A Brief Exposure-Based Intervention for Service Members With PTSD

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Cognitive and Behavioral Practice 18 (2011) 98–107

A Brief Exposure-Based Intervention for Service Members With PTSD

Maria M. Steenkamp, Boston UniversityBrett T. Litz, National Center for PTSD, VA Boston Healthcare System, and Boston University

Matt J. Gray, University of WyomingLeslie Lebowitz, Private Practice, Newton, MAWilliam Nash, Defense Centers of Excellence

Lauren Conoscenti, National Center for PTSD, VA Boston Healthcare SystemAmy Amidon, University of California, San Diego

Ariel Lang, University of California, San Diego, and VA San Diego Healthcare System

1077© 2Publ

The growing number of service members in need of mental health care requires that empirically based interventions be tailored to theunique demands and exigencies of this population. We discuss a 6-session intervention for combat-related PTSD designed to fosterwillingness to engage with and disclose difficult deployment memories through a combination of imaginal exposure and subsequentcognitive restructuring and meaning-making strategies. Core corrective elements of existing PTSD treatments are incorporated andexpanded, including techniques designed to specifically address traumatic loss and moral conflict.

AS of spring 2009, more than 1.4 million U.S. troopshave served in the wars in Afghanistan and Iraq, with

37% having deployed at least twice (Department ofDefense, 2009). Findings from epidemiologic studiessuggest that 10% to 18% of combat troops experiencesignificant psychological difficulties related to theirdeployment, such as posttraumatic stress disorder(PTSD), generalized anxiety, and depression (e.g.,Hoge et al., 2004). Rates of PTSD have increased overthe span of the wars (e.g., Milliken, Auchterlonie, &Hoge, 2007), and concomitant problems such as sub-stance abuse (Jacobson et al., 2008), physical healthproblems (Hoge, Terhakopian, Castro, Messer, & Engel,2007), and functional disability (Hoge, Auchterlonie, &Milliken, 2006) have increased the symptom burdenassociated with the disorder.

Providing psychological treatment for combat-relatedPTSD falls chiefly within the purview of both theDepartment of Veterans Affairs (DVA), which primarilytreats veterans who are no longer actively serving in themilitary and who have reentered civilian life, and theDepartment of Defense (DoD), which treats active-dutyservice members while they are still serving. Although theDVA has become well-prepared to offer high-quality,evidence-based care for chronic combat-related PTSD,

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with exceptions, the DoD is lagging in expert careproviders and evidence-based specialty care for PTSD.One reason is that the principal evidence-based treatmentstrategies, prolonged exposure (PE) and cognitive-processingtherapy (CPT), which were developedmainly with civilians,may not sufficiently address combat and operationaltrauma in active-duty troops. They may also not fit thehigh operation and training tempo of the active-dutygarrison-life because they are lengthy and requireextensive homework. Nevertheless, early intervention inthe military context is a critical mandate because manyservice members want to regain functional abilities and,once entrenched, PTSD can lead to discharge and serioussubsequent functional impairment. Later treatment mayalso be significantly complicated by comorbid conditionsand life problems, overlearned coping strategies, andpossible secondary gain.

In an effort to improve and expand existing programsfor combat-related PTSD in the military, in 2007,Congress appropriated funds to pilot promising service-specific mental health intervention projects. The inter-vention we describe is a program development andevaluation project in support of the Combat andOperational Stress Control operations of the U.S. MarineCorps and the U.S. Navy Bureau of Medicine, and is acollaboration between the National Center for PTSD atthe VA Boston Healthcare System, the VA San DiegoHealthcare System, and Marine Corps and Navy partners.In our pilot project, we developed and implemented a

99Brief Intervention for Combat Stress

brief psychotherapy for active-duty Marines with combat-related PTSD. We aimed to develop an evidence-informed treatment specifically tailored to the uniqueexigencies of newly redeployed Marines (i.e., Marinesrecently returned from Iraq and Afghanistan) and theircombat and operational stress and trauma. In this article,we discuss the rationale, empirical basis, and compo-nents of the intervention, which we call “AdaptiveDisclosure (AD).”

Tailoring PTSD Treatments to Active-DutyMilitary Personnel

As the mental health consequences of the current warshave become more manifest, the military has increasedefforts to identify and treat combat stress in theater andPTSD in garrison in an evidence-based manner. Offeringeffective interventions for combat-related PTSD in garri-son (i.e., while service members are stationed at astateside military post) provides the important advantageof redressing symptoms at an early stage (secondaryprevention). However, although interventions for PTSDare common in the civilian academic and medicalcommunities and in the VA, they have been relativelyunexamined in the military (DoD) context. Only twotrials have targeted PTSD among active-duty militarypersonnel: one examined the efficacy of critical incidentstress debriefing (CISD; Adler et al., 2008) and the otherexamined the efficacy of a web-based self-managementCBT (Litz, Williams, Wang, Bryant, & Engel, 2004).Neither of the trials targeted PTSD in garrison (the CISDtrial occurred in Kosovo and the web trial was on-line).Outcome studies exploring the efficacy of interventions inthis population are thus sorely needed. Such trials wouldallow for the development and fine-tuning of earlyinterventions that preempt the development of chroniccombat-related PTSD, compared to the majority ofexisting trials in which treatment occurred decades afterreturn from war.

