Psychotherapy Brown Bag

Free online resource for learning an evidence-based treatment of PTSD

by Michael D. Anestis, M.S.

A few days ago, I received notice of what appears to be a remarkably valuable resource.  The Medical University of South Carolina has developed a website entitled CPTWeb, funded by the United States Navy Bureau of Medicine and Surgery, that provides free instruction on how to implement cognitive processing therapy (CPT) for post-traumatic stress disorder (PTSD).  CPT is an empirically supported treatment for this disorder (although it is not the only one) and a number of trials we have discussed in earlier PBB posts have demonstrated its efficacy and effectiveness in treating the disorder.

Here is some basic information about the site:

• There is no charge for using this program
• The entire course requires 9-hours, but clinicians can learn the material at their own pace
• Patricia Resick, who developed CPT, played an integral role in the development of CPTWeb
• The material is focused primarily on military populations, however, it should generalize well to civilian clients as well
• Clinicians who complete the online course can receive 9 contact hours of continuing education from the Medical University of South Carolina (from the publicity materials I have seen, it is unclear if this only applies to clinicians treating military clients; however, I suspect this generalizes regardless of the population being treated).

The course consists of a number of modules covering different components of CPT and each module includes:

• Video introduction to the technique
• Pre- and post-tests of knowledge of the treatment component
• Overview of module's learning objectives
• Description of the technique of the treatment component
• Step-by-step instructions for how to implement the technique and sample scripts for introducing the technique to clients
• Multiple video demonstrations of the technique
• Suggested practice assignments for clients
• Discussions of common obstacles to implementing the technique in "real world" practice

The URL for the online course is http://cpt.musc.edu/index

Although I have not taken the course myself, at first glance it appears to be exactly the type of translational product that this field needs.  By making instructions in empirically supported treatments free and available online, we enhance the likelihood that a greater proportion of people involved in mental health will approach psychotherapy from a scientifically-minded stance.  Only good can come from that type of shift and Joye and I wholeheartedly support the efforts being made here by MUSC and those involved in funding and developing the project.

If any readers end up taking part in this course, we would love to hear about your experiences, good and bad.  Readers would definitely benefit from that information.

If you would like to learn more about PTSD and its treatment, we also recommend the following items, each of which is available through our online store for scientifically-minded psychological resources:

• Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide by Edna Foa, Elizabeth Hembree, and Barbara Rothbaum

• Cognitive Processing Therapy for Rape Victims: A Treatment Manual by Patricia Resick and Monica Schnicke

• Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide by Edna Foa, Kelly Chrestman, and Eva Gilboa-Schechtman

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Dismantling cognitive processing therapy (CPT): How we can determine which components of an empirically supported treatment for PTSD are most useful

by Michael D. Anestis, M.S.

An interesting interaction in the comment section on the recent "bad science" article got me thinking about today's topic: dismantling studies.  When we design treatments, our underlying belief is that each aspect of treatment contributes to the improvement of the client.  In other words, we do not design treatments that we believe include useless activities.  That being said, like any belief, this one is subject to empirical investigation and one of the ways that we do this is through dismantling studies.

Let's say, for instance, that it was me rather than Aaron Beck who designed cognitive behavioral therapy (CBT) for depression.  Let's also say that, in my version, I included an added component at the end of therapy during which the client ate a ham sandwich - a wonderfully tasty ham sandwich.  Let's further say that my theory behind the ham sandwich component was that ham is inherently a positive experience due to its extreme tastiness and that my belief was that having such a wonderful experience at the end of treatment was pivotal in helping the client accept that they had healed and to move forward into their newly happy life with confidence.  I suspect that nobody reading this believes my ham theory; however, regardless of the general consensus of the theory's validity, we actually do not have to simply wonder or take somebody's word for it.  This is an empirical question that can be tested.  We simply need to recruit a sample and randomly assign individuals to either receive the Anestis ham sandwich CBT approach or Beck's hamless CBT and see if there are any differences between the groups.  If the ham sandwich was important, the ham group would exhibit greater improvements.  If not, there would be no difference - or alternatively, the other group might demonstrate that the ham addition was harmful or at least an obstacle in treatment by exhibiting greater improvement.

