights. This is a high-stress situation, linked to vulnerability to posttraumatic morbidity.

Asnis, et al. (2004) reported that soldiers of one group who had been debriefed were compared with another, which, for operational reasons, had not. The debriefed group was no better at longer-term follow-up: no benefits could be demonstrated for the debriefing in groups that appeared to be equivalent in experience and vulnerability to these stressors. PTSD was not prevented by this intervention. Peacekeepers also suffer experiences which may be psychologically traumatic-for instance, witnessing genocide, violence, bombing, or deaths from famine, without being able to intervene. Fairweather & Garcia, (2007) have demonstrated significant psychological morbidity in a group of peacekeepers, and cases of PTSD have also been reported in such groups. Yet these groups have had extensive briefing and debriefing in recent times. For many, however, their experiences in the developing countries where they had these peacekeeping roles were overwhelming and may well have added to their vulnerability. Soldiers, like emergency workers and others in structured crisis response services, may have their own informal "debriefing" mechanisms in socially sanctioned modalities and in more secure settings (Caplan, 1964).

III: Proposed Project Method

A proposed modality developed from Caplan's (1964) original ideas of preventive intervention following stressful life events. It has been applied as a brief intervention in association with bereavement (Seal, et al. 2007), motor vehicle accidents (Bordow & Porritt, 1979), and acute injury and illness (Martenyi, 2005). When provided in accordance with this theoretical modality, it has been shown to be effective in high-risk populations in lessening the likelihood of morbidity. Although potentially "traumatic" stressors could have been identified in each of these studies, the traumatic stress model did not inform them. While it is now known that traumatic bereavements can be associated with PTSD, that motor vehicle accidents may lead to the development of PTSD, and that life-threatening illness and injury may be associated with vulnerability to PTSD, further research in crisis intervention is needed to test this model as an acute posttraumatic intervention. Nevertheless, it is potentially so. The recontextualizing of debriefing in the crisis intervention frame- work is not really helpful, as its format, intervention, timing, and hypothesized mode of action are quite different.

IV. Proposed Project Evaluation/Data Analysis

This modality has become a subject of research in recent times, with studies showing that specific focused counseling can lessen the risk of PTSD after acute rape trauma (Asnis, et al. 2004). Trauma counseling has often been provided as a nonspecific general counseling aimed at both making better the psychological hurt and preventing the development of PTSD. Unfortunately, the marketplace demand for trauma counseling and the belief in its value have far outstripped the knowledge base of what is effective and the skills of many would-be providers. The effectiveness of focused interventions which are provided over a number of sessions in the later (2 weeks or more) acute post trauma period appears to be established (Bergfeld, 2006). These interventions are chiefly in cognitive behavioral formats which focus on the specific trauma and support reconfrontation and working through. Fairweather & Garcia, (2007) carried out a pilot study of a brief preventive intervention program for female sexual assault survivors.

The intervention built on what was known to be effective in the treatment of some chronic PTSD in such circumstances (Kennedy et al. (2007) and included exposure, relaxation training, and cognitive restructuring. The authors compared intervention and nonintervention subjects, both groups having an intervention, of four weekly 2-hour sessions which began within a month of the assault. Although numbers were small and it was not a controlled trial, those who would have met criteria for PTSD diminished significantly in the intervention group and did not in the control group.

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Symptoms were far less severe for the intervention group. These benefits were sustained. The authors note that intervention did not start until 2 weeks later.

While they initially believed this might contribute a difficulty, they subsequently considered that those affected may have been better able to benefit from these interventions at this later time. This would fit with findings of bereavement counseling. With these findings in mind, and the comparative effectiveness of cognitive behavioral interventions for treatment of some cases of established PTSD, there is a sound framework for using this modality of trauma-focused cognitive behavioral therapy in short-term counseling as the basis for an acute post trauma intervention provided in the early weeks but not immediately post trauma.

Some debriefing and other acute posttraumatic interventions are provided in a structured and integrated framework which seems to have been associated with some positive results. This is exemplified in Kennedy et al.'s (2007) rotation and support for officers working after the Lockerbie plane crash in Scotland and Alexander's structural support of police body recovery workers after the North Sea oil rig disaster. In the latter case, a support system was provided by briefing workers. This consisted of pairing a younger with an older, more experienced officer and providing informal debriefing merged with support by a psychiatrist known to and trusted by these men (Bergfeld, 2006).

The security provided by such a structured environment, where there was a need to get on with the work, which was continuing, suggests that such a model could be of value in other such circumstances. This could become a structural approach as part of an occupational health program (Defense Link, 2008). System-based interventions include those in post disaster response programs such as those of consultation with affected communities, as well as supportive interventions such as group meetings for relatives of those killed in a plane crash or other disasters where information can be provided and mutual support and reassurance can be built. Information plays a central part in recovery processes, and emergency organizations in the post trauma period frequently develop systematic formats to provide this. This in itself is likely to be a supportive post trauma intervention.

Education and Learning Interventions

While there is general agreement that education about anticipated responses is helpful, and it is reported to be so when it is provided, for instance, in de- briefing or support programs. There has been inadequate investigation of this intervention method and its effectiveness. It is of interest that the formal learning of debriefing in the CISD model is toward a pathology focus (e.g., symptom lists). Other learning in debriefing formats has been highlighted by Kennedy et al.'s (2007) who suggest that the learning a group may do with the use of its own processes and without the intervention of a mental health professional may be very helpful to the future functioning of its members. They may develop a sense of positive mastery. It might also be said that the cognitive behavioral interventions listed above promote a specific and focused learning to undo the fear response to the trauma that was involved. This whole area promises to be a valuable field for further research.

V. Summary

The possibility of pharmacological interventions in the acute post trauma period is of interest, particularly in view of the greater understanding of neuro-physiological, and neuroendocrine reactive processes following trauma. Martenyi, F. (2005) and Seal, et al. (2007) have suggested that there is an alteration in the acute stress process that reflects an over reactive system and that with such understandings a biological method may be able to alter vulnerability. While there are a number of clinical hypotheses, there is no clearly determined appropriate intervention in the acute post trauma period. Rather, the decision for such interventions should have a strong clinical rationale (i.e., for those most distressed and dysfunctional, and addressing these two parameters).

Several other interventions have been developed, but as of this writing their overall effectiveness has not been established. Eye movement desensitization and reprocessing (EMDR) is one such intervention-attractive to many, but not as yet with evidence of significant benefits as an acute intervention (Sontag & Alvarez, 2008). Other interventions have had a vogue but not been continued, and there is little evidence of their effective use in the acute post trauma period; where benefits are claimed, these have not been substantiated.....

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