To date, treatments for combat-related PTSD havelargely involved applying protocols developed and testedon civilians, such as sexual assault and motor vehicleaccident survivors. Rather than simply seeking to overlaycivilian treatment onto veteran and active-duty servicemembers, treatments for combat-related PTSD should betailored to the distinct nature of combat and operationaltrauma, which is multidimensional and extensive (Litz,2008). Service members are exposed to prolongedperiods of stress, anxiety, and hardship while separatedfrom their usual support networks (King, King, Guda-nowski, & Vreven, 1995), and they typically experiencemultiple traumatic and distressing events during thecourse of deployment (Hoge et al., 2004). Importantly,deployment not only places service members in situationsin which their own life is threatened, but may also lead

them to witness intense human suffering and cruelty,experience traumatic loss of close peers, and kill others inthe line of duty or perpetrate nonsanctioned violence.These different types of experiences may lead to differentemotional sequelae, ranging from prototypical fear- andanxiety-based reactions, to less well-appreciated reactionsin the trauma arena, such as guilt and shame from moralinjury (e.g., Litz et al., 2009), and prolonged griefdisorder (e.g., Neria & Litz, 2004; Prigerson et al.,2009). What these different experiences have in commonis that they can be haunting (reexperienced); disruptingof behavioral, emotional, and relational repertoires; andmay cause sufficient distress and impairment to lead theservice member to seek care.

The importance of addressing difficulties related togrief and guilt in treatment with military personnelbecame apparent to us when, prior to the developmentof the current treatment, we began a separate ongoingcombat-related PTSD treatment trial with returningveterans (the aim was to evaluate the efficacy of d-cycloserine versus placebo, each in combination withexposure therapy). The intervention consisted of sixsessions of imaginal exposure of a traumatic deploymentexperience. It soon became clear that many veterans werepresenting with difficulties that were not sufficientlyaddressed in the fear- and extinction-based frame thatunderlies exposure therapy. For many, the most persis-tently bothersome deployment incidents did not involvethreat of death, injury, or loss of physical integrity (asoutlined in the DSM-IV-TR; APA, 2000), although suchfear-based events had typically occurred during deploy-ment. Instead, non-fear-based events, particularly thoseinvolving perceived moral transgressions or the loss of afriend in combat, were subjectively experienced by manypatients as more haunting and impactful, and were agreater treatment priority. In developing the currentprotocol, we thus explicitly sought to address issuespertaining to traumatic loss and moral injury, constructswe discuss briefly below.

Combat-Related Traumatic Grief

Despite widespread recognition of the strong attach-ment bonds that develop between service membersduring war (e.g., Davidovitz, Mikulincer, Shaver, Izsak, &Popper, 2007), grief associated with the death of a friendin combat has been surprisingly overlooked in the study oftrauma. The limited evidence available suggests thatcombat-related grief can be highly distressing andimpairing. In a study of unresolved grief among Vietnamcombat veterans, for example, grief symptoms stemmingfrom the loss of a fellow soldier 30 years prior were foundto be greater than that of even bereaved spouses whosepartner had died in the previous 6 months (Pivar & Field,2004).

100 Steenkamp et al.

Loss of a friend in combat is not uncommon in thecurrent wars: An estimated 80% of soldiers and Marinessurveyed in Iraq or Afghanistan in 2003 knew someoneseriously injured or killed during their deployment (Hogeet al., 2004). Although most service members will be ableto recover from such a loss, a significant minority maydevelop more problematic and persistent grief reactions(Papa, Neria, & Litz, 2008). A valuable framework forunderstanding such reactions has in recent years beenadvanced by the construct of “complicated grief,”“traumatic grief,” or “prolonged grief,” which highlightsgrief reactions that are pathological and beyond what isconsidered normal bereavement (e.g., Gray, Prigerson, &Litz, 2004; Horowitz et al., 1997). These reactions areparticularly unremitting and chronic, and becomeimpairing when the individual is unable to accommodatethe loss and regain or reclaim connections with othersand life goals. Traumatic grief reactions are more likely inthe event of a sudden, traumatic loss (e.g., Ott, Lueger,Kelber, & Prigerson, 2007), as is the case with combat loss.Unfortunately, to date, the incidence of problems relatedto traumatic grief has not been studied specifically inservice members or new veterans and there are as yet noclinical trials addressing grief in service members.

Trauma-Related Guilt and Moral Injury

Combat veterans may experience severe guilt andshame related to various acts of omission or commissionduring deployment (Kubany, 1994; Wong & Cook, 1992).An overarching term, moral injury, has been proposed toconceptualize the psychological sequelae of events incombat that result in guilt, shame, or inner conflict. Litz etal. (2009) have described moral injury as witnessing,failing to prevent, or perpetrating acts that transgressdeeply held moral beliefs and expectations. Examples ofpotentially morally injurious experiences include killingor seriously injuring others in combat and participating inor witnessing cruel and inhumane actions. Such experi-ences may be intrusively reexperienced and lead to shameand social disengagement, as well as self-handicapping,self-harm, and demoralization.

Studies have linked potentially morally injuriousexperiences to the development of combat-relatedPTSD. Killing and wounding others has been associatedwith PTSD in a number of studies (e.g., Fontana &Rosenheck, 1999) and killing is a better predictor ofchronic PTSD symptoms than other indices of combatexposure. For example, in one study Vietnam veteranswho killed and experienced light combat had more PTSDsymptoms than those who did not kill and experiencedheavy combat (MacNair, 2002). Several researchers havealso linked participating in, or witnessing, war atrocities tochronic PTSD in Vietnam veterans (e.g., Beckham,Feldman, & Kirby, 1998; King et al., 1995; Singer, 2004).