Fortunately, several less ridiculous hypotheses have been tested and today I would like to discuss one of them.  In a study recently published in the Journal of Consulting and Clinical Psychology, Patricia Resick and colleagues (2008) dismantled cognitive processing therapy (CPT).  CPT is one of two well-established empirically supported treatments (EST's) for post-traumatic stress disorder (PTSD), with the other being prolonged exposure (PE).  CPT involves two basic components: cognitive therapy aimed at challenging distorted cognitions and 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 individuals components of treatment would offer equally promising results.

Before describing the study itself, it is important to note that, while dismantling studies provide a lot of value, they are imperfect.  When a treatment is designed, the individual components only make up a portion of the treatment.  As such, when you compare the full treatment to treatment consisting only of individual components, that means that you are going to adjust the amount of time spent on any particular part of treatment.  In other words, if treatment is designed to last 12 sessions, those sessions are generally spent on a variety of skills.  If only one component is used, however, the dosage of that component will increase substantially.  As a result, when we compare a full treatment to treatment consisting only of particular components, we are not truly making an equal comparison. This imperfection, however, does not detract from the value provided by this type of study.

So, back to the study at hand.  The authors' plan was to compare full CPT to cognitive therapy only (CPT-C) and written accounts only (WAs) in order to see if any particular component was particularly useful and if the full protocol offered incremental value over the components individually.  All of the participants in the study were women who met criteria for PTSD as determined through a structured diagnostic interview.  Participants were excluded if they were illiterate (WA's would not work) or currently psychotic, suicidal, or dependent upon drugs or alcohol.  Individuals struggling with substance abuse were permitted to participate if they agreed to abstain throughout the course of treatment.  Participants also had to be at least 3 months removed from the traumatic event, as this is the period during which natural improvements independent of therapeutic interventions are most likely to occur and the authors wanted to ensure that their results were not better accounted for by the simple passage of time.  The intent-to-treat (ITT) sample included 150 individuals.

The authors were very careful to ensure that the therapists were faithful to the treatment protocol, taping every session, reviewing the sessions, and meeting for weekly group supervision to discuss cases.  Participants were randomly assigned to one of the three conditions.  For a full description of the therapeutic approaches, I recommend that you read the actual article, but here is a brief description of each condition:

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Standard CPT

Session 1: Education about PTSD, overview of treatment, rationale for treatment, assignment to write a description of the meaning of the traumatic event (impact statement)

Session 2: Read and discuss impact statement, learn about relationship between thoughts, behaviors, and emotions

Session 3: Assigned to write detailed description of traumatic event.  Clients are encouraged not to avoid emotional responses and to read the description to themselves daily

Session 4: Client reads statement to the therapist and therapist uses cognitive therapy approaches to question distorted cognitions.  Client again is assigned to write a description of the event for homework.

Sessions 5-6: Same as session 4, but with greater emphasis on teaching the client to challenge distorted thoughts

Sessions 7-12: Clients use more advanced worksheets to practice challenging thoughts and understanding the relationship between thoughts, emotions, and behaviors.  In session 11, the client is asked to again write a description of the event, this time reflecting new beliefs, and the new version is read and discussed during the final session.

Cognitive therapy only (CPT-C)

The protocol for CPT-C was identical to standard CPT, minus the use of written accounts.

Written accounts only (WA)

Whereas in standard CPT, the clients write their WAs at home, in this condition, the clients write the descriptions in session in order to ensure that they take sufficient time and are exposed to thoughts of the trauma for a substantial period of time.  Clients are instructed to frequently note their subjective units of distress (SUDs), a measure of how much general distress he or she feels at a given moment - through the writing process in order to chart shifts in negative affect.  The client reads the WA to the therapist, but no cognitive therapy approaches are used in response.  Instead, the therapist is only allowed to make nondirective supportive comments. Again, the clients are told to rewrite and read the WA to themselves throughout the week as homework.

***********

And the results...

