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In the development of the Ft Carson IOP, there are several treatment modalities and theoretical concepts that come together to form the essence of the program. Though essentially based on cognitive behavioral principles, the central focus of the IOP is the development of resiliency within the group participant. This task is accomplished through the use of Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT) principles, and Cognitive Processing Therapy (CPT) as well as concepts associated with mindfulness and resiliency. This review of the literature will focus on an examination of those treatment modalities as well as an examination of the theoretical concepts associated with mindfulness training and resiliency.
Cognitive Behavioral Therapy
CBT focuses on reframing the thought patterns of individuals into more functional pro social patterns. CBT, which is based on Beck's model of emotional disorders, suggests that experience leads people to form assumptions. These assumptions are developed over time and based upon experiential learning, which the individual then uses as a guideline when dealing with their environment. These organized perceptions form the foundation of the individual's behavioral pattern determining how an individual will react to given situations (Beck, 1964 is cited in Renton, Dunn, Williams, & Bentall, 2004).
Therefore, how an individual responds to a given situation is triggered by what they have learned what they believe about that particular situation. Beck referred to these believes as schemas which basically form an individual's worldview and guides their behavior based upon this world view. In other words, if an individual believes that large crowds pose a threat to their safety; this individual will avoid large crowds. It is thoughts such as this, which become the foundation of CBT therapeutic treatment. Thus, it can be seen that a person's present difficulties are a product of prior experience, schema development and information processing, assumptions, external events and their interpretation, and behavior (Renton, Dunn, Williams, & Bentall, 2004). It then becomes the task of the therapist to help the individual reframe their thinking around these schemas that prevent them from living was considered a normal functional life style.
Since John Beck developed the principles of cognitive behavioral therapy in 1959, the modality has proved to be a successful treatment for substance abuse. "The National Institute on Drug Abuse which supports more than 85 percent of the world's research on drug abuse and addiction has found that the most effective treatment approaches include both biological and behavioral components." (Leshner, 1998, Forward. para 1)
What makes cognitive behavioral therapy so effective is its focus on how thoughts affect actions. (Beck, 1995) Focusing on thoughts and examining them in the light of reality and logic can reframe them resulting in different actions.
However, where these thoughts originate from is still a matter of debate. It is believed that there are essentially two areas of functioning that contribute to a person's behaviors one is conscience while the other is unconscious. Ellis (1962), and Meichenbaum (1977 automatic thoughts, i.e. those thoughts that occur without conscious effort based upon a given stimuli, are part of the conscious cognitive processing function. While behaviors that are associated with underlying beliefs are a function of the unconscious system of cognitive functioning causing a person to react in a given away even though the individual finds it difficult to explain or understand the rationale for the behavior. In other words, their reactions are based on feelings that they find difficult to understand or explain (Brewin, 1996).
Problem-Solving and Cognitive Therapies
Problem-solving therapy began in the late 1960s and early 1970s. This solution focused treatment modality seeks to address the resolution of immediate problems. Problem-solving therapy's design is to provide the most effective solution for a problem: The four skill sets which provide the foundation for the therapy are: 1. Problem definition and formulation, 2 generation of alternative solutions 3 decision-making and 4 solution implementation and verification. (Dobson, 2003)
The difference between cognitive therapy and problem-solving therapy is subtle. Problem-solving therapy focuses on providing an immediate resolution to a particular situation while cognitive therapy tends to focus on the thoughts and feelings surrounding a particular event, which leads to actions and outcomes. (Beck, 2003) Cognitive therapy has a subjective focus and seeks to reframe personal thoughts and beliefs about a situation or problem while problem-solving therapy focuses on the problem and the skills necessary to resolve that problem. (Dobson, 2003)
An example of how the two therapies might differ in handling a particular situation is one where an individual might find himself stuck in rush hour traffic angry and frustrated because he is going to be late for work. Problem solution therapy would focus on what the individual could do to avoid this problem in the future. Possible solutions might be leaving home earlier or taking a different route to work. Cognitive therapy would focus on the individual's feelings of frustration. The individual may be feeling frustrated because of a core belief that if he is late than his boss Might think he is a responsible and he could be fired. (Hanson, n.d.)
