By Major Dr Carolyn Deans MAPS and Major Kristi Heffernan MAPS
1st Psychology Unit, Australian Defence Force
Australian military personnel are currently working in dynamic and challenging operational environments such as the Middle East Area of Operations and East Timor. Military psychologists and other mental health professionals who are based in these operational environments will be asked to assess and make decisions about how and where to treat reactions to traumatic or stressful events. A review of the evidence and anecdotal experience from providing psychological treatment in these environments has shown that interventions beyond immediate psychological first aid are possible. However, the decision about where to treat (i.e., within the operational environment or back in Australia) is complex and involves consideration of factors including whether evidence-based treatment is possible, whether resilience factors are present and whether certain organisational factors exist to ensure successful treatment.
There is some evidence (and broad acceptance) that frontline treatment provided to personnel who experience a stress reaction improves mental health outcomes (Solomon, Shklat, & Mikulincer, 2005). Frontline treatment (often referred to as PIES) involves treating close to the frontline (proximity) when there is an onset of symptoms (immediacy), whilst maintaining an expectation that personnel will return to duty. The focus is on simple strategies to treat the initial stress reaction.
Evacuation of military personnel from the operational environment for treatment is not consistent with PIES, and in some cases can be destructive to the sense of self efficacy and wellbeing of personnel affected. For example, soldiers' sense of meaning about the mission may be damaged by prematurely ending their time on operations. It also sets up the expectation that they will be returning home permanently as opposed to being assessed and treated with the possibility of returning to the operation. They may begin to focus on going home and seeing friends and family, as opposed to being motivated and actively engaged in a stress or trauma treatment plan.
One mechanism to ensure forward treatment of trauma is the use of Australian Defence Force policy on the treatment of personnel who are exposed to a critical incident (e.g., death of a colleague, serious illness or injury, or witness to bomb blasts). Critical Incident Mental Health Support (CIMHS) allows for early screening and psychological first aid (Department of Defence, 2006). During a CIMHS response, the psychologist is also able to build a relationship with command and medical staff to ensure a multi-disciplinary approach when making decisions about returning military personnel to active duty following exposure to trauma. There is limited evidence to advise on the variables that are important, however Creamer and Forbes (2004) suggest that a client's prior history, pre-existing risk factors, presentation severity, and response and motivation to treatment are important, while the final decision will be a matter of clinical judgment.
Initially, operational stress responses are treated with psychological first aid (remove, rest and reassure) with a focus on stress buffers such as exercise, reducing avoidant coping and social support. It is widely considered that the application of other evidence-based treatments for trauma (e.g., exposure and cognitive processing) can be resource intensive and difficult to achieve in the operational environment. Yet, it is the experience of the authors that these treatments can be applied successfully in operational settings.
On operations, the risk of future trauma exposure can be high. Therefore reducing symptoms of hyperarousal is critical due to the potential harmful effects that open pathways have for the laying down of future traumatic memories. Arousal reduction techniques endorsed by Creamer and Forbes (2004) - such as grounding, distraction, breathing, progressive muscle relaxation and exercise - have been trialled on operation. In our experience military personnel are willing to try these techniques and accept that they could be useful in reducing arousal levels. The benefits of arousal reduction techniques include: their ease of use in an operational context within a brief period of time; the ability to introduce the techniques during psycho-education and develop further during therapy; and the provision of military personnel with practical techniques that they can continue to use throughout their tour of duty.
Processing and graduated re-exposure
Once arousal reduction techniques are mastered, graduated re-exposure to traumatic memories becomes the treatment goal (Australian Centre for Posttraumatic Mental Health, 2007; Creamer & Forbes, 2004). Journal writing to enable processing of the traumatic memory (as endorsed in the literature on cognitive processing therapy) and thought evaluation techniques for guilt, resentment or anger, have been successfully implemented on operations as precursors to in-vivo exposure. If personnel are moved ‘rearward' (to a less dangerous base) for support, the first goal is to return them to their operating base in a functional capacity. By incorporating the need for meaningful tasks to maintain self efficacy, it has been possible to place personnel in alternative jobs (e.g., working in stores or the administration room) while they learn to control and/or overcome their symptoms, without encouraging avoidant coping.