So, what did they find?  Actually, the results were a bit surprising.  First of all, all three groups showed substantial improvement not only in PTSD symptoms, but also in depression, anxiety, anger, guilt, shame, and cognitive distortions.  Additionally, these benefits were maintained at a 6-month follow-up assessment after treatment had ended.  The success of all three groups was not particularly surprising, but the success of each group relative to one another was.  Full CPT, combining cognitive therapy and WAs, did not result in greater improvements than did either component on its own.  In other words, cognitive therapy alone and WAs alone were just as effective as full CPT.  On a measure of PTSD symptoms, cognitive therapy outperformed WAs; however, both groups produced impressive reductions in PTSD symptoms.

These findings are important, as they highlight the point that, while CPT is an effective treatment for PTSD, clients might benefit just as much from a protocol that only utilizes WA's or cognitive therapy.  Given that this is only one study and that the authors had to adjust the structure of WA's from what is typically done in CPT, we need to be conservative in our interpretations of the data and careful not to assume too much.  That being said, Resick and colleagues (2008) did a great job of directly assessing the question of whether or not a therapist needs to administer the entire CPT manual as outlined in order to attain the desired effect in treatment.  This early evidence suggests that the protocol can be adjusted to only reflect one component without losing the benefits of the entire protocol, but more research is needed in order to more fully address the question.

Importantly though, be careful not to look at these results an interpret them to mean that therapists can deviate from a protocol at random or simply as they see fit and produce equivalent results.  No therapist did this in this study, so there is absolutely no support for that assumption.  Deviation from the protocol in this study involved a pre-determined alteration with very specific steps designed prior to the onset of therapy.  As such, the idea of being "eclectic" and simply integrating what seems to work in an idiosyncratic manner is not an approach that is supported by this study. 

**Edit** I want to send a quick thank you to Dr.Resick.  In a thoughtful email, she alerted me to a point in this paper that was not properly emphasized.  In most studies on PTSD, the sample sizes and statistical methods used prevent researchers from being able to detect anything other than large effect sizes.  In other words, unless the difference between treatments is enormous, the difference is difficult to detect statistically and, as a result, some studies have failed to find expected differences between approaches.  Quite simply, it is difficult and expensive to recruit a sufficiently large sample and many researchers do not have the background in statistics to use the most efficient analytical procedures.  In this study, however, the sample size and particularly the data analytic procedure allowed for the detection of a smaller, but vital effect: the superior PTSD finding for CPT-C relative to WA.  Why is this so important?  Because it indicates that extinction (the removal of the fear response to cues related to the traumatic event) is not necessarily the end all be all of PTSD treatment and that cognitive processes may, in fact, be a more important target in treatment.  It will be very interesting to see how this plays out in future studies looking at outcomes across treatment approaches.

If you would like to learn more about PTSD or cognitive processing therapy, we recommend the following resources, all of which are available through our online store:

Cognitive Processing Therapy for Rape Victims: A Treatment Manual by Patricia Resick and Monica Schnicke

Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide by Edna Foa, Elizabeth Hembree, and Barbara Olaslov Rothbaum

Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide by Edna Foa, Kelly Chrestman, and Eva Gilboa-Schnechtman

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Bringing mental health treatment to the troops: An empirically-based process improvement for veterans with PTSD symptoms in primary care - April 2009 Psychotherapy Brown Bag featured article

by Craig J. Bryan, Psy.D.

Given that military service members are willing to sacrifice their lives to secure the safety of the nation, it is beholden upon us to ensure that proper care is available to them upon their return from deployment.  Such care includes not only interventions for physical injuries, but also effective treatments for mental illness.  In order to implement such treatments, however, a scientifically-minded approach is necessary, using data to inform the degree to which a treatment is actually accomplishing its purpose.  Additionally, the treatment must be portable and efficient so as to fit the demands of primary care environments.  In this article, I intend to provide a background regarding the current state of treatment for service members diagnosed with post-traumatic stress disorder (PTSD) and to detail efforts we have made to integrate empirically supported treatments into our health care protocol.  