The similarities between the two are more apparent. The most noticeable similarity is that both recognize automatic thoughts and schemata as they pertain to problems found in daily living. However, problem-solving therapy tends to focus on the fact that problems are an inevitable part of daily life as opposed to things that occur because of some personal defect or deficiency. (Dobson, 2003)
The pros of problem-solving therapy lie in the fact that it is solution focused and common sense based. One solution focused approach SODAS (Stop, Options, Decide, Act, and Self - Evaluate) takes a logical and organized approach to problem solving. It calls for the individual to Stop - identify the problem and clarify the goal; look looked at all possible options; decide the best course of action by evaluating the pros and cons of each alternative; take action; and evaluate the outcome. (Hanson, n.d.) This approach takes a logical course of action to problem solving that is simple, structured, and leads to a clearly identified outcomes.
Cognitive therapy focuses on core beliefs and automatic thoughts that may prevent one from implementing problem-solving techniques. In a sense, cognitive therapy addresses the limitations of problem-solving therapy and problem-solving therapy addresses the limitations of cognitive therapy. Therefore, when the two are combined both therapies provided an effective treatment modality.
When it comes to deciding which the better approach is, it really depends upon the situation that one is dealing with. I would most likely use problem solution therapy with a client when it comes to dealing with and identifiable problem. Problem solution therapy offers the best approach to addressing issues at hand and resolving them in the most efficient and effective manner. But if the individual is overwhelmed by the problem to the point that they are incapable of gathering the necessary internal resources to deal with that problem, I would use cognitive therapy to examine their automatic thoughts and core beliefs surrounding the issue. It is at this point that cognitive therapy will provide the best means of addressing those automatic thoughts and core beliefs that serve as a roadblock to the individual's development of the internal resources needed to address the problem
The effectiveness of CBT as a treatment method 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 several others. In this study, 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 adolescents 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. (Muck, Zempolich, Titus, & Fishman, 2001) In another study, the combination of cognitive therapy and antidepressants was shown to effectively manage severer or chronic depression. Numerous studies and meta-analyses have shown that cognitive behavioral therapy is more effective than other treatment methods to include pharmacotherapy for mild forms of depression (Rupke, Belcke, & Renfrow, 2006).
Group therapy has also proven to be efficacious in the treatment of numerous mental health disorders using CBT as a treatment modality. In addition to the medications, according to McCabe & Antony (2002) the following group therapy treatments can be used in conjunction with the appropriate medication.
Psychoeducation. This includes a number of components: information about common reactions to trauma (e.g., that it is normal to be upset and have distressing symptoms shortly after a trauma); emotional support and reassurance to help relieve irrational feelings of guilt; encouragement to seek support from family and friends by talking about the trauma and associated feelings; education for the family about the importance of listening and being tolerant of the individual's emotional reactions and need to retell the event.
Anxiety management. This involves teaching skills to help manage the symptoms of PTSD including relaxation and breathing retraining, positive self-talk, and assertiveness training.
Behavioral and cognitive behavioral models have been developed and found to be very effective for reducing PTSD symptoms (Taylor, 2004). In addition, CBT has also been shown to be effective in dealing with anger, which often is a huge factor in someone dealing with PTSD (Cahill, Rauch, Sheila, Hembree & Foa, 2004).
The group members often use cognitive behavioral techniques when they challenge other members regarding automatic thoughts revolving around a failure when it comes to experiencing relapse. They remind the individual of the strength it took to come as far as they have in their struggle with drugs. The impact this has on the group member is powerful. When someone who knows what the struggle is like challenges their automatic thoughts regarding failure, it has a huge impact on changing those automatic thoughts. Another cognitive technique a group will use is helping each other examine their schemas. Each group member comes from a different background and experience based on their gender and ethnic background. By examining and challenging those long held beliefs about their world, group members help each other view things they always believed to be true from different perspectives. And, even though group members are diverse in their background and drug experience, they treat each other with dignity and respect. For many in the group the reason they return, even after the time in the group required by their probation officer has expired, is because they have found people who understand and care about them.
While CBT has proven to be an effective treatment therapy, it has not been proven that it is more effective in a group setting as opposed to other treatment settings. While data comparing group to other treatment settings is rare, nevertheless, there are studies that indicate group is no more effective than other treatment modalities. (Panas, et al., 2003) In a study based on the outcomes of 44 patients in a treatment study, pre and post-test results showed no significant difference between behavioral group therapy, behavioral individual therapy, and a traditional process-oriented interpersonal group therapy. (Shapiro, Sank, Shaffer, & Donovan, 1982)
The posttraumatic stress disorder clinical team from the Atlanta VA hospital conducted a field test on 102 veterans for 16-18 weeks and found statistically significant results at the conclusion of the treatment as well as six months posttreatment (Ready et al., 2008). Additionally, according to recent findings reported by the Institute of Medicine, it was determined that exposure therapy has proven efficacious in treating patients with PTSD (Law, 2008). However, because the Army is overwhelmed with soldiers returning from the battlefield with psychological and emotional problems, there currently are not enough counselors available to treat the disorder.
