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The history of mental health in the US

In order to fully understand the dynamics behind any subject, one must understand its history. We hope that the history is positive marked by compassion, gentleness, and concern for all of humankind. However, when one looks at the history of mental health in the United States, it is not characterized by the adjectives previously mentioned. Instead, it is often characterized by fear, misunderstanding and inhumane treatment.

According to historian Gerald N. Grob, who authored a series of books in 1983, 1991, and 1994, the history of mental health practice in the United States is less than stellar. The roots of modern mental health treatment has a humble beginning when mental health treatment was initially accomplished in the home. In the 1700s when an individual suffered from what is now considered a mental illness, their treatment and did not take place in an institution but rather in the family home. As the of population of this country grew, mental health treatment moved to population centers and into hospitals such as in Philadelphia, and to asylums as in Williamsburg, Virginia. Those who were not fortunate enough to be cared for in the home, or in a hospital or in an asylum often found themselves in jails or in work houses.

With the advent of the 19th century, a movement towards "moral treatment" was in vogue spearheaded by reformers Dorothea Dix and Horace Mann. These reformers believed the best way to treat mental health problems was in an asylum. There the individual would receive a mixture of somatic as well as psychosocial treatments in a controlled environment. During this time, the understanding of "moral" meant that the individual was treated in such a fashion that they were ultimately restored to full mental health and were considered no longer chronically mentally ill (Grob, 1994 as cited in Chavez, Hayman, & Arons, 2009).

Following the Civil War, it was recognized that the understanding of “moral treatment” was unrealistic and asylums became a refuge for the untreatable chronic patients. Because of the level of their illness, they became forgotten members of society and the quality of mental health care deteriorated. As a result to move overcrowding and lack of funding treatment became more inhumane.

It was during this time that a new reform movement devoted to "mental hygiene" came into being. This new movement ultimately formed the National Committee on Mental Hygiene which eventually transformed into what is now known as the National Mental Health Association (NMHA). The committee on mental hygiene advocated for early treatment of mental health in the belief that early treatment would prevent the development of chronic mental health problems. As such, these reformers advocated for outpatient treatment as opposed to the standard at that time which was inpatient treatment in an asylum or hospital. It was their belief that by treating patients early in the form of outpatient treatment, that individuals would not develop chronic mental health problems.

With the advent of World War II, enthusiasm for early intervention grew. It ultimately culminated in the concept of community mental health programs, which we have today. The NMHA, figured prominently in this reform, because it recognized that previous inpatient care was often ineffective, neglectful, and even harmful (Chavez, Hayman, & Arons, 2009). The belief surfaced that mental health outpatient treatment could be more effective and ultimately less harmful than lengthy inpatient hospital treatment.

Since the terrorist attack on September 11, 2001, and the beginning of the war on terrorism, approximately 1.64 million soldiers have deployed to Iraq and Afghanistan (RAND, 2008). Approximately 300,000 soldiers returning from Iraq and Afghanistan deal with a variety of mental health issues often related to him Posttraumatic Stress Disorder (PTSD), which is the predominant mental health issue facing treatment providers who serve the military, at this time. However, for a variety of reasons, which will be discussed later in this paper, only approximately 150,000 soldiers have sought treatment (Bavolek, 2008).

In 2008, the RAND Corporation conducted a study to determine the mental health status of returning soldiers. They focused on three major areas PTSD, depression, and traumatic brain injury (TBI). The study looked at the prevalence of these issues among soldiers returning from the war zone as well as the programs and services designed to meet their needs and the cost of those programs. The study focused on a segment of returning service members and found that approximately 18.5% met the criteria for PTSD or depression, 19.5% met the criteria for TBI, and another 7% met the criteria for combination of TBI and PTSD.

One of the significant problems that was identified in the RAND study was the existence of a huge gap between those who need mental health services as a result of their war experience and availability of services within the military. The reason for this gap often can be found in two areas; limited provider availability as well as the cultural attitude within the military structure regarding mental health issues. Often servicemembers will talk about the perceived negative consequences for those who seek mental health treatment. Soldiers have come to believe that to seek mental health treatment is to display weakness which ultimately affects how their unit views their mission readiness capability ultimately ending the soldier’s career.

Lack of available providers also impacts the ability of the military to provide adequate mental health services to the soldiers. While the military is actively recruiting and hiring new providers, the ratio between those who need mental health services and those who can provide those services still remains quite large.