A related line of evidence indicates that the emotionalconsequences of such acts, like shame and guilt, are oftenassociated with combat PTSD. Factor analytic studies showthat guilt emerges as a factor in symptom presentation ofcombat veterans (Watson et al., 1991) and severity of guiltsymptoms correlate positively with overall PTSD severity,particularly reexperiencing and avoidance symptoms(Henning & Freuh, 1997).

In terms of the current wars, there is evidence tosuggest that issues pertaining to moral injury may beprevalent: In 2003, 52% of soldiers and Marines surveyedreported shooting or directing fire at the enemy, 32%reported being directly responsible for the death of anenemy combatant, and 20% endorsed responsibility forthe death of a noncombatant (Hoge et al., 2004). A recentanalysis indicates that taking another life during deploy-ment is a significant predictor of PTSD, alcohol abuse,anger, and relationship problems, even after controllingfor combat exposure (Maguen et al., 2010).

Overview of Treatment

AD is a six-session manualized intervention designedspecifically for active service members with combat-related PTSD stemming from life-threat/fear-basedexperiences, moral injury, and traumatic loss. We usethe relatively neutral term adaptive disclosure as a less off-putting and stigmatizing label for service members. Thelabel captures the essence of the exposure-based therapy,which is driven by self-disclosure and sharing. Thetreatment consists of individual therapy and is designedfor service members who have redeployed (i.e., who havereturned to the U.S. after deployment to Iraq orAfghanistan) and are in garrison, seeking clinical care.Sessions are 90 minutes, each implemented over sixconsecutive weeks. AD begins with an introductorypsychoeducational session, followed by four exposure-based sessions, and concludes with a final wrap-up session,which focuses on planning for the future in light of whathas been learned in treatment. The treatment targetsmechanisms that reduce the risk for chronic combat-related PTSD and is currently being pilot tested withMarines at Camp Pendleton, California.

In conceptualizing the aims of AD, we had to considerseveral complex issues. We were targeting Marines,typically young males, who are part of a military culturein which emotionality, vulnerability, and help-seeking arepotential sources of shame. Most Marines will experience(much) more than one traumatic deployment event(Hoge et al., 2004), will be ambivalent and reticent aboutparticipating in psychological care, and will be highlyavoidant of thinking about and disclosing traumaticmemories, particularly events that entail loss and moralinjury. Military personnel have limited time and inclina-tion to pursue treatment as in-garrison responsibilities,


training, and preparation for deployment absorb a gooddeal of service members' time and attention. Motivationto pursue treatment may also be limited by the stigma thatsurrounds mental health care in the military (e.g., Gould,Greenberg, & Hetherton, 2007) and those most in needof care are also most likely to be deterred by concernsabout the potential career impact of care-seeking (Hogeet al., 2004). In addition, service members are oftenconcerned that typically civilian providers would fail tounderstand what they have been through (this is also trueof veterans seeking care). Consistent with our d-cycloser-ine and exposure therapy trial with new veterans, we thusset out to keep the therapy brief and we ensured themilitary-related validity of our approach by partneringwith individuals well-versed in the active-duty culture andthe nature of combat and operational trauma.

Consequently, AD is designed to initiate a processexperientially, rather than expecting full symptomremission or exhausting therapeutic tasks for Marines.The aim is to “plant seeds” by initiating a process thatteaches patients a different way of coping with andthinking about combat and operational experiences. ADis intended as an example of how change can occur andprovides a roadmap of how combat-related difficultiescould be dealt with going forward. In introducing thetherapy, we tell Marines that one of the goals is to changetheir negative expectations about disclosing painfulmemories, increasing their motivation to process andshare difficult deployment events with natural supportsystems (family, peers, and clergy) or further formal careproviders, if necessary.

AD aims to foster patients' willingness to disclose andshare (rather than avoid and conceal) traumatic combatexperiences, and challenges rigid, destructive appraisalsof the events that prevent the service member frommoving forward in their life. By doing so relatively early inthe postcombat adjustment period, AD hopes to shiftmaladaptive adaptation trajectories by identifying andaltering avoidant coping strategies and unhelpful beliefsthat, if unchanged, will result in chronic PTSD andfunctional impairment.

The strategies used in AD are drawn from existingempirically supported treatments, and consist of anintegration of strategies from PE (Foa, Rothbaum, &Hembree, 2007), CPT (Resick & Schnicke, 1992),cognitive behavioral therapy (CBT) for prolonged griefdisorder (Shear, Frank, Houck, & Reynolds, 2005), andGestalt therapy (Perls, Hefferline, & Goodman, 1957).The interventions contained in AD were specificallyadapted to resonate with the language and culture ofservice members who served in Iraq or Afghanistan.Terms such as qpatient,q qtreatment,q “therapy,” and“PTSD” are not used. AD is instead conceptualized as a“training” that will enhance the service member's

effectiveness and performance by teaching him or herbetter ways of coping with and managing combat stressreactions.

There are three main components to the treatment:(a) a core imaginal exposure component; (b) a “break-out” component designed to target loss/traumatic grief;and (c) a “breakout” component designed to target moralinjury (and attendant shame and guilt). Although allpatients receive the imaginal exposure component of thetreatment, additional loss or moral injury strategies areused on an as-needed basis with patients whose mostpressing traumatic memory includes traumatic grief ormoral injury. Decisions on whether to use a breakoutcomponent is left to the discretion of the therapist, basedon the type of deployment event identified by the patientas being the most upsetting and impactful (fear-based,moral injury, or loss). An outline of the treatmentcomponents is provided in Fig. 1. The three treatmentcomponents are first described below, followed by asession-by-session description of the treatment using acase example.