These studies demonstrate group counseling's effectiveness with clients suffering from the following problems and disorder such as trauma, (Gross, 2006). The 2-year follow-up of 74 Vietnam combat veterans diagnosed with PTSD, who received 4 weeks of mostly group therapy, reported an overall improvement rate of 28% and a relapse rate of 69% who were subsequently hospitalized for PTSD (Perconte, Griger, & Bellucci, 1989 as cited in Murray, 1992). Also, group counseling provide much needed support (Dowben, J., Grant, J., & Keltner, N. (2007, July). In addition, group counseling is a widely used practice in the military when dealing with a variety of psychiatric issues. According to Valvincent and Thomas treatment interventions for psychiatric illness were individual counseling, and group therapies (Valvincent & Thomas, 2005).
An example of group effectiveness is often seen in The Critical-Event Debriefing (CED). A CED is a group-counseling service conducted after a potentially traumatic incident that could affect the soldiers involved. CED's are conducted whenever there are extreme tragic incidents involving soldiers (Leary, 2007).
Emotion regulation is beginning to be recognized as an essential element in addressing many issues associated with psychopathology, such as depression and anxiety, posttraumatic stress disorder, substance abuse, and stress reduction (Cicchetti et al, 1995 as cited in Kumar, Feldman, & Hayes, 2008). Emotion regulation, also known as mindfulness training, is based upon ancient Buddhist philosophical training and thought. Its purpose is to enable the practitioner to recognize that events are not permanent and therefore the practitioner is able to decentralize the event thus minimizing rumination and avoidance (Kumar, Feldman, & Hayes, 2008). The practitioner learns to regulate their approach to experiences without avoiding the experience or over engaging in the experience. But rather, the individual learns to approach the experience from a perspective of acceptance and observation regardless of the intensity of the event (Bishop et al. 2004 as cited in Kumar, Feldman, & Hayes, 2008). By teaching individuals to develop a distance or decentralize from the relationship one has with their internal and external experiences, the result is a decrease in the emotional reactivity to events in a quicker return to baseline after experiencing the initial reaction to the event (Segal et al. 2002; Teasdale 1999 as cited in Kumar, Feldman, & Hayes, 2008). Recent studies have shown that the teaching individuals emotion regulation through mindfulness training, they are better able to refrain from avoidance and over engagement when it comes to dealing with events thus reducing depression and anxiety when faced with adverse stimuli (Kumar, Feldman, & Hayes, 2008).
Though mindfulness training is deeply rooted in Buddhist traditions, it was developed in the West by Kabat-Zinn as the backbone of his Stress Reduction and Relaxation Program at the University of Massachusetts Medical Center (Kabat-Zinn, 1990, 1994 as cited in Hamilton, Kitzman, & Guyotte, 2006). A technique often used in mindfulness training is yoga which enables the individual to focus on their bodies. By enabling them to relax more effectively and by becoming aware of the tension that exists in their body, the individual can decentralize from the tension and eliminate it. Through this learning experience, it is hoped that the individual can generalize this experience of tension identification and elimination to the stress the body feels when it experiences adverse stimuli.