In addition to the lack of available providers, there is also some confusion that surrounds the issues of PTSD and the need for treatment which, as stated before is a significant issue facing military members today. For many, the confusion surrounding PTSD centers around why some military members are affected and others are not. Perhaps the best way to understand PTSD is to first develop an understanding of trauma itself. To say that all trauma is the same would be ludicrous. However, it would be just as ludicrous to say that all trauma affects people in a similar manner. The impact of trauma often depends upon an individual's perception of the event as well as their own sense of vulnerability. This is certainly true for individuals engaged in the war on terror. Whether an event becomes traumatic for the individual or not often depends on several things. First of all it depends upon the event itself, there are some events that occur in war which are truly traumatic and leave lifelong scars, such as the loss of a child because of hostile actions. However the cause of traumatic impact of other events are not so clear. Often what makes an event traumatic for one person and not for another depends upon the individual’s perception of that event in relationship to their own sense of vulnerability as well as how closely it may relate to or trigger remembrances of events from their past. Still, for others, their perception of the role they play in the overall conflict can often determine whether or not the individual is traumatized by certain events. For example, an individual who perceives their role in the war on terrorism as an expression of their patriotism or just simply as a job that needs to be done will often be less traumatized by an event as opposed to a person who sees himself involved in a conflict or performing a job where there is no sense of emotional attachment or dedication.

In addition to understanding the individual’s perception of their role in the war on terror and the power of trauma to engender feelings of shock, disbelief, fear, and helplessness. One must realize as with any event, it is not the incident that causes the response, but rather our reaction to the incident along with whatever meaning we might personally attach to that event. McLean and Woody cite a study conducted by Peter J. Lang (1979), who developed a bio-informational theory of emotional imagery which consists of interconnected information about the characteristics of the emotional situation, the individual's reaction to the situation, and the meaning of the situation to the person (McLean & Woody, 2001). Chemtob et al. speculate that trauma survivors are prone to interpret situations that occur around them as threatening thus triggering the memory of the traumatic event (Chemtob et al as cited in McLean & Woody, 2001, p. 211). For many this sense of generalizing the emotional experience of the traumatic event to every aspect of their life leads to avoidance of certain aspects of daily living such as large crowds in a shopping center . Thus, by keeping the impact of the trauma alive within their memory, the person keeps reliving the traumatic event resulting debilitating consequences. According to Witvliet (1997), this information-processing theory accounts for the cognitive phenomena observed in PTSD. McNally et al. also speculated that the veterans who are having trouble recalling personal memories are having this trouble because the preoccupation with intrusive recollections of trauma consume a disproportionate share of cognitive resources, thus disrupting other types of thinking. McNally et al. further conjectured that negative attributes dominate the self-representations of people with PTSD, thereby impeding access to positive self-representations (McNally et al as cited in McLean & Woody, 2001). These informational theories all hypothesize a fear structure, or its equivalent, of neuronal networks involved in emotional processing of fearful information. These theories suggest that modification of fear structure reactivity can occur through two channels: habituation and alteration of meaning (Foa & Kozak, 1986 as cited in McLean & Woody, 2001).

Purpose of the Study

At Fort Carson, Colorado where there is an increase in deployment responsibilities, the need arose for a treatment program that focused not only on addressing PTSD, but also enabling the soldier to develop a greater resiliency to a variety of life situations which ultimately allows them to perform their mission with increased confidence and competence.

To address this need, an Intensive Outpatient Program (IOP) was developed by Dr. Kenneth Delano. This program focuses on providing skills that assist the soldier in the development of greater resiliency to life stressors. While PTSD is often a predominant issue for many of the participants in the program, the IOP groups focus on enabling the soldier to develop a variety of different skills that help them address variety of different problems such as marital problems as well as their inability to cope with job related stress as well as the stress of a variety of personal issues.