The problem

    Symptoms of PTSD among U.S. military veterans deployed during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) have been detected at rates as high as 17%. Not unlike the civilian world, as the “first stop” for the majority of one’s health care needs, patients in the military have more frequent and feasible contact with medical providers in primary care clinics versus specialty mental health settings. Recent reports of psychiatric prevalence rates (i.e., meeting criteria for at least one mental health disorder) for OIF/OEF veterans seen in primary care were determined to be as high as 25% (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). PTSD symptoms are a significant health problem, contributing to poorer general health and somatic symptoms including headaches, chest pain, dizziness, fainting, and digestive problems (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). It should not be surprising that veterans with PTSD, therefore, visit primary care medical providers more frequently, and miss twice as many days of work, than veterans without PTSD (Hoge et al., 2007). These health problems and functional impairment increase with comorbid depression (Campbell et al., 2007), as does the risk for suicide (Oquendo et al., 2003).
    The convergence of these data, in combination with anecdotal reports and clinical experience, point to the primary care clinic as the most likely health care setting where military members’ PTSD symptoms will first be identified. Unfortunately, only 10% of male and 26% of female active duty personnel reporting mental health symptoms will pursue specialty mental health treatment (Visco, 2008). The reasons for low help-seeking behaviors among active duty personnel are wide-ranging and include such factors as avoidant coping strategies associated with PTSD, frequent re-deployments that contribute to instability in living arrangements, and mental health stigma stemming from fears that seeking mental health treatment will negatively impact the service member’s career.
    When I first started working in an integrated family medicine clinic, I found there was a sizable percentage of active duty veterans who returned to the primary care clinic again and again for sleep disturbances, low energy, diffuse pain, and other somatic symptoms that would not improve with traditional medical treatments. Often times these members would be referred to numerous medical specialties and undergo a wide range of tests and procedures that ultimately would result in negative findings. The impact of these veterans on the medical system was considerable, both in terms of financial expenditures and increased utilization of limited resources. As time passed, these service members continued to suffer and became increasingly discouraged and hopeless as specialist after specialist was unable to pinpoint the disease process underlying their health issues. It seemed very clear to me at the time that the problem with this subgroup of veterans was unrecognized PTSD (and oftentimes comorbid depression). Through consultation with the primary care providers (PCPs) in my clinic, we improved screening and identification of deployment-related health problems, and PCPs increased their referrals to me for behavioral health consultation.
In the beginning of this process, when I met with veterans whom I believed met criteria for PTSD, I would routinely encourage them to access specialty mental health treatment at the local outpatient clinic to initiate one of two empirically-supported treatments (ESTs) for PTSD: prolonged exposure (PE) or cognitive processing therapy (CPT). It did not take me long to recognize a significant problem with this approach: the overwhelming majority of service members outright refused to access specialty mental health services, preferring to “just deal with it on my own.” By and large, these individuals continued to experience functional impairment and continued to access medical services at a high rate. One variable that stood out was the persistence of re-experiencing symptoms (i.e., nightmares, memories, flashbacks), and, critically, the veteran’s continued employment of avoidance strategies in response to these experiences. It quickly became evident that, if any improvements were to occur with this group of veterans, targeting of re-experiencing and avoidance symptoms would be necessary, which would necessitate a re-engineering of how PTSD symptomatology was approached within primary care.

The parameters

    Various models of collaboration between mental health and medical providers—often termed integrated primary care—have been implemented to address the finding that 70% of medical visits in primary care are due to psychosocial factors. The models vary in terms of how the mental health provider interacts with patients and, more importantly, who maintains primary responsibility for treatment decisions. One model of integrated primary care is the behavioral health consultant (BHC) model, which is marked by collaborative decision-making between PCPs and mental health professionals, who serve as consultants to the PCP. The BHC model of integrated primary care has been implemented by the United States Air Force (USAF) at hospitals and medical clinics world-wide. A thorough discussion and explanation of the BHC model is not practical for the purposes of this article, but readers are directed to Robinson and Reiter (2007) and Gatchel and Oordt (2003) for further information about the BHC model.
    Based on the philosophy and practice standards of the BHC model, the following parameters were established a priori to guide treatment development within the scope of care of the BHC:

1. Interventions must be able to be delivered in less than 30 minutes. Because BHC appointments mirror the pace and structure of the primary care clinic, appointments are generally only 20-30 minutes in duration. Interventions must therefore be designed to be rapidly demonstrated and learned by the patient.
2. Interventions must demonstrate rapid, clinically-meaningful improvement. Because the typical course of care within the BHC model is very brief and time-limited, interventions must be highly-focused on the presenting problem and must demonstrate effectiveness in less than 5 appointments.
3. Intervention approach must be based on a self-management model. Interventions must be problem-focused and geared towards the development of specific skills that can be learned, implemented, and sustained by the patient with minimal support by the clinician, since appointments with the clinician typically occur in 2-3 week intervals.
4. Interventions must be supportable by the PCP. Because the PCP maintains full control of the patient’s treatment plan, any interventions developed must be acceptable and easily supported by the PCP. Similarly, the PCP must have a basic understanding of the rationale and mechanisms behind the intervention so they can explain treatment recommendations clearly to patients and effectively choose how and when to incorporate such interventions into their treatment plan. 

Assessing outcomes

    In order to determine the effectiveness of any interventions implemented, it was first necessary to define and measure the constructs of interest in a manner that was appropriate for the clinical context. Extensive assessment with multiple measures or lengthy questionnaires is inconsistent with primary care and impractical in a fast-paced setting that emphasizes volume over intensity of services. Outcomes measurement must, therefore, balance brevity and pragmatics with reliability and validity, and should be limited to only those constructs of interest. Two self-report checklists that were both brief and psychometrically sound were chosen.
     PTSD Checklist-Military Version (PCL-M). A particularly useful and practical measure for use with post-deployers seen in primary care is the PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993), which is a 17-item self-report inventory that assesses the severity of each DSM-IV-defined PTSD symptom. The PCL-M is widely used in the DOD and the VA, and it has excellent reliability and validity (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers, et al., 1993). Members referred for deployment-related issues can routinely complete the PCL-M in about 2-3 minutes either before or during each BHC appointment.
    Behavioral Health Measure-20 (BHM). The Behavioral Health Measure-20 (BHM) is a brief self-report questionnaire that uses a five-point Likert Scale to assess the three domains of mental health, consistent with the phase model of psychotherapy: well-being, psychological symptoms, and life functioning (Kopta & Lowry, 2002). The 20 items of the BHM aggregate to a total score that provides an index of overall mental health called Global Mental Health (GMH). The measure has considerable psychometric strength (Kopta & Lowry, 2002) and can be used to distinguish several levels of mental health functioning (Healthy, Mild Distress, Moderate Distress, Severe Distress) based on the clinical significance criteria recommended by Jacobson and Truax (1991). As such, the BHM is designed to detect clinically meaningful changes in mental health functioning.