Pharmacological and Non-Pharmacological Treatment Modalities
Current Drug Treatment Standards
Soldiers diagnosed with combat related posttraumatic stress disorder, display symptoms congruent with the DSM-IV diagnostic criteria such as complaining of recurring intrusive thoughts, inability to sleep at night, hypersensitivity, increased vigilance, and increased anger (American Psychiatric Association, 1994). From a pharmacological perspective, drugs such as Zoloft, Paxil and Prozac have been studied and used extensively in intriguing individuals with PTSD. These selective serotonin reuptake inhibitors (SSRI) have demonstrated over the years to be effective when dealing with traumatic stress disorder. In addition other drugs such as Effexor XR, a serotonin norepinephrine reuptake inhibitor, were found to improve both the re-experiencing and the avoidance symptoms of PTSD, but not hyperarousal (Bhagar & Schmetzer, 2007). The drug was effective and well tolerated in both short-term and continuation treatment of PTSD. In addition, because veterans with PTSD find it hard both to fall asleep and to maintain sleep because of hyperarousal and vivid nightmares related to combat, Remeron, and the benzodiazepine class of drugs, such as temazepam, and non-benzodiazepines, such as zolpidem (Ambien[TM]) and ezopiclone (Lunesta[TM]) are being used to address the issue of sleeplessness as well as panic attacks (Bhagar & Schmetzer, 2007). Significant others often report that patients scream in their sleep and may even wake up soaked in sweat. Prasozin and clonidine both decrease the central nervous system's noradrenergic activity. They have been found to be effective in decreasing hyperarousal symptoms and improving sleep in patients (Boehnlein as cited in Bhagar & Schmetzer, 2007). Other drugs used for sleep are the benzodiazepine class of drugs, such as temazepam, and non-benzodiazepines, such as zolpidem (Ambien[TM]) and ezopiclone (Lunesta[TM]). The danger here is that benzodiazepines can be habit-forming and caution is always advised (Bhagar & Schmetzer, 2007).
In addition to some of the posttraumatic stress symptoms listed above some soldiers return from the war zone with psychotic features. These features evidence themselves in hallucinations, delusions and hyperarousal. The drugs most often used to address these issues are strong antipsychotic drugs such as Zyprexa, and Seraquil. It is important to note that according to the US Dept of Veteran Affairs, pharmacotherapy is rarely used as a stand-alone treatment for PTSD and is usually combined with psychological treatment (Ruzek et al., 2009).
Drug Use vs. Non-Drug Use in the Treatment of Mental Health Disorders
Whether using pharmacotherapy or therapy without drugs, each modality has positive and negatives surrounding its use. The negative side of psychotropic medication would suggest that all the drugs really do is alter a person's state of reality and cause that person to feel better merely by altering brain chemistry and creating the illusion that they are doing better when in fact without the drug they really are no better than they were before. However, on the positive side, the use of psychotropic medication seems to provide an immediate relief for symptoms that could otherwise take months and possibly years of therapy to deal with. From a pharmacological point of view its proponents would argue that the drugs alleviate the problem and enable the soldier to deal with his/her life on a reasonably normal basis. The danger, of course, is that the soldier will begin to rely on the medication to just simply live day to day, refilling the prescription each time it runs out, thus perpetuating a cycle of drug use that keeps the person a slave to the drug as surely as any addict on the street. From a nonpharmacological point of view some would argue that suffering is a part of life and actually sees it as a character building technique, that rather than causing harm, builds strength in the individual ultimately making them a better person (Breggin & Cohen, 2000, p. 3). In much the same way, it would be like saying a person who has treatable cancer should just simply learn to deal with it without seeking the benefit that can be derived from chemotherapy because in the end, they will become a better person through the experience, albeit a dead person.
Combining Group Therapy and Pharmacotherapy as a Treatment Modality
However, according to the literature, by combining the two treatment modalities, soldiers may be able to benefit for the best of both worlds. Medications are warranted particularly when symptoms are significant and daily functioning is severely impaired, such as if the person has severe insomnia, an additional psychiatric condition (e.g., depression) is present, or if significant symptoms are still present following treatment. Among medications, selective serotonin reuptake inhibitors (SSRI's) have the most data supporting their effectiveness (McCabe & Antony, 2002).
When symptoms have lasted less than three months (acute PTSD) it is generally recommended that the medication is continued for 6 to 12 months. When symptoms have lasted more than three months (chronic PTSD) it is generally recommended that medication is continued for one to two years. Longer treatment may be required if significant symptoms are still present (McCabe & Antony, 2002).
The decision of whether to take medication for PTSD, and which medication to take should be based on the individual's past treatment history, the individual's medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and any other relevant factors.
Resilience and Trauma
The question of why some are affected by traumatic events to the degree that their life becomes debilitated by the experience and others, while moved by the experience, are not debilitated by the experience, remains a mystery for many. As a result, there's a growing interest in trying to understand those factors that provide a buffer to traumatic events creating a higher level of resilience in the individual experiencing the trauma (Hoge, Austin, & Pollack, 2007).