Exposure

The primary vehicle for disclosure in this treatment isimaginal exposure of an upsetting deployment experience,preferably of the “worst” or most pressing (and reexper-ienced) deployment event. The service member recountsthe experience in detail and in such a way that previouslyavoided thoughts and emotions related to the event areevoked. Although exposure therapy for PTSD has beenhypothesized to promote change via extinction, weleverage the overarching frame first articulated by Foaand Kozak (1986) and expanded upon by Foa andRothbaum (1997), namely that exposure therapy fostersnew learning via emotional processing of an event allowingfor accommodation (see Resick & Schnicke, 1992). As usedin AD, exposure is primarily designed to provide oppor-tunities for service members to modify negative expecta-tions about disclosing traumatic combat experiences.Service members learn that catastrophic expectationsregarding fully remembering and disclosing the event,such as “going crazy,” losing control, or being judged andrejected, are not realized. Such negative expectations mayunderlie their reluctance to engage with and share traumamemories, and lead to avoidance, concealment, andwithdrawal. By giving patients a mastery experience withdisclosure in which negative expectations are not realized,they may be more willing to disclose difficult deploymentexperiences with natural support networks (family, friends,fellow service members) or, if need be, with formal supportservices in the military and VA.

A second important lesson that the service memberlearns is that interpersonal sharing holds the advantage ofallowing for objective feedback from another person, in

Figure 1. Flow of AD sessions.


which new perspectives and understanding can be gained.Service members with combat-related PTSD will likelyhave a host of maladaptive interpretations about thetrauma that underlie symptoms and thwart recovery.Imaginal exposure helps make these harmful appraisalsmore salient so that they can be more easily recognizedand addressed. The goals are to help the service memberbecome more aware of their beliefs about the causes,meaning, and implications of the event, to shed light onthe degree to which these beliefs might be extreme andunhelpful, and to encourage the consideration ofalternative, less rigid and self-damning appraisals. Al-though this work cannot be fully completed in the contextof a brief intervention, starting the process early in thepostcombat adjustment period arguably helps shift thesebeliefs and prevent them from becoming intractable andentrenched. Also, demonstrating to service members thatit is useful and beneficial to get feedback and supportfrom a person outside the military may also help themshare and disclose with trusted others in the future.

Exposure as used in this treatment thus differs fromtypical PE in that it does not include multiple retellings ofthe event with the goal of in-session extinction. Instead, itis used as a vehicle for fostering willingness to engage withand share difficult memories by showing patients that theycan tolerate the emotion associated with rememberingand sharing. It also demonstrates the value of revealingand challenging formerly tacit maladaptive appraisals andmeanings that serve to maintain symptoms. Service

members begin exposure in the second session of thetreatment, and repeat exposures of the same event for atotal of four sessions.

Strategies for Addressing Combat-Related Traumatic Grief

In the absence of empirically validated treatments forcombat-related traumatic grief, our approach to treatingtraumatic loss draws on existing validated interventionsfor prolonged grief disorder (PGD). These therapiestarget maladaptive cognitions and avoidance related tothe loss (Boelen, de Keijser, van den Hout, & van denBout, 2007) and focus on processing previously avoidedemotions related to the loss, and on developing anunderstanding of the meaning and implication of the loss(Shear et al., 2005). Randomized controlled trials of CBTtargeting PGD have shown promising results. For exam-ple, a study comparing CBT for PGD and supportivecounseling showed stronger clinical improvement amongCBT participants, with effect sizes of d = 1.32 forparticipants receiving cognitive restructuring followedby exposure, d = 1.55 for participants receiving exposurefollowed by cognitive restructuring, and d = .047 forparticipants receiving supportive counseling (Boelen etal., 2007). Similarly, CBT demonstrated higher responserates (51%) than interpersonal therapy (28%) for thetreatment of complicated grief symptoms, and significant-ly faster response times (Shear et al.).

Techniques used in AD draw on Shear and colleagues'grief treatment. This includes a modified imaginal


exposure procedure in which the patient retells the storyof the death, as well as techniques designed to foster asense of connection with the deceased person, includingan imaginal conversation with the deceased. In applyingthese techniques with service members in garrison, therewere two considerations. First, in war zones there is littleopportunity to fully experience and process intenseemotions stemming from loss and to sufficiently processand make sense of what happened (e.g., Nash, 2007).Second is the question of responsibility for the loss:military personnel in combat settings may feel deeplypersonally responsible for each other's safety and mayreact with intense feelings of personal failure and guiltwhen one of them is lost, no matter how (e.g., Elder &Clipp, 1988). If a service member believes strongly thatthey failed to protect their peer from harm and betrayedthe trust of the deceased, this may result in a particularlyvirulent form of combat-related guilt and a sense ofpersonal failure.

As in the model developed by Shear and colleagues(2005), AD employs a modified empty chair technique toexplore and address beliefs surrounding the loss. Thisapproach is analogous to the empty chair technique inGestalt therapy, and involves a conversation with thedeceased person. Randomized controlled trials haveshown empty chair dialogue techniques to be significantlymore effective than psychoeducation in reducing symp-toms of distress, increasing self-acceptance and forgiveness,and resolving “unfinished emotional business,” with gainsbeing maintained at long-term follow-up (Greenberg,Warwar, & Malcolm, 2008; Paivio & Greenberg, 1995).