Graduated exposure back to their main role becomes the next stage in treatment. In the case of infantry soldiers, this has included conducting a graduated program of short patrols, encouraging familiarity with the environment whilst learning to manage symptoms before expecting them to return to their jobs at full capacity. Emphasis has been placed on cognitive coping, arousal reduction and social support, as well as incorporating resilience factors (sense of purpose for the mission, reinforcing good training and skills) so they can continue to perform their job with a sense of empowerment and possible post-traumatic growth.
Social support is one of the strongest predictors of positive trauma outcomes. Whilst on operations, military personnel are removed from many of their domestic social supports. They do however become involved in a new social support system that can be an effective buffer against stress. Within the military, social support is often enacted through the medium of morale and team cohesion: morale is the enthusiasm and persistence with which a member engages in the activities of the group; cohesion is the tendency for a group to sustain a sense of collective identity, and remain united in the pursuit of its objectives. Both individual morale and team cohesion have been found to buffer against deployment stressors.
Psychological treatment at the front line must aim to maintain morale not only within the individual, but within the entire team. Treatment must also take into consideration the strong military ethos of ‘not letting your mates down', which can motivate military personnel to overcome their stress reaction so they can continue doing their job and be an active member of the team. In our experience, military teams vary in their attitude and approach to someone who requires treatment for a stress reaction. Often it is the amount of inherent risk in the job that dictates whether or not a team will continue to accept the risk associated with someone who is predisposed to further stress-related problems.
Good leadership from military commanders is an important variable in the psychological treatment process. The perennial challenge of command is to look after troops whilst achieving tactical and operational outcomes, i.e., balancing safety with the mission. Good leadership has been found to protect against mental health problems in military personnel (Castro & McGurk, 2007). The acceptance and support for the treatment of personnel exhibiting stress reactions is important when deciding when, where and how to provide treatment. It is difficult to develop a graduated exposure plan without the support of command. It is also difficult to develop treatment plans without clients feeling as though they have the trust of their team, their commander and their health care personnel.
Decisions around psychological treatment in an operational environment such as the Middle East or East Timor are based on a wider set of variables than the clinical assessment. The process involves the psychologist asking many questions to make integrated decisions informed by evidence-based treatment principles, resilience factors and organisational aspects that are likely to enhance or detract from a client's ability to respond effectively to treatment.
Military psychologists have an effective function far beyond that of simply initiating evacuation of personnel following exposure to stressful or traumatic events. Given the dynamic nature of the military, particularly on operations, frontline treatment of trauma must allow for a flexible delivery of services with a focus on early intervention that considers a number of processes in the decision making process. The ultimate end goal is to ensure the ongoing wellbeing of military personnel despite their exposure to potentially traumatic and stressful events.
The principal author can be contacted at Carolyn.Deans@vu.edu.au.
Australian Centre for Posttraumatic Mental Health [ACPMH]. (2007). Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder: Practitioner Guide. Melbourne: ACPMH.
Castro, C., & McGurk, D. (2007). MHAT IV Commentary. Traumatology, 13, 59-60.
Creamer, M., & Forbes, D. (2004). Treatment of posttraumatic stress disorder in military and veteran populations. Psychotherapy: Theory, Research, Practice, Training, 41(4), 388-398.
Department of Defence. (2006). ADF Critical Incident Mental Health Support Manual. Canberra: Department of Defence.
Solomon, Z., Shklar, R., Mikulincer, M. (2005). Frontline treatment of combat stress reaction: A 20-year longitudinal evaluation study. American Journal of Psychiatry, 162, 2309-2314.