Intervention Project

THE UNIVERSITY OF MEMPHIS

POST TRAUMATIC STRESS DISORDER

EARLY INTERVENTION FOR OUR SOLDIERS

LESLIE JAYROE

4/25/2011

HPRO 7720

Post Traumatic Stress Disorder and Our Soldiers- Providing Earlier Intervention

History

There is a significant amount of information out there on post traumatic stress disorder and the

military, and this is mostly due to the fact that our combat soldiers were the ones observed over

time to determine the effects war has had on them. Post traumatic stress disorder (PTSD) can

be thought of as a "young" diagnosis. PTSD has been around for centuries, but it was n~t until

1980 that it was made an official disorder. However, throughout history, people have

recognized that exposure to combat situations can have an intensely negative impact on the

people who are involved in these situations. (Mathew Tull, 2009) PTSD has previously been

described ia-410J e ~s "combat fatigue," "shell shock," or "war neurosis," and is defined by the

American Psychiatric Association as an anxiety (emotional) disorder which stems from a

particular incident evoking significant stress. (Bentley, 2005) PTSD is not limited to combat

soldiers but can also be found among survivors of the Holocaust, of car accidents, of sexual

assaults, and of other traumatic experiences. War has always had a severe psychological effect

on people, and with the war our country is currently in, more and more of our soldiers are

suffering from PTSD. After a traumatic experience, the mind and the body are in shock, but as

the victim makes sense of what happened and processes his/her emotions, healing takes place

leading toward normal function once again. With PTSD, one remains in psychological shock.

The memory of what happened and their feelings about it are disconnected. In order to move

on, it's important to face and feel those memories and emotions. One effective approach is

through counseling. (Mathew Tull, 2009)

The symptoms of PTSD can occur all of a sudden, progressively, come and go over time, or

appear out of nowhere. Sometimes, symptoms are triggered by something that reminds a

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person of the original traumatic event, such as a noise, an image, certain words, or a smell.

While everyone experiences PTSD differently, there are three main types of symptoms:

(Bentley, 2005)

1. Re-experiencing the traumatic event

2. Avoiding reminders of the trauma

3. Increased anxiety and emotional arousal

According to the Graffiti of War Project, in 2007, the number of diagnosed cases in the military

jumped 50%. One in every five military personnel returning from Iraq and Afghanistan has

PTSD, and 20% of the soldiers who've been deployed since 2001 have PTSD which is over

300,000. More troops are serving their second, third or fourth tours of duty, which dramatically

increases stress according to medical heath experts. Also, extended tour lengths from 12

months to 15 months were done to provide enough troops for buildup, but is another factor that

has caused extra emotional strain. {The Graffiti of War Project, 2007)

Statement of Purpose

The purpose of this paper is to provide an early intervention for first time deploying soldiers from

Arkansas by applying the Precede/Proceed Model in hopes of preventing post traumatic stress

disorder brought on by combat. The Precede/Proceed Model consists of 9 phases which were

applied for the sack of this intervention. The first five phases are within the Precede part of the

model: 1) social assessment 2) epidemiological assessment 3) behavioral and environmental

assessment 4) educational and ecological assessment 5) administrative and policy assessment.

The last four phases are within the Proceed part of the model: 6) implementation of the program

7) process evaluation 8) impact evaluation 9) outcome evaluation. (Edberg, 2009) By following

these phases in order, I was able to create a successful intervention while applying the Theory

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of Planned Behavior. The Theory of Planned Behavior, simply stated, is about the associ

of attitudes and behaviors.

Phase 1: Social Assessment

A person's quality of life is greatly impacted by post traumatic stress disorder, and can cause

serious social, emotional, and psychological problems for soldiers returning to the civilian life .

Twenty soldiers made up the study group for this program. They were selected through the

recruitment office in Little Rock, Arkansas at random and had to meet the following criteria:

• First-time deploying soldier

• An Arkansas resident

Age, sex, and ethnicity were not deciding factors for being part of the study. The main social

problems that were documented in medical and work records from this group of soldiers after

post-deployment were an increased number of absences from work, lack of sleep, and domestic

problems. Prior to their first deployment, they were each assessed for any social disorders, work

records were noted, and medical records were evaluated so a baseline could be established for

the study. There were no soldiers before deployment with these issues. This information was

obtained through the recruitment office in Little Rock, Arkansas to determine each soldier's

deployment status and medical records from their personal physicians as well as former

employee records were used for the sake of the intervention.