The technique is employed after completing theexposure component described above (reliving thetraumatic event related to the loss) and incorporatesthree sequential steps, which can be repeated duringmultiple sessions: First, the service member is asked todescribe the deceased person in question—who theywere, what they were like, and what the person meant tothem. Using imagination, the service member is theninstructed to have a conversation with the deceasedperson, telling them what the loss meant to them andwhat has changed in them and in their behavior sincethe loss, using the present tense. Third, after the servicemember has sat with and described the emotions arisingfrom the conversation, they are asked to consider anddescribe how the deceased person would respond tothem after hearing what has just been said. For example,what would the deceased person want for the patient? Ifthe service member is overly self-punitive, the therapist isinstructed to be directive and introduce content that isforgiveness-related. Alternatively, the service membermay also be asked to reverse the position, as if he orshe were the one who had died and was listening to thesurviving friend talk about how the death was affecting

his or her life. They are asked to consider what theywould want for their friend if the situation were reversed.The aim is to activate forgiveness-oriented and accep-tance themes (and themes related to moving on andliving life well), which the therapist can then extend andemphasize.

Strategies for Addressing Moral Injury

There is some evidence that to be effective, maladap-tive beliefs driving guilt need to be explicitly addressedand reorganized in treatment. For example, studiescomparing CPT and PE found the two treatmentscomparable in decreasing PTSD and depression, butCPT, which focuses more directly on guilt cognitions, hadgreater effects on guilt symptoms (Resick, Nishith,Weaver, Astin, & Feuer, 2002). PE without cognitiverestructuring has been found to be no more effective intreating guilt than relaxation training (Stapleton, Taylor,& Asmundson, 2006). Moreover, cognitive therapy fortrauma-related guilt (Kubany, 1998), an interventionaimed entirely at traumatic guilt, focuses explicitly oncorrecting thinking errors that underlie irrational guilt.

AD uses two versions of the empty chair exercise as away of explicitly targeting guilt cognitions and generatingan alternative perspective about the event. First, after theexposure component processing the morally injuriousexperience, the service member is asked to have animaginary conversation with another person for whomthey have great respect, and who can weigh in as arelevant and generous moral authority. They are asked tothink of someone who has always been supportive andunderstanding. If they cannot think of such a person,then figures in religious or popular culture can be used.Second, the service member is asked to have a conversa-tion with the moral authority figure, in the present tense.They are instructed to tell the moral authority figure whathas changed in them and their behavior since the event,and to describe the impact of the guilt and shame on theirlife. Third, the service member is asked to consider whatthe moral authority figure would say to them after hearingwhat has just been said. The goal is to produceforgiveness-related content from the authority figure;the therapist is highly directive, if necessary.

An alternative exercise may be used in which theservice member is asked to choose someone to whom theyfeel protective, such as a younger brother or juniorcomrade. They are asked to imagine that particularperson confessing the actions that they have justconfessed and describing their consequent suffering.The service member is then instructed to consider whatthey would say and want for this individual, again with theaim of highlighting forgiveness-related themes.

We next discuss the session-to-session flow of AD, usingan illustrative case example. The case is an amalgam of a


number of different service members who have partici-pated in the AD pilot project to date.

Outline of Sessions

Sergeant Cortez is a 31-year-old married Marine with11 years of active-duty service. He served two tours in thecurrent wars: one in Iraq in 2004 and one in Afghanistanin 2008. He presented with severe symptoms of combat-related PTSD (he readily met the diagnostic criteria forPTSD as well as major depressive disorder). Sgt. Cortezstated that he was seeking help at the urging of his wife,who had become afraid of him due to his frequent angryoutbursts. He had avoided treatment prior to presentingat the clinic.

Session 1: Assessment and Introduction to ADThe first session began with a discussion of Sgt. Cortez's

current functioning, the changes he wanted to see, andwhat he was like before his first deployment. The therapistprobed for changes in Sgt. Cortez's self-view, interperson-al relationships, trust in others, and general outlook onlife, stating that by knowing better what had changed, Sgt.Cortez could start to reclaim some of who he was beforedeployment. Sgt. Cortez reported that he had noticedsignificant changes, particularly feeling tense and easilyangered, and having trouble sleeping due to frequentnightmares. Additionally, although he reported that he“couldn't wait” for his next deployment, he found himselfdoubting decisions he made at work and hesitating indrills, leaving him worried he would no longer have “theedge” needed to lead his men.

The therapist made the important point that althoughcombat changes everyone, Sgt. Cortez had some controlover what those changes would look like moving forwardand that the treatment would help facilitate this byinitiating a process for a different way of coping withdifficult deployment experiences, one in which painfulmaterial is approached and shared.

Sgt. Cortez expressed anxiety when the rationale forAD was explained, stating that he had never spoken toanyone about the incident that was most bothering him.He noted that he wasn't sure if he could qhandleq talkingabout the event and worried that he would “lose it” if hewas to fully think about it. The notion of having to talkabout things to move past them (having to look back inorder to look forward) was introduced and, in acknowl-edging that AD would be difficult, combat stress waslikened to physical injuries that require diagnosis,attention, cleaning, and treatment to repair. As withphysical injuries, treatment could sometimes be painful,but this was necessary to regain former functioning.

