by Michael D. Anestis, M.S.
In recent years, I have developed a strong interest in researching and treating mental health issues in military personnel. That being said, PBB has published featured articles by members of the military (Craig Bryan, Chad Morrow) as well as a number of articles in which I have summarized research findings on this topic. Today, I would like to build upon that knowledge base by discussing an article just published in the Journal of Consulting and Clinical Psychology by Amy Adler, Paul Bliese, Dennis McGurk, and Charles Hoge of the Walter Reed Army Institute of Research (WRAIR), and Carl Castro of the Medical Research and Materiel Command (2009). In this article, the authors examined the degree to which Battlemind - an early intervention designed by WRAIR - would help reduce symptoms of post-traumatic stress disorder (PTSD), depression, and sleep difficulties in soldiers returning from year-long deployments to Iraq relative to standard Army stress debriefing protocols.
Before going any further, I would like to stress that my efforts to summarize these interventions will by no means provide readers with a full understanding of the procedures involved. As such, I highly recommend that you consult the official Battlemind website, developed by the US Army, if you would like a more complete understanding of the protocols.
Okay, on to the study itself. Adler and colleagues (2009) opened by discussing a pressing problem facing the United States today: increased rates of PTSD, depression, and sleep difficulties in soldiers exposed to deployment-related stress (Hoge et al., 2004; Neylan et al., 1998). Unfortunately, mental health difficulties appear to increase dramatically in the initial months following return from deployment, with 20%-30% of US military personnel reporting symptoms of psychopathology 3-6 months after returning home (Bliese, Wright, Adler, Thomas, & Hoge, 2007; Dohrewend et al., 2006). Clearly, these numbers point towards a pressing need for interventions to help soldiers returning from deployment to more successfully reintegrate into civilian life and to prevent increases in dangerous symptoms of mental illness.
Adler et al (2009) attempted to address the lack of research on early interventions in military populations by developing a randomized controlled study comparing four different treatment conditions:
- Standard Army post-deployment stress debriefing
- Battlemind debriefing
- Small group Battlemind training
- Large group Battlemind training
The authors compared small and large Battlemind training groups in order to ensure that the size of the group of individuals in an intervention was not the primary mechanism of change in treatment. The paper itself did not provide a particularly thorough description of the difference between Battlemind debriefing and Battlemind training; however, it did delineate clear differences between those conditions and the standard Army stress debriefing protocol (if anyone has a more thorough understanding of the differences and wishes to share in the comment section, that would be fantastic). Specifically, Battlemind procedures focus on the manner in which occupational skills developed leading up to and during deployment (e.g., unit cohesion, maintaining tactical awareness, accountability) are vital during deployment but potentially problematic when taken to an extreme upon reintegration to civilian life. Unit cohesion can, in theory, cause post-deployment soldiers to seek out connections only with fellow soldiers, leading to a sense of distance, withdrawal, and emotional numbness with family and peers. Maintaining tactical awareness can theoretically lead to PTSD symptoms such as hypervigilance, hyperreactivity, startle, and sleep difficulties. High levels of accountability can lead to an intolerance of mistakes by others, which could result in social difficulties and anhedonia. Battlemind takes a cognitive perspective and works with soldiers to harness those skills in a productive manner so as to help them more smoothly utilize their skills for a successful reintegration into civilian life. In other words, they are not taught to blame themselves for their troubles, but rather to take control of their health by applying the same skills they have come to rely on in deployment environments in a manner likely to be more productive in their current environment. Standard stress debriefing, on the other hand, simply educates soldiers on common reactions to stress, potentially harmful symptoms, positive coping behaviors, and warning signs to look out for in peers.