Empirically-based modifications to primary care treatment for PTSD 

    In 2007, the Institute of Medicine’s (IOM) Committee on Treatment of Post-traumatic Stress Disorder published the most comprehensive scientific review to date of treatments for PTSD, which included results from 90 randomized clinical trials of psychotherapy and pharmacotherapy treatments for PTSD (IOM, 2007). The committee found that evidence of efficacy was sufficient only for exposure-based psychotherapies, while the scientific evidence currently available for other psychotherapy treatment modalities and pharmacotherapy were judged to be inadequate to determine efficacy. Prolonged exposure therapy (Foa, Dancu, Hembree, Jaycox, Meadows, & Street, 1999; Foa, Hembree, Cahill, Rauch, Riggs, Feeny, et al., 2005; Foa, Rothbaum, Riggs, & Murdock, 1991; Schnurr, Friedman, Engel, Foa, Shea, Chow, et al., 2007) and cognitive processing therapy (Resick, Nishith, Weaver, Astin, & Feurer, 2002; Resick, & Schnicke, 1992; Monson, Schnurr, Resick, Friedman, Young-Xu, & Stevens, 2006) have emerged from the past decade of clinical research as effective, first-line treatments for PTSD, and were therefore considered as potential candidates for modification and integration into a primary care clinic.
    Written exercises were initially utilized to target the re-experiencing symptoms (e.g., intrusive thoughts, memories, and dreams) that contribute to avoidance and emotional detachment, which are the primary mechanisms underlying the functional impairment among trauma survivors. These exercises entailed directing veterans to record any specific events from their deployment that they find particularly problematic or bothersome and were heavily influenced by the work of Pennebaker, who has demonstrated that writing about stressful events (which he termed expressive writing) can contribute to a range of improved health outcomes (Pennebaker & Chung, 2007). Referring to the intervention as “combat writing” instead of “expressive writing” seemed to increase the appeal of the exercise among veterans. Asking veterans to write and re-write an account of their traumatic deployment experience through combat writing mirrors the process of prolonged exposure (PE), which repeatedly exposes the patient to distressing memories until they habituate to the physiological and emotional arousal, which eventually contributes to the modification of beliefs and perceptions of the traumatic event and the reduction of the avoidant response patterns that fuel PTSD.
    Combat writing was employed in primary care because of its time-efficiency given the context of primary care, while maintaining an emphasis on repeated exposure to the traumatic memory and avoidant responses. In this way, it dovetails with the structure of the BHC service, in which the patient actively works to reduce symptoms outside of the appointment. Combat writing was utilized with a number of patients with some evidence of effectiveness (see Corso et al, in press, for a report of findings), with patient non-adherence being a particularly troublesome barrier. Patients cited several factors that reduced their adherence to the exercise:

1. Veterans would often avoid the task because the memories were uncomfortable. Because appointments with the BHC were spaced out over periods of 2-3 weeks, it was difficult for the clinician to promptly target avoidance and reinforce adherence. This contributed to delayed clinical response, which was problematic given the time limitations of BHC work.
2. Some veterans did not report a specific, identifiable traumatic event in which their lives, or the lives of others, were in danger or threatened, but rather reported a more generalized dissatisfaction or disgust with some aspect of their deployed experience. These veterans seemed to be experiencing more “existential” conflicts related to the meaning of their experiences, rather than a fear or anxiety response.

    In short, although this initial attempt demonstrated some effectiveness, it could not be delivered in a manner that remained within the four parameters established at the outset, and therefore was not adequate for this setting.

Empirically-based revisions

    The research literature was again reviewed, and discussions were initiated with colleagues and peers in the field. During one such discussion, Patti Resick brought my attention to a recent dismantling study of cognitive processing therapy (CPT; Resick, Galovski, Uhlmansiek, Scher, Clum, & Young-Xu, 2008) in which she found that cognitive restructuring without a written account of the trauma was not only as effective as cognitive restructuring with a written account, but (critically) also demonstrated more rapid symptom remission. She, therefore, suggested adapting some of the interventions and procedures from CPT for use within primary care clinics. A core intervention within CPT is the impact statement (IS), which helps to identify how the traumatic event is construed and coped with by the person who is trying to regain a sense of mastery and control in his or her life (Resick, Monson, & Chard, 2007). CPT focuses on the content of thoughts and the effect that distorted, unrealistic thoughts have on emotional responses and behaviors. Adopting a more realistic perspective of the traumatic event contributes to decreased emotional activation associated with memories of it. Thus, the IS could be used as a tool to identify unrealistic beliefs and perspectives, which can then be modified through basic cognitive restructuring skills.
    Use of the IS within our clinic demonstrated good preliminary effectiveness (see Corso et al, in press) and circumvented the primary barriers experienced with combat writing. Specifically, veterans seemed much more willing to complete the assignment, which resulted in clinically-meaningful improvements in very few appointments.

Discussion

    The outcome results of the process outlined above are reported in Corso et al. (in press). Although preliminary effectiveness for these strategies was found, further research under controlled conditions is clearly needed to truly establish the efficacy of these interventions for PTSD in primary care; currently, a randomized controlled trial is underway. The key conclusion of this clinical program, however, was the demonstration of the feasibility of brief interventions within integrated primary care clinics when they are based on sound science.

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, the Department of the Air Force, or the U.S. Government.

Craig Bryan is a captain in the United States Air Force and a clinician at Wilford Hall Medical Center.