Phase 2: Epidemiological Assessment

Of the twenty soldiers being studied, the most common health problems documented from

medical records were alcohol abuse, the use of narcotics, and post traumatic stress disorder.

The pre-assessment also evaluated them for these issues before the first deployment, and

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again, none of the soldiers exhibited these issues before the deployment. Of the three issues,

post traumatic stress disorder is the most important and most changeable for the given

population. If PTSD can be prevented, then the other issues should also resolve. Pre and post

deployment medical records were used to make this evaluation for these soldiers and a national J health database was used for comparison as well as reviewing the literature on this particular

issue.

Phase 3: Behavioral and Environmental Assessment

There are behavioral and environmental factors that contribute to PTSD in soldiers .

Environmental factors: (Corporation, 2008)

• combat

• deployments longer than 12 months at a time

• multiple deployments

• suicide bombers

Behavioral factors:

• Worried about medication side effects

• Feel that friends and family can help more than counseling

• Fear that there will be damage to career

• Fear of peers lacking confidence in him/her

The environmental factors cannot be changed for soldiers at war unless they change

cC)reers, but the behavioral factors can be changed. With more education on PTSD, and the

acceptance of the disorder by the military, soldiers could alleviate the behavioral barriers.

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Goal and Objectives

Goal: The goal of this program is to provide early intervention to twenty Arkansas soldiers

before their first deployment to Afghanistan as to prevent the development of post traumatic

stress disorder before and after their second deployment with success rate set at 85% after 48

months of the start of the intervention. /

Objective 1: To increase awareness of post traumatic stress disorder among twenty soldiers by I 100% within two weeks before their first deployment to Afghanistan.

Objective 2: To provide four sessions of post deployment counseling to the twenty soldiers aft/

each deployment, at 85% counseling attendance rate.

Phase 4: Educational and Ecological Assessment

For this phase, three areas are looked at: Predisposal, Reinforcing Factors, and Enablers .

Predispose: Unlike major depression and other psychological disorders, PTSD shows

biochemical changes in the brain and body. Individuals diagnosed with PTSD have a higher

response to a dexamethasone suppression test than individuals diagnosed with clinical

depression. Most people with PTSD also show a low secretion of cortisol and high secretion of

catecholamines in urine, with a norepinephrine/cortisol ratio compared to people who do not

have the disorder. Low cortisol levels may predispose individuals to PTSD. Because cortisol is

important in restoring homeostasis after the stress response, trauma survivors with low cortisol

tend to be distressed more over the situation(s) and suffer from it longer, setting the stage for

PTSD. (RWMC, 201 0) Each soldier was evaluated for low cortisol levels through a urine test

before deployment. Of the twenty soldiers, only one showed a markedly low level.

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Reinforce: Factors that are reinforced for the possible development of PTSD include the

environment that these soldiers are placed in and also the military's policies on length of time

and redeployment. The environment that they are in puts them under a great deal of stress and

most of which can't be altered . Combat, suicide bombers, long hours without sleep, lack of

communication with loved ones, the loss of fellow soldiers, and the possibility of killing innocent

people are all part of what they have to go through on a daily bases while deployed . The

military policy for deploying soldiers for longer than 12 months at a time and multiple

deployments are factors that could be altered.

Enable: Enabling factors include a lack of knowledge of what exactly post traumatic stress

disorder is , lack of counseling for the disorder either due to lack of knowledge or not seeking

treatment because the military tends to look down upon soldiers with PTSD, and also the lack of

healthcare facilities where these soldiers can go to receive help. The military does administer

post deployment testing to determine if a soldier has any physical or psychological problems I once they are back, but some cases still go undiagnosed . Soldiers know that if they answer

certain questions honestly, it may keep them from getting to go home sooner.