Importantly, before describing the results of their study, Adler and colleagues (2009) were careful to point out the somewhat controversial nature of stress debriefing interventions. You might recall from our discussion of Lilienfeld's (2007) list of iatrogenic treatments that research has shown critical incident debriefing to be a potentially harmful treatment. In other words, when individuals are debriefed about stress and asked to discuss the details of a traumatic event immediately following the trauma, studies have found that the result is, on average, an increased likelihood of developing PTSD. Studies of this nature, however, have involved two important differences that vastly diminish the degree to which they relate to early interventions in military populations. First, clients receiving critical incident debriefing tend to be individuals who were traumatized by an event that had no relation to their chosen occupation (e.g., victims of natural disasters). Second, individuals receiving critical incident debriefing interventions are often asked to discuss, in detail, the traumatic event. Although research has demonstrated that exposure exercises are critical in treating PTSD, such treatments (e.g., cognitive processing therapy, prolonged exposure) occur well after the event has occurred, allowing for normative responses to trauma to run their course. Military populations receiving post-deployment early interventions do not discuss traumatic events in detail, take part in the intervention after some time has passed following the trauma, and perhaps most importantly, are dealing with trauma related to their chosen profession in the company of peers who experienced the same event. This is not to say that the trauma is any less debilitating because it was related to the soldiers' profession, but rather that the lessons learned from the event are different and the social support structure is more firmly in place.
In this study, the authors randomly assigned 2,297 soldiers returning from 12-month deployments in Iraq to one of the four conditions mentioned above. Soldiers were always assigned to the same condition as the rest of their platoon. Four months after the intervention, 1,060 of those soldiers (46.1%) completed follow-up assessments (only soldiers still assigned to the same unit were included in Time 2). Given the small sample sizes utilized in most treatment studies, this is a remarkable sample.
The authors hypothesized that individuals in the Battlemind conditions would view training more positively than would individuals in the standard stress debriefing condition. Additionally, they hypothesized that individuals in the Battlemind conditions would report fewer symptoms of PTSD, depression, and sleep problems than would individuals in the standard stress debriefing condition. Also, the authors believed that individuals in the Battlemind conditions would report less concern regarding stigma relative to individuals in the standard stress debriefing protocol. Finally, because prior work by some of the authors (Ader et al., 2008) has indicated that soldiers exposed to higher levels of combat trauma experience the greatest benefit from early interventions, the authors also hypothesized that individuals with higher levels of trauma exposure who were in the Battlemind conditions would report fewer symptoms of psychopathology and concern for stigma than would similar individuals in the standard stress debriefing protocol.
So what did they find? Here is a quick summary:
- Neither group experienced immediate increases in distress or increases in levels of psychopathology at follow-up. This indicates that the treatments were not iatrogenic (they did not cause harm)
- Although different conditions were rated more highly on particular components of the larger question, the Battlemind conditions were viewed as substantially more positive than was the standard stress debriefing
- All three Battlemind conditions resulted in fewer PTSD symptoms than did the standard stress debriefing, but only for individuals with high levels of combat exposure
- Battlemind debriefing led to fewer symptoms of depression than did standard stress debriefing, but only for those with high levels of combat exposure
- Large group Battlemind training led to fewer symptoms of depression than did standard stress debriefing, regardless of individuals' level of combat exposure
- Battlemind debriefing and small group Battlemind training led to fewer sleep problems than did standard stress debriefing, but only for those with high levels of combat exposure.
- Large group Battlemind training led to fewer concerns regarding stigma than did standard stress debriefing, but only for those with high levels of combat exposure
- Small group Battlemind training did not result in better results than did large group Battlemind training, thereby indicating that group size is not the primary mechanism of change.
On the whole, the Battlemind conditions appear to be substantially better at reducing symptoms of psychopathology than is the standard stress debriefing protocol when applied to individuals with high levels of combat exposure. This tells us several important things: first, the concerns regarding iatrogenic effects for stress debriefing may not apply to military populations (when administered properly) and second, individuals who experience high levels of combat may be particularly good candidate for such interventions.
This study was impressive in a number of ways. The large sample size allowed the authors to detect small effects. There were no exclusionary criteria, meaning that the sample was representative of general post-deployment military personnel. The sample consisted of soldiers returning from extended deployments in an active war zone, meaning that the participants being studied actually represented an at risk population, thereby extending the generalizability of the findings.
If you would like to learn more about the treatment of post-deployment mental health difficulties, we recommend the following resource, which is available through our online store of scientifically-based psychological resources:
- The Post-Combat Field Manual to Sanity: Including Combat Stress, PTSD, and mTBI by Charles Hoge
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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