In the past several years there have been a number of theories have developed in an effort to try and explain the phenomenon of why some are affected by it, and others are not. One such theory suggests that as children one's intellectual capacity plays a role in the effects of trauma. While another theory suggests that intellectual capacity actually makes the individual more vulnerable because of increased sensitivity (Garmezy et al., 1984; Werner, 1989; Zimrin, 1986 as cited in Hoge, Austin, & Pollack, 2007). Another theory, and one that seems to be the most viable according to the research, is the belief that individuals who are more socially expressive or have greater verbal communicative skills along with a stronger internal locus of control are less affected by the trauma and those who do not possess these qualities (Luthar, 1991; Rutter, 1987; Werner and Smith, 1982 as cited in Hoge, Austin, & Pollack, 2007). Rutter (1999), believes that resilience is strongly influenced by the personal relationships that the individual develops particularly within their own family system.
According to Rutter (1999), begins in childhood and is formed within the family system. Rutter believes there are several factors associated with the family system that can cause a lack of resilience. Therefore, the development of psychopathology in the event of stressful situations is not only the results of the event itself, but the result of several factors that are preexisting in the individual's life. Rutter suggested that impaired family functioning and relationships in the face of traumatic events can add a significant influence on the development of resiliency within a child. In addition, Rutter also suggested that genetics plays a role in the development of childhood resiliency. Rutter stated that "parents who provide increased genetic risks for their children also tend to be more likely to provide sub-optimal environments and rearing conditions" (Rutter, 1999 p. 121). Rutter also suggested that how a child impacts his or her environment, rather than the other way around, can influence the development of resiliency within the child (Rutter, 1999). Therefore, Rutter believed that an individual's response to psychosocial stress and adversity has a great deal to do with their vulnerability to risk. Rutter also stated,
The findings emphasize that multiple risk and protective factors are involved; that children vary in their vulnerability to psychosocial stress and adversity as a result of both genetic and environmental influences; that family-wide experiences tend to impinge on individual children in quite different ways; that the reduction of negative, and increase of positive, chain reactions influences the extent to which the effects of adversity persist over time; that new experiences which open up opportunities can provide beneficial 'turning- point' effects; that although positive experiences in themselves do not exert much of a protective effect, they can be helpful if they serve to neutralize some risk factors; and that the cognitive and affective processing of experiences is likely to influence whether or not resilience develops (Rutter, 1999).
In 1979, Kobasa introduce the concept of "hardiness" to describe adults with stable personalities who are less affected by trauma because they possess three basic psychological characteristics and cognitions: commitment, challenge, and control (Hoge, Austin, & Pollack, 2007). Kobasa defined commitment is the ability of the individual to turn in events into something meaningful and important, while control refers to the individual's belief that they can control circumstances and events around them, and challenge refers to the belief that ultimately one grows and gains fulfillment and life by facing and dealing with life's challenges (Maddi and Khoshaba, 1994, as cited in Hoge, Austin, & Pollack, 2007).
In recent years, the study of resilience has focused on the impact of traumatic events on individuals who might develop posttraumatic stress disorder as a result of combat related stress, natural disasters such as hurricanes like Katrina, tornadoes, or events such as 911. Studies have shown that about 50-60% of Americans are exposed to significant traumatic events over the course of their lifetime; of those exposed, 8-20% develop PTSD (Kessler et al., 1995 as cited in Hoge, Austin, & Pollack, 2007). The studies have shown that there are several factors that contribute to the possibility of the individual developing posttraumatic stress disorder from the experience of traumatic events. These factors have been identified as pretrauma, peritrauma, and
Pretrauma variables are those variables that exist before the trauma occurs. Variables such as lower educational level, preexisting psychological factors, as well as lower intellectual capacity have been identified by researchers as possible contributing factors to decreased resilience in the face of trauma (Hoge, Austin, & Pollack, 2007). According to Carlier et al., (1997), as cited in Hoge, Austin, & Pollack, 2007) significant peritraumatic variables include the magnitude of the stressor and immediate reactions to the stressor, such as fear of threats to one's safety (Basoglu et al., 2005 as cited in Hoge, Austin, & Pollack, 2007) or dissociation (Marmar et al., 1994 as cited in Hoge, Austin, & Pollack, 2007). Pertinent posttraumatic variables include perceived social support (King et al., 1998; Koenen et al., 2003 as cited in Hoge, Austin, & Pollack, 2007), subsequent life stress (Green and Berlin, 1987 as cited in Hoge, Austin, & Pollack, 2007), and ongoing threat to safety (Basoglu et al., 2005 as cited in Hoge, Austin, & Pollack, 2007). A meta analysis conducted by Brewin et al. (2000), as cited in Hoge, Austin, & Pollack, 2007), revealed that a significant contributing factors to posttraumatic stress were in order, lack of perceived social support, subsequent life stress, trauma severity, adverse childhood, and low intelligence. Peritraumatic dissassociation has also been suggested as a possible predictor of posttraumatic stress disorder following a traumatic event. Several studies have shown that survivors of the event exhibited dissassociative characteristics following the event. However, recent studies have shown that in post 911 survivors higher rates of peritraumatic dissassociation was not a predictor of eventual posttraumatic stress disorder (Hoge, Austin, & Pollack, 2007).