Phase 5: Administration and Policy Assessment

With Arkansas not having a program established for the prevention of Post Traumatic Stress

Disorder for soldiers prior to this intervention, policies and administration had to be developed .

With the help of Veterans Affairs, personnel from the military recruitment office in Little Rock,

and The University of Arkansas for Medical Sciences Hospital (UAMS), a board was appointed ,

polices were made and presented to the House for approval.

The program took place at The University of Arkansas for Medical Sciences Hospital (UAMS) in

Little Rock. With the administrative and financial support provided by this hospital, an office with

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a conference room, counseling rooms , secretary, counselors, computers, printers, office

supplies, educational material, and office furniture were all provided, and 1 was appointed as the

Director of the program .

Once the staff was hired, policies and procedures were reviewed by all, and everyone

underwent post traumatic stress disorder training in order to have an understanding of the

people they would be working with .

Phase 6: Implementation of the Program

Along with the application of the Precede/Proceed Model, I will apply the Theory of Planned

Behavior (TPB). TPB is a theory about the link between attitudes and behavior. The attitude

toward a particular behavior is determined by a person's assessment of what the consequences

of their actions are. If the consequences are negative, the less chance there is for a person to

behave a certain way. In regards to this intervention, if a soldier feels that they may lose their

job, lose respect, or be treated differently for admitting they have PTSD and receive treatment

for it, they are less likely to admit they have a problem and seek help.

In order to select soldiers for this program , the recruitment office in Little Rock, Arkansas was

asked for referrals . Once the twenty soldiers were selected based on their deployment status,

they were evaluated by a counselor to determine any underlying psychological disorders.

These initial evaluations were added to their charts .

A test was given at the beginning of the program to determine the knowledge these soldiers had

on PTSD before starting the program. Afterwards, educational material was distributed and

reviewed two weeks before initial deployment. Educational material consisted of handouts ,

DVDs, and guest speakers who discussed with the soldiers their experience with PTSD. During

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this time, the soldiers were also introduced to the counselors they would be working with upon

completion of the deployment.

Counseling sessions will start once post deployed soldiers return from their first tour of duty.

Every three months they are required to meet with the counselors on staff at UAMS, and

express their feelings and emotions. If additional sessions are recommended by the counselor,

the soldier will submit to treatment, and continue individual counseling sessions until the

counselor feels that the soldier is no longer at risk for PTSD.

Content of Counseling Sessions:

The sessions will take place during a specified three day weekend every three months for a total

of four sessions (totaling 12 months). Every three months, the soldiers will return to UAMS for

the counseling sessions and the same structure will be followed.

Day 1: Counseling will begin as a group therapy session the first day where each

soldier talks about his/her experiences from the deployment. The purpose of starting

with group sessions is for the soldiers to have a support group, hear other soldier's

stories that might bring back memories they may have tried to block, and to get them

talking about the issues they are dealing with after their first deployment. The

counselors will be present and leading the session which will be recorded for

documentation purposes and evaluation. The session will last four hours with two 30

minute breaks incorporated within that time . Participants will sit in a circle and the

group sessions will be conducted in a casual atmosphere.

Day two: Each soldier will meet with a counselor individually in a professional setting

and will be encouraged to express their feelings and emotions through discussion.

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The individual session will last two hours, and the counselor will keep records during /

the meeting which will be placed in the soldier's program intervention file. V

Day 3: The weekend counseling session will conclude with questionnaires that will

assist in determining if there were any changes mentally, socially, or psychologically,

j and then be compared to the questionnaires given before deployment. Waiting until day three for the questionnaires will allow for a more accurate evaluation, allowing for

incidences that were previously blocked to surface . Review of the questionnaires,

counseling session, and group session will establish if there is a need for further

treatment.

After the second tour of duty, each soldier will undergo four more counseling sessions which will

also be held on a specified three day weekend every three months (total of 12 months). If

additional sessions are recommended, soldiers will submit to additional treatment which will be

individual counseling sessions where they will continue to express feelings and emotions until

the counselor feels that the soldier is no longer at risk for developing PTSD.