Next, Sgt. Cortez and the therapist together identifiedwhich traumatic deployment experience would be thefocus of treatment. He was asked to think about the most

difficult or impactful event, and to give a brief descriptionof what happened. It was explained that the event wouldbe discussed during the next session in detail, in order toget a clearer sense of the event and its meaning for Sgt.Cortez, and how it was keeping him frommoving forward.Sgt. Cortez reported that he had experienced numerousdifficult events while deployed, such as several intensefirefights, being injured, and losing several men. Heidentified the index event as an incident in 2004 in whichhis best friend, a fellow sergeant, was hit by an ImprovisedExplosive Device (IED) and in which they were subse-quently ambushed by several insurgents. The sergeantdied on the scene during the firefight. Although at thetime Sgt. Cortez questioned whether he would come outof the battle alive, he expressed little fear over theincident in session, but rather grief and intense sadness.

Towards the end of the first session, Sgt. Cortez wasasked to write an impact statement about the traumaticevent for homework. This assignment is similar to that inCPT (Resick & Schnicke, 1992), in which the servicemember is asked to write at least one handwritten page onwhy they think the traumatic event occurred. They are notasked to provide a detailed account of the event, but toinstead write about what they think is the cause andmeaning of the event. The aim of assigning this task is tokick-start the AD by stimulating the process of identifyingmeanings and appraisals associated with the event.

Session 2: Exposure-Based Activation and Restructuring ofDeployment-Related Difficulties

The second session began with Sgt. Cortez reading hisimpact statement aloud. The therapist listened for beliefsabout the causes and reasons for the event that requiredcognitive restructuring later in the session. In hisstatement, Sgt. Cortez described a lot of self-blameabout the incident, stating that he should have saved hisfriend by reaching him sooner and seeing that he receivemedical attention.

Because Sgt. Cortez's index event was the death of afriend in combat, strategies for addressing traumatic losswere used in his treatment. Sgt. Cortez was first asked todescribe his friend in detail (for example, what he lookedlike, what he was like interpersonally, what Sgt. Cortezliked about him), priming him for the imaginal exposure.During the exposure Sgt. Cortez was asked to recount thetraumatic event in detail, using first person, present tense,and with his eyes closed (for further information onimaginal exposure procedures, see Foa, Rothbaum, &Hembree, 2007). When Sgt. Cortez began the exposureusing a lot of “mission speak,” a form of emotionalavoidance in which the event is matter-of-factly recountedin terms of the operational strategy or tactics employed,the therapist probed for sensory details and peritraumaticemotions and cognitions. Sgt. Cortez also initially quickly


skimmed over the part of the narrative in which his friendwas hit with the IED. When asked to return to this part ofthe memory and focus on the image of seeing his friendlying on the ground bleeding, Sgt. Cortez' voice crackedand he had difficulty speaking. He began crying as hedescribed being unable to get to his friend due to intensegunfire that was coming at him from all angles. He statedthat he was “weak,” “not a real Marine,” that he “shouldhave just ran to him,” and asked, “What kind of a friendleaves their best friend to die?”

Using the empty chair technique, Sgt. Cortez was askedto imagine that his friend was in the therapy room and tohave a conversation with him, telling him what heremembered about him when he was alive, how muchhe missed him, and how his death had affected him.When doing so, Sgt. Cortez began to sob, telling his friendhow sorry he was, how he should have done more, andhow he thought about him every day.

Sgt. Cortez was then asked to imagine receivingfeedback from his friend about what he had shared. Inconsidering what his sergeant friend would say for the firsttime, Sgt. Cortez was able to get a more accurateperspective on the true difficulties that he had facedthat day, and on the impossibility of being able to domore. He reported that his friend would have wanted himto take cover and focus on preventing the other men inthe unit from being injured, and that he would not havewanted anyone to get injured trying to save him. Theexercise helped Sgt. Cortez see how he had done what hisfriend would have wanted, and how his friend would wanthim to carry on despite the loss. The session concludedwith a discussion of the meanings and implications of theevent, and what Sgt. Cortez would take away from thesession. Sgt. Cortez was able to see how his previousunderstanding of the event—that he had failed as a friendand as a Marine—was not entirely accurate, which in turnincreased his confidence in his ability to carry out hisduties on his next deployment.

Session 3These same procedures were repeated in Session 3,

and Sgt. Cortez reported that it was a little easier to tell thestory in session and to think about it outside of session.

Session 4During the imaginal exposure in the fourth session Sgt.

Cortez began discussing new aspects of the firefight thathe had previously omitted. He described “going into arage” after his friend died, “shooting at anything thatmoved” and “killing just to kill,” and noted that a civilianmay have been killed as a result of these actions. He wasdetached and sullen when describing this, and found itdifficult to look at the therapist, stating that he was “evil”and that Marines “don't lose it that way.” He alsoexpressed concern that he no longer knew who he was

(could he still consider himself a good man and a goodMarine?), and that he would not know how to react insimilar situations on his next deployment. Using thebreakout on moral injury, Sgt. Cortez was asked to engagein a conversation with a benevolent moral authorityfigure. He identified his gunnery sergeant (a superior), aman who he deeply respected and admired. In talking tothe gunnery sergeant, he was asked to describe how stuckhe was, focusing on his confusion over what kind of a manhe was, and whether he would be able to fulfill his dutiesduring his upcoming deployment. Through the perspec-tive of the gunnery sergeant, Sgt. Cortez was able toidentify how the context of battle and of that situation inparticular could have contributed to his actions. Duringthe conversation, the gunnery sergeant also remindedSgt. Cortez of his accomplishments as a Marine and of thenumerous times he successfully led his men throughhighly dangerous situations.