Skill development for participants in the IOP program is accomplished through Cognitive Behavioral Therapy (CBT) techniques, which is the suggested treatment model, and has been successful in dealing not only with trauma, but also enabling the participant to develop greater resiliency across the board (Taylor, 2004). The effectiveness of CBT as a treatment modality has been clearly demonstrated with a variety of populations. It is a recommended treatment for a number of mental disorders including mood disorders, obsessive-compulsive disorder, eating disorders, substance abuse, and trauma. The effectiveness of CBT was confirmed in a 2001 study conducted by Muck, Zempolich, Titus, & Fishman, when a comparison was made between the effectiveness of behavioral therapy to that of a supportive counseling modality. The result of the study demonstrated that the number of participants using drugs decreased by 73% for those in the behavioral group as compared with a decrease of only 9% for those in the supportive therapy group. These findings were substantiated in a 2006 study conducted by Rupke, Belcke, & Renfrow who discovered the combination of cognitive therapy and antidepressants was shown to effectively manage more severe or chronic depression. The authors concluded from their research in conjunction with a meta-analyses, that cognitive behavioral therapy is more effective than other treatment methods to include pharmacotherapy for mild forms of depression.

In addition to CBT, Cognitive Processing Therapy (CPT) is shown to be effective in dealing with anger, which often is a an additional problem for someone who lacks resiliency skills (Cahill, Rauch, Sheila, Hembree & Foa, 2004).

In a study conducted by Resick (2008), and her colleagues sought to demonstrate effectiveness CPT as an effective treatment for PTSD, by using a prolonged exposure (PE) therapy model.  CPT involves two basic components: cognitive therapy aimed at challenging distorted cognitions, altering the meaning of the traumatic event and written accounts (WAs) in which the client writes detailed accounts of the traumatic event and repeatedly reads the description both at home and in session in order to habituate to the anxiety provoked by reminders of the trauma.  The question that Resick and her colleagues (2008) wanted to answer was whether the full protocol of CPT was the most effective approach or whether individual components of treatment would offer equally promising results. The results of the study showed that each group, in their own way, had an impact on reducing the effect of PTSD. However, what was surprising was not that the groups were successful, but that the groups were successful relative to each other. In other words, each group was just as successful as the other in its own right.

In the IOP program, each soldier selected for the group is chosen because they have a significant psychiatric impairment that, if not treated adequately may require a medical evaluation board and separation from the Army. The mission is to take these highly motivated soldiers who desire to get better remain in the Army, and provide them the opportunity to receive treatment which enables them to return to mission capable status.

The IOP program is primarily for soldiers who have not made adequate progress in routine outpatient behavioral health treatment they need more intensive treatment without the restrictions of the psychiatric inpatient setting. Often, these soldiers may also have been recently discharged from an inpatient treatment program, and based on further assessment it is determined that additional treatment is needed in order to accomplish their treatment goals.

Soldiers are identified for IOP by their treatment provider who refers the soldier to the program based upon their clinical assessment of the soldier’s need for further, more intense treatment. The selection of soldiers is also endorsed by the Battalion Commander, who provides the support for the soldier by allowing them time during the normal duty hours to attend the program.

Significance of the Study

A critical issue facing Fort Carson is the limited number of behavioral health treatment providers as well as the providers’ availability to have sufficient time in their treatments schedule if to therapeutically address the issues facing many of the soldiers assigned to the Post. With the increase in operations tempo, a significant number of soldiers have develop the need for skills that enable them to develop greater resiliency to not only the trauma experienced while on deployment that the normal stressors of daily living. Prior to the initiation of the IOP program, many of the soldiers dealing with behavioral health issues, often found treatment coming in the form of pharmacotherapy with limited or no exposure to individual or group therapy. However, studies have been reported by reported by the Institute of Medicine, which has shown that group therapy has proven efficacious in treating patients with a variety of behavioral health issues (Law, 2008).

Behavioral health providers at Fort Carson recognized the valuable role that group therapy, based on cognitive behavioral techniques, can play in helping soldiers develop greater resiliency to the stressors they are experiencing. The therapeutic techniques used in the program are helping soldiers develop the coping skills necessary to deal with the stresses they experienced as a result of combat, as well as their general life experiences. Research continues to support the notion that group therapy is as an effective treatment modality for soldiers who are dealing with a variety of behavioral health issues. Foy et al. (2002) demonstrated the effectiveness of Trauma Focused Group Therapy (TFGT) on soldiers dealing not only with combat PTSD but other life stressors.

It is anticipated that through the IOP program, soldiers will learn to develop new skills that to help them cope more effectively with day-to-day stress issues interfere with their ability to perform their mission. The outcome of this treatment process is that soldiers are able to return to their units fully mission capable. It is also anticipated that with newly acquired skills, the soldiers will be able to demonstrate their ability to handle crisis events during the week because they have been taught to generalize those skills in their daily activities. The following is a model of the program.