Content of Counseling Sessions:

Day 1: Like the first post-deployment sessions, day one will consist of group

counseling where each soldier will share their experiences from the previous

deployment. Counselors will be present as before, and they will be in charge of

leading the session while it is being recorded for documentation purposes and

evaluation. This session will last four hours total with two 30 minute breaks

implemented in.

Day 2: The second day will be devoted to individual counseling sessions where each

soldier will meet with a counselor and express their feelings and emotion through

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discussion. The individual session will last two hours, and the counselor will record

information to add to the soldier's program intervention file.

Day 3: It will be devoted to the questionnaires that evaluate social, psychological , and

emotional changes, and these will be compared to the previous questionnaires as

well as the group and individual counseling sessions in order to determine if

additional counseling is needed.

Phase 7: Process Evaluation

Process evaluation was done by examining the program's components and if they were carried

out the way they were stated initially. Before each soldier's initial deployment, they were each

educated on post traumatic stress disorder, the signs and symptoms, and the need for

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treatment if he/she or someone they knew started to develop any of the symptoms. Four

counseling sessions were completed after each deployment by each soldier that remained in

the program, and the counselors along with the medical exam staff completed documentation of

changes in the soldiers with particular regard to psychological changes.

Phase 8: Impact Evaluation

The impact evaluation shows the program's effectiveness by observing the objectives that were

set for the program. Soldier's medical records, counseling records, and work records were

reviewed periodically and at the completion of the 48 months . Objectives for this intervention

were:

Objective 1: To increase awareness of post traumatic stress disorder among twenty soldiers

by 100% within two weeks before their first deployment to Afghanistan.

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Objective 2: To provide four sessions of post deployment counseling to the twenty soldiers after

each deployment, at 85% counseling attendance rate.

Objective one was at 100%. The twenty soldiers all received education on PTSD two weeks prior

to being deployed, and there was a 100% increase of awareness among the soldiers of this

disorder which was determined by comparing pre and post PTSD testing.

Objective two was met at 90% which was 5% above the goal set. Of the twenty soldiers who

participated in the program, one was killed in action during the first tour of duty, and another

soldier was killed in action during the second tour of duty. Of the eighteen soldiers remaining,

1 00% compliance was met with the counseling sessions over the 48 months.

Phase 9: Outcome Evaluation

The overall goal of this program was to provide early intervention to twenty Arkansas soldiers

before their first deployment to Afghanistan as to prevent post-traumatic stress disorder from

developing before and after their second deployment with the success rate set at 85% after 48

months of the start of the intervention. Upon completion of the 48 month intervention, the

outcome evaluation revealed that our goal and objectives were met. Of the twenty soldiers who

began the program, eighteen completed the program, two lost their life in combat, and one

developed PTSD. 85% of the 20 soldiers in the program did not develop PTSD after the 48

months which met the goal of the intervention.

With the program's success, UAMS has decided to continue this intervention program and offer

it to more first time deploying soldiers in Arkansas. The recruitment office will still be

responsible for referrals, and an assistant director will be appointed to assist with the

implementation of the future programs.

Sources:

Bentley, S. (2005, March/April). Helpguide.org. Retrieved from A Short History of PTSD : From

Thermopylae to Hue Soldiers Have Always Had A Disturbing Reaction To War :

http:/ /www.vva.org/archive/TheVeteran/2005_03/feature_HistoryPTSD.htm

Corporation, R. (2008, April17) . One In Five Iraq and Afghanistan Veterans Suffer from PTSD or Major

Depression . Retrieved from http :/ /www.rand.org/news/press/2008/04/17 .html

Edberg, M. (2009). Essential Readings in Health Behavior Theory and Practice. Sudbury, MA: Jones & I

Bartlett Learning. //

Mathew Tull, P. (2009, January 25) . About. com. Retrieved from Overview of PTSD and the Mili~try: http:/ /ptsd.about .com/od/ptsdandthemilitary/a/Mii_Overview.htm •

RWMC. (2010). Post- Traumatic Stress Disorder Effecting Those WHo Protect Us And Those Who ive

Beside You. Retrieved from http://www.supportforptsd.com/WhatCausesPTSD.aspx

The Graffiti of War Project. (2007). Retrieved from http:/ /www .graffitiofwar.com/ptsd-facts--stats.htm l

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