Session 5As Sgt. Cortez conducted the fourth and final imaginal

exposure of the event and continued the discussion withhis gunnery sergeant, he began loosening the rigid beliefsthat he had held about the event having made him “evil.”He developed a clearer understanding of the reasons forhis actions that day and how they were distinct from whohe was as a person, as well as a renewed confidence in hisabilities as a Marine sergeant.

Session 6: Wrap-up and Planning for the Long HaulDuring the final session, the therapist solicited

feedback on what Sgt. Cortez had learned and discussedthe work that remained to be done, emphasizing theongoing challenges ahead. The therapist reiterated thatthe intervention represented the beginning of a continu-ing process in which the therapy provided a roadmap ofhow remaining difficulties could be dealt with. Potentialtriggers for deployment-related difficulties (e.g., anniver-sary reactions of his friend's death) were discussed, andcoping strategies were planned that could be used duringsuch times. The therapist also initiated a discussion aboutthe importance of self-care and social reengagement,delineating specific adaptive behaviors that Sgt. Cortezmight engage in.

Summary and Conclusion

As the number of service members in need of mentalhealth care continue to grow, it is vital that evidence-basedinterventions be tailored to the unique demands andexigencies of redeployed troops. In this article, wediscussed a six-session intervention for combat-relatedPTSD in active-duty service members. AD targets mechan-isms that reduce the risk of chronic PTSD, and is bynecessity brief to be feasibly applied in an in-garrisonsetting. It intends to facilitate adaptive ways of coping with


memories of traumatic deployment experiences, specifi-cally by providing patients with a success experience withfully remembering and disclosing a traumatic combatevent. By doing so while the individual is still an active-duty service member, AD teaches positive ways of dealingwith combat stress before maladaptive, avoidant strategiesbecome entrenched and lead to secondary problems.Treatment consists of a combination of imaginal exposureand cognitive restructuring techniques that draw onexisting empirically supported therapies for civilianPTSD. Because difficulties related to moral injury andtraumatic loss are frequently salient presenting problemsin returning service members, AD specifically includestechniques to address these concerns. Overall, byproviding a meaningful and useful disclosure experiencewith a difficult combat memory, service members learnthat they can share, tolerate, and gain a useful perspectiveabout the implications of what they experienced whiledeployed, and use this to move forward in their lives in ahopeful, engaged, and reflective manner.

As discussed, we are piloting AD as part of a programdevelopment and evaluation project with active-dutyMarines at Camp Pendleton, California. Patients arereferred from care providers at the San Diego NavalHospital and outpatient clinics at Marine Corps CampPendleton. A therapy manual has been written, whichincludes information about combat and operationaltrauma and the military culture, and several therapistshave been trained (and supervised weekly). Eight active-duty Marines have completed the pilot to date and thepreliminary data are encouraging: The effect sizes are d =1.41 for the PTSD Checklist and d = 2.05 for the PatientHealth Questionnaire. The therapy is also well toleratedand accepted by patients, and providers are enthusiasticand motivated to learn the model. In the pilot, we use asimple pre-post design because service members may bedeploying and are thus hard to follow up. Nevertheless,we plan to conduct a randomized controlled trial in thecoming year. Only a more sophisticated design will informus about the efficacy of AD.

References

Adler, A. B., Litz, B. T., Castro, C. A., Suvak, M., Thomas, J. L., Burrell,L., et al. (2008). A group randomized trial of critical incidentstress debriefing provided to U.S. peacekeepers. Journal ofTraumatic Stress, 21, 253–263.

American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders, 4th ed. Washington, DC: Author textrevision.

Beckham, J. C., Feldman, M. E., & Kirby, A. C. (1998). Atrocitiesexposure in Vietnam combat veterans with chronic posttraumaticstress disorder: Relationship to combat exposure, symptomseverity, guilt, and interpersonal violence. Journal of TraumaticStress, 11, 777–785.

Boelen, P. A., de Keijser, J., van den Hout, M. A., & van den Bout, J.(2007). Treatment of complicated grief: A comparison betweencognitive-behavioral therapy and supportive counseling. Journal ofConsulting and Clinical Psychology, 75, 277−284.

Davidovitz, R., Mikulincer, M., Shaver, P. R., Izsak, R., & Popper, M.(2007). Leaders as attachment figures: Leaders' attachmentorientations predict leadership-related mental representationsand followers' performance and mental health. Journal ofPersonality and Social Psychology, 93, 632–650.

Department of Defense, Public Affairs Office, (2009). Number ofmembers deployed by service component andmonth/year (basedon the contingency tracking system).

Elder, G. H., & Clipp, E. C. (1988). Combat experience, comradeship,and psychological health. In J. P. Wilson, Z. Harel, & B. Kahana(Eds.), Human adaptation to extreme stress: From the Holocaust toVietnam (pp. 131–156). New York: Springer.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear:Exposure to corrective information. Psychological Bulletin, 99,20–35.

Foa, E. B., & Rothbaum, B. O. (1997). Treating the trauma of rape. NewYork: Guilford Press.

Foa, E. B., Rothbaum, B. A., &Hembree, E. A. (2007). Prolonged exposuretherapy for PTSD: Emotional processing of traumatic experiences.Therapist Guide New York: Oxford University Press.

Fontana, A., & Rosenheck, R. (1999). A model of war zone stressorsand posttraumatic stress disorder. Journal of Traumatic Stress, 12,111–126.

Gould, M., Greenberg, N., & Hetherton, J. (2007). Stigma and themilitary: Evaluation of a PTSD psychoeducational program.Journal of Traumatic Stress, 20, 505–515.