In light of these studies, it would seem logical to assume that one could simply look at resilience factors compared to stress factors to determine an individual's ability to respond to stressful situations and a more positive manner. However, Rutter (1987), as cited in Hoge, Austin, & Pollack, 2007) has suggested that resiliency is more than just the flip side of the risk factors associated with a traumatic event. Instead, resiliency encompasses factors and mechanisms that when engaged provide a level of resilience for the individual but otherwise may not even been known to be present until activated. In other words, an individual may not be aware that they have positive coping skills until challenged by risk factors associated with the traumatic event (Hoge, Austin, & Pollack, 2007). Additionally, studies have shown that a positive coping skills associated with an individual's perception of the event provide signific and resilienc see factors in the face of trauma. A study conducted by Johnsen et al. (2002) of soldiers who survived an avalanche found that "task focused" coping skills and "emotionally focused" coping skills verses an avoidant approach play a significant role in the reduction of PTSD scores. Task focused self talk such as "I can develop a plan to get out of a deal with the situation" or emotionally focused approach such as talking about one's feelings following the event as opposed to "I can't believe this is really happening" help to provide a level of resilience for the individual that reduces the outset of overwhelming stress.
Along with positive coping skills several other resiliency factors have demonstrated in several studies their protective nature regarding stress. Factors such as psychological preparation as well as those who felt a sense of commitment to a particular cause have been shown to provide protective factors when dealing with stress. In a study conducted by King et al. (1998), as cited in Hoge, Austin, & Pollack, 2007), 1632 Vietnam veteran soldiers were found to have lower PTSD scores because of their association with organizations that provided both structure and social support.
The researchers have concluded that while there are many factors associated with providing resilience in the face of traumatic events there are still much research that needs to be a conducted. Research that focuses in the area of providing interventions for individuals who lack the necessary resiliency factors to deal with overwhelming stress would be very useful particularly in working with soldiers were headed for combat.
Cognitive Processing Therapy
A growing body of research has explored the relationship between traumatic events and subsequent cognitions. For instance, survivors sometimes exhibit self-blaming thoughts and guilt about actions that they did or did not engage in during a traumatic incident (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999; Frazier & Schauben, 1994; Janoff-Bulman & Wortman, 1977; Kubany, 1994; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Resick & Schnicke, 1993 as cited in Sobel, Resick, & Rabalais, 2009). Because of their experiences, survivors sometimes develop cognitive distortions, which are inaccurate thoughts. Foa and Rothbaum (1997, as cited in Sobel, Resick, & Rabalais, 2009) proposed that posttrauma cognitions can be classified into two general categories: beliefs that the world is dangerous and thoughts about being incompetent. A more elaborated theory by McCann, Sakheim, and Abrahamson (1988, as cited in Sobel, Resick, & Rabalais, 2009) delineated trauma-related cognitive distortions in five areas: agency-which refers to the attributed cause of a traumatic event-safety, trust, power, esteem, and intimacy.
It is believed that when an individual is confronted with the traumatic event which is inconsistent with the experiential world of the individual, the cognitive processing that takes place is either to assimilate or to associate the experience in to the person's preexisting schemas. Assimilation occurs when the individual incorporates into their existing schema the events which just occurred. But the manner in which the individual assimilates the traumatic event into their schema can be a determining factor in whether or not the individual will experience the event an overwhelmingly stressful moment in their life. With assimilation the individual may expect what they have experienced is a normal function of an event. In other words, the soldier to going into combat may expect that there will be shooting possibly resulting in death and therefore because they expect and anticipate this kind of action if they are able to assimilate it into their schema if and when it occurs. However, if the individual believes that when the traumatic event occurs they should have or could have done something to prevent it from happening. Thus the resulting belief creates an association of guilt with the event and makes the individual responsible for the event itself. Because the individual now feels responsible for either all or some portion of the event that challenge is to reframe their thinking around that event to the degree that it enables them to function on a day to day basis as they did prior to the event. According to Foa and Rauch, (2004, as cited in Sobel, Resick, & Rabalais, 2009) and methodology that has been successful in reframing those maladaptive cognitions is cognitive processing therapy (CPT).