Summary of Methodology

Data Collection and Instrumentation

The data will be collected using a quantitative research approach involving the use of several instruments. These instruments are: the Posttraumatic Stress Disorder Checklist-Military (PCL-M), Primary Care Post Traumatic Stress Disorder (PC-PTSD), Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST), OQ - 45.2, Beck Anxiety Inventory (BAI), Beck Depression Index-II (BDI-II), Locke Wallace Relationship Inventory (LW), and a job performance inventory based upon the Army’s Noncommissioned Officer Effectiveness Report (NCOER). In addition to these instruments, this study will look at and compare the individual's involvement in pre-and post-administrative incidents such as DUIs and domestic violence episodes which are often reflect a lack of resilience to daily stressors.

Design Procedures

The study will involve group and individual therapy conducted by licensed providers in the Department of Behavioral Health. The IOP group is primarily for soldiers who have not made adequate progress in routine outpatient behavioral health treatment and need more intensive treatment without the restrictions of the psychiatric inpatient setting. These soldiers may have been recently discharged from an inpatient treatment program. However, it is determined through additional evaluation methods that further treatment is needed in order to accomplish their treatment goals. Soldiers will be identified for the IOP by their treatment provider who refers the soldier to the program based upon their clinical assessment of the soldiers need for further, more intense treatment. The selection of soldiers is also endorsed by the Battalion Commander, who provides the support for the soldier by allowing them time during the normal duty hours to attend the program. In the IOP group, individuals are selected for the group based on established criteria by a single provider. In addition, the treatment providers in the IOP program will be constant throughout the treatment process.

Data will be collected at baseline and at the program’s conclusion. Each individual will be administered the instruments and results will be analyzed to determine if there is a statistically significant difference between pre-and post-scores. In addition, the individual’s commander with be given the job performance inventory at baseline and at 90 days post treatment to determine if there is a statistically significant level of improvement in duty performance.

This study will include the following chapters: Chapter 2 will focus on a critical review of the literature. The literature review will focus on IOP treatment and conventional outpatient modalities such as pharmacotherapy as well as various treatment modalities such as CBT, CPT, and DBT and their overall effectiveness especially within the military population.

Chapter 3 will focus on the methodology used in the IOP program. It will examine the instrumentation being used, the selection process for the soldier, the treatment process that takes place in the groups for the 4-6 weeks of treatment. It will also will examine the validity of the instruments and the methodology used to determine the overall effectiveness of the treatment program. The results which will be discussed in Chapter 4. Chapter 5 will Review the IOP program as a treatment modality, compared to traditional Army IOP and its focus on PTSD. In addition, it will examine the unique focus of this IOP program and its focus on resiliency and return to duty (RTD). This chapter will also include a discussion of the results and the impact the IOP program has had on the soldier and his/her increased mission capabilities. Finally, there will be a discussion of the study limitations and thoughts about future studies.

Research Questions

The key questions for this study focus on soldier resiliency. Is the soldier improving in his/her ability to manage crisis events that take place during the week? Are they learning skills in treatment which they can generalize to their daily life?

Assumptions

It is assumed that the overall effectiveness of the IOP will be demonstrated statistically and empirically through the data collected as well as IOP participants’ self-report. It is further assume that the standards for selection of individuals for participation in the IOP will be applied equally to all individuals being considered.

Definition of Terms

Resiliency is being defined as "an individual's capacity to withstand stressors and not manifest psychology dysfunction, such as mental illness or persistent negative mood" (Neill, 2006).  In other words, the ability of an individual to have the capacity to deal with difficult life issues without developing some form of psychopathology.

According to Neill (2006), psychological stressors or "risk factors" are often considered to be experiences of major acute or chronic stress such as death of someone else, chronic illness, sexual, physical or emotional abuse, fear, unemployment, and community violence. In case of the military population we would have to their combat stress, increased unit tension due to increased operations tempo, and mission responsibilities.