CPT is an evidenced-based 12 session program that researchers believe provides an effective treatment for individuals who have experienced a traumatic event. CPT uses cognitive therapeutic techniques and written accounts to help the patient reframe their thinking around a traumatic event. CPT endeavors to help patients understand that they are not at fault for the cause of the event nor is there anything they could go on to prevent the event, occurring (Sobel, Resick, & Rabalais, 2009).
Dialectical Behavioral Therapy
Dialectical behavioral therapy (DBT) is based on cognitive behavioral principles designed to address suicidal and destructive behaviors and emotion regulation among individuals diagnosed with a borderline personality disorder (BPD) (Linehan, 1993, as cited in Black Becker & Zayfert, 2001). In addition to using cognitive behavioral practices DBT also involves Eastern meditative practices into its treatment methodology.
While the DBT is infinitely more complicated and complex than this paper will cover, there are several principles associated with DBT and that are applicable to the work being done in the Ft Carson IOP. Those principles include biosocial theory, balancing acceptance and change, validation, mindfulness skills and distress tolerance skills.
According to Linehan (1993), biosocial theory is associated with individuals who have temperamental vulnerability to emotional dysregulation due to being raised in an invalidating environment. The understanding of this theory enables providers in the program to be more sympathetic to patients who presented as extremely needy and distressed. In addition it also serves as a rationale to the patience for skills training that enables them to reduce their distress.
Acceptance and Change
As with many things in life there is a delicate balance between acceptance and change on the part of the patient who is dealing with stress related issues. For the patient, the challenges to recognize and to accept the reality that there are things in their life that have occurred which may be affecting them now, and these things cannot be changed. For the patient attempting to develop resilience in their life the struggle begins when they tried to change the behaviors of others as well as immutable circumstances in their life only to find that their efforts are unsuccessful. This lack of success breeds frustration and disappointment which ultimately results in the individual developing a feeling of being overwhelmed by circumstances they cannot control or understand. The concept of change enters the picture after the individual recognizes and accepts the reality that the event they wish to change or the circumstances or situation they find it uncomfortable in and of itself cannot be changed, but what can be changed is how they deal with that event or circumstance. Once the patient begins to realize that how they approach the situation plays a significant role in how that situation impacts them creates a positive power dynamic for the patient enabling them to feel a sense of control over a situation where event that previously seem to control them.
The importance of balancing acceptance and change for patients who lack resilience in their life is an essential ingredient in their ability to create a sense of hope and positive direction for their life. Many patients come into treatment believing that they are incapable of affecting any positive change in their life because many have received limited or nonexistent validation of what they have experienced or are currently experiencing. Many have been told to simply "forget about it" or "stop being such a wimp" or other less encouraging and a more colorful phrases all designed to diminish and invalidate not only the experience that the patient is dealing was that the patient him or herself.
Validation is an important concept in the treatment of individuals who are experiencing overwhelming stress; whether that stress is from their lack of resilience to daily stressors or the result of combat stress experienced while deployed. According to Linehan the essence of validation in treatment is defined in the following manner:
The therapist communicates to the client that her responses make sense and are understandable within her current life context or situation. The therapist actively accepts the client and communicates this acceptance to the client. The therapist takes the client's responses seriously and does not discount or trivialize them. Validation strategies require the therapist to search for, recognize, and reflect to the client the validity inherent in her response to events. (Linehan, 1993a, pp. 222-223)
While validation is an important ingredient in any psychotherapeutic technique it is an indispensable ingredient in the development of the therapeutic relationship especially in the use of DBT techniques. Validation plays a crucial role in DBT due to its role as a core intervention in the treatment of patients (Black Becker & Zayfert, 2001).
In the Ft Carson IOP, validation takes place with the providers recognize the experiences of the patient's and rather than debating those experiences or diminishing the impact that those experiences had on the patient, the providers seek to explore different ways of reframe the those experiences through the use of mindfulness skills building techniques and distress tolerance skills.
Skills training techniques are used in DBT to increase and bolster the patient's ability to cope with negative emotions as well as creating a greater sense of resilience to stressful situations. Mindfulness skills as one of the skill sets that is used frequently and DBT to help the patient and understand the framework of their mind and as it relates to their approach to various events. DBT describes three states of mind with which an individual can approach various events. According to Linehan (1993) these states of mind are the reasonable mind, the emotion mind and the wise mind. The reasonable mind is engaged when the individual is thinking logically and rationally. By contrast, the emotion mind is engaged when the patient is thinking primarily with their emotions and the wise mind is displayed when the reasonable mind and emotion mind are integrated and the whole becomes greater than the sum of its parts (Black Becker & Zayfert, 2001). The value of understanding this concept for the patient provides an explanation for those times when they can be completely without emotion regarding one subject well on the other hand completely overwhelmed by emotion when dealing with another subject. For many patients the ability to understand the dichotomy between the rational mind and emotional mind enables them to understand the feeling that on the one hand they know that stressful events need not completely overwhelmed them and control their lives on the other hand they feel absolutely powerless to prevent that from happening.
The value of mindfulness training is that it enables the patient to understand the importance and value of the emotions as well as enabling them to be present in the moment and except all that being present entails. Through the use of DBT mindfulness skills are broken down into two areas: "what" skills which include observing, describing, and participating, and the "how" scales which include taking a nonjudgmental stands and focusing on one thing in the moment (Linehan, 1993).
The use of mindfulness skills to generally in dealing way of patients who are experiencing a lack of resilience to overwhelming stress enables the patients to embrace the emotions associated with those stressful events. For many patients the avoidance of emotion in an attempt to deal with their inability to effectively handle the stressful event or moments in their life often becomes a practice that manifests itself in impulsive behaviors, suicidal ideations, substance abuse, and increased tension and marital relationships. By understanding the concept of rational mind, and emotional mind, the patient can understand the predominant mindset they are using to deal with events and then by focusing on using their wise mind can reframe the event into something more manageable thus creating greater resilience for the patient. In other words, when an event occurs and the patient is feeling overwhelmed by the event, they can pause for a moment and ascertain whether or not they are stuck in their emotional mind or rational mind. Then by merging the two into their wise mind they can effectively deal with the event in an appropriate manner without numbing themselves emotionally or allowing their emotions to so completely overwhelm them that they lose their ability to make effective decisions.
Distress Tolerance Skills
When dealing with distress, DBT differs from other treatments in its ability to focus exclusively on acceptance and tolerance of the emotions associated with the event as opposed to simply focusing on changing the distressing situation and the emotions associated with that situation (Linehan, 1993). The value of learning distress tolerance skills enables the patient to avoid maladaptive behavioral practices when dealing with distress such as suicidality, disassociation and impulsive behaviors.
According to Linehan (1993) the first step in developing distress tolerance is to accept the reality that the traumatic event actually happened. For many patients the behavioral practice is too avoiding acknowledging any emotional distress as the result of a traumatic event and those living in denial of their emotions and feelings regarding that event. By living outside of their emotions the patient believes they are able to carry on normal life functions while at the same time pretending that the event which they're trying to escape never occur. The problem with this behavior is that the traumatic event in reality it does not disappear but simply moves into the subconscious part of the brain only to resurface again in dreams and nightmares causing the patient sleepless nights or violent episodes while sleeping. By focusing on accepting the reality of the event, and the emotions associated with that event, it enables the patient to process the event in the present while at the same time recognizing that what happened in the past need not complicated or impede on the present.
With the increase in operations tempo, the result is more soldiers are returning from the battlefield with the need for increased resiliency skills that will enable them to deal not only with the stresses they experienced in combat but also the stresses the experience on a day to day basis. When the soldiers present for mental health treatment, many are given a variety of medications which for them is like putting a Band-Aid on a laceration that requires stitches. It may help for a while but it is not sufficient enough to deal with the seriousness of the problem. When it comes to treating stress related issues it is sometimes easy to just simply prescribe medication and hope that the problem is solved. But the reality is that providing only medication for the treatment a lack of resiliency and inability to cope is simply running the risk of creating an additional problem that results in a lifetime of reliance on psychotropic medication. However, treating mental health issues with psychotherapy as well as pharmacotherapy methods in the end produces a balanced treatment regimen that has the potential to provide lasting long-term effects for the soldier. Without a doubt we want our soldiers to have the best equipment when we asked them to do the job, therefore it only make sense that we should provide them the best in treatment when they have completed that job and need our help in order to return to normal living.