Neill believes that the central process involved in building resilience is the training and development of adaptive coping skills. The basic flow model (called the transactional model) of stress and coping is: A stressor (i.e. a potential source of stress) occurs and cognitive appraisal takes place (deciding whether or not the stressor represents something that can be readily dealt with or is a source of stress because it may be beyond one's coping resources).  If a stressor is considered to be a danger, coping responses are triggered. Coping strategies are generally either be outwardly focused on the problem (problem-solving), inwardly focused on emotions (emotion-focused) or socially focused, such as emotional support from others.

Neill states that, “in humanistic psychology, resilience refers to an individual's capacity to thrive and fulfill their potential despite or perhaps even because of such stressors.  Resilient individuals and communities are more inclined to see problems as opportunities for growth” (Neill, 2006).  Stated plainly, people who exhibit resilience not only deal effectively with stressful experiences they see them as a challenge and use the entire event as an opportunity ror a learning experience and growth development.

While some individuals may seem to prove themselves to be more resilient than others, it should be recognized that resilience is a dynamic quality, not a permanent capacity.  In other words, resilient individuals demonstrate dynamic self-renewal, whereas less resilient individuals find themselves worn down and negatively impacted by life stressors.

John Dewey (1859-1952 as cited in Neill, 2006), the renowned 20th century American educational philosopher, describes this sense of continuance through dynamic self-renewal:

A stone when struck resists.  If its resistance is greater than the force of the blow struck, it remains outwardly unchanged. Otherwise, it is shattered.  While the living thing may easily be crushed by a superior force, it nonetheless tries to turn the energies which act upon it into means of its own further existences...  It is the very nature of life to strive to continue in being.  Since this continuance can be secured only by constant renewals, life is a self-renewing process.

Post Traumatic Stress Disorder, according to the Mayo Foundation for Medical Education and Research (2009), is being defined a type of anxiety disorder that's triggered by a traumatic event. You can develop post-traumatic stress disorder when you experience or witness an event that causes intense fear, helplessness or horror.

Intensive Outpatient Program (IOP) as defined by the American Society of Addiction Medicine (ASAM) as treatment which consists of anything greater than 9 hours of therapy per week. Furthermore, an IOP is an alternative to inpatient hospital treatment or partial hospitalization of certain psychiatric or chemical dependency conditions as determined by patient’s symptoms and level of functioning. An IOP must provide a comprehensive intake assessment including both mental health and chemical dependency. An IOP must offer multi-modal, multi-disciplinary structured outpatient treatment that is significantly more intensive than outpatient psychotherapy and medication management. Intensive outpatient programming is indicated for patients, often in crisis, who require structured, multi-modal treatment (individual therapy, group therapy, family and/or multi-family as appropriate and unless contraindicated, and psycho-education) to achieve alleviation of symptoms and improved level of functioning. The program will have a variable length of treatment and will have the ability to reduce each participant’s frequency of attendance as symptoms are alleviated and the individual is able to resume more of his/her usual life obligations. All treatment plans must be individualized, focusing on stabilization and transition to community based outpatient treatment and/or support groups as needed. The IOP must be administered by a licensed professional and sufficiently staffed to allow for rapid professional assessment of a change in mental status which could warrant a shift to a more intensive level of care or change in medication (North Carolina State Health Plan, 2007).

Noted Limitations

While this study will be comprehensive, there are several limitations that will impact the final results. Individuals who are selected for the IOP are also required to be engaged in weekly individual therapeutic session. While this study will examine overall effectiveness of the IOP, it does not take into consideration the confounding affect that the individual therapy may have on the IOP therapeutic results. In addition, soldiers involved in the IOP will also have the opportunity to receive family and marriage therapy which can also impact the data gathered on the IOP program. Furthermore, unit support or the lack thereof can be a critical issue in the overall effectiveness of the outcome of treatment from the soldier’s perspective. An additional limitation is that the standards for entrance into the IOP are subjective in nature and therefore may not be equally apply to all individuals requesting entrance in the program.

Summary

There are currently numerous efforts to help soldiers successfully return from combat experience in the War on Terror. However, the impact of the Iraq and Afghanistan conflict has been always evident because many of the soldiers returned with wounds that cannot be seen but nevertheless present. As such, these wounds will be felt by soldiers and their families for many years to come. Therefore, it is imperative that we provide the best treatment options available to assist the soldiers in their recovery and return them to society and the world they in order to go and serve their country. Through the IOP it is hoped that soldiers will be able to develop greater resiliency that allow them to deal effectively with their combat experiences as well as a daily stressors they must deal with while in garrison.

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