Gray, M., Prigerson, H., & Litz, B. T. (2004). Conceptual anddefinitional issues in traumatic grief. In B. Litz (Ed.), Earlyintervention for trauma and traumatic loss (pp. 65–86). New York:Guilford Press.

Greenberg, L. S., Warwar, S. H., & Malcolm, W. M. (2008). Differentialeffects of emotion-focused therapy and psychoeducation infacilitating forgiveness and letting go of emotional injuries. Journalof Counseling Psychology, 55, 185–196.

Henning, K. R., & Freuh, B. C. (1997). Combat guilt and itsrelationship to PTSD symptoms. Journal of Clinical Psychology, 53,801–808.

Hoge, C. W., Auchterlonie, J. L., &Milliken, C. S. (2006). Mental healthproblems, use of mental health services, and attrition frommilitaryservice after returning from deployment to Iraq or Afghanistan.Journal of the American Medical Association, 295, 1023–1032.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., &Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan,mental health problems, and barriers to care. New England Journalof Medicine, 351, 13–22.

Hoge, C.W., Terhakopian, A., Castro, C. A., Messer, S. C., & Engel, C. C.(2007). Association of posttraumatic stress disorder with somaticsymptoms, health care visits, and absenteeism among Iraq Warveterans. American Journal of Psychiatry, 164, 150–153.

Horowitz, M. J., Siegle, B., Holen, A., Bonanno, G. A., Milbrath, C., &Stinson, C. H. (1997). Diagnostic criteria for complicated griefdisorder. American Journal of Psychiatry, 174, 67–73.

Jacobson, I. G., Ryan, M. A. K., Hooper, T. J., Smith, T. C., Amoroso,P. J., Boyko, E. J., Gackstetter, G. D., Wells, T. S., & Bell, N. S.(2008). Alcohol use and alcohol-related problems before andafter military combat deployment. Journal of the American MedicalAssociation, 300, 663–675.

King, D. W., King, L. A., Gudanowski, D. M., & Vreven, D. L. (1995).Alternative representations of war zone stressors: Relationships toposttraumatic stress disorder in male and female Vietnamveterans. Journal of Abnormal Psychology, 104, 184–195.

Kubany, E. (1994). A cognitive model of guilt typology in combat-related PTSD. Journal of Traumatic Stress, 7, 3–19.

Kubany, E. S. (1998). Cognitive therapy for trauma-related guilt. In V.M. Follette, J. I. Ruzek, & F. R. Abueg (Eds.), Cognitive-behavioraltherapies for trauma New York: Guilford Press.

Litz, B. T. (2008). Early intervention for trauma: Where are we andwhere do we need to go? A commentary. Journal of Traumatic Stress,21, 503–506.

Litz, B. T., Williams, L., Wang, J., Bryant, R., & Engel, C. C. (2004). Atherapist-assisted Internet self-help program for traumatic stress.Professional Psychology: Research and Practice, 35, 628–634.


Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Silva, C., Maguen, S., &Nash, W. P. (2009). Moral injury and moral repair in war veterans:A preliminary model and intervention strategy. Clinical PsychologyReview, 29, 695–706.

MacNair, R. M. (2002). Perpetration-induced stress in combat veterans.Peace and conflict. Journal of Peace Psychology, 8, 63–72.

Maguen, S., Lucenko, B. A., Reger, M. A., Gahm, G. A., Litz, B. T., Seal,K. H., et al. (2010). The impact of reported direct and indirectkilling on mental health symptoms in Iraq War veterans. Journal ofTraumatic Stress, 23, 86–90.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinalassessment of mental health problems among active and reservecomponent soldier returning from the Iraq War. Journal of theAmerican Medical Association, 298, 2141–2148.

Nash, W. P. (2007). The stressors of war. In C. R. Figley, & W. P. Nash(Eds.), Combat stress injury: Theory, research, and management(pp. 11–31). New York: Routledge.

Neria, Y., & Litz, B. T. (2004). Bereavement by traumatic means: Thecomplex synergy of trauma and grief. Journal of Loss & Trauma, 9,73–87.

Ott, C. H., Lueger, R. J., Kelber, S. T., & Prigerson, H. G. (2007).Spousal bereavement in older adults: Common, resilient, andchronic grief with defining characteristics. Journal of Nervous andMental Disease, 195, 332–341.

Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinishedbusiness” Efficacy of experiential therapy using empty-chairdialogue. Journal of Consulting and Clinical Psychology, 63,419–425.

Papa, A. T., Neria, Y., & Litz, B. T. (2008). Traumatic bereavement inwar veterans. Psychiatric Annals, 38, 686–691.

Perls, F. S., Hefferline, R. F., & Goodman, P. (1957). Gestalt therapy.NewYork: Dell.

Pivar, I. L., & Field, N. P. (2004). Unresolved grief in combat veteranswith PTSD. Journal of Anxiety Disorders, 18, 745–755.

Prigerson, H., Horowitz, M. J., Jacobs, S. C., Parkes, C., Aslan, M.,Goodkin, K., et al. (2009). Prolonged grief disorder: Psychometricvalidation of criteria proposed for DSM-V and ICD-11. PublicLibrary of Science (PLoS) Medicine, 8, 1–11.

Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A.(2002). A comparison of cognitive-processing therapy withprolonged exposure and a waiting condition for the treatmentof chronic posttraumatic stress disorder in female rape victims.Journal of Consulting and Clinical Psychology, 70, 867–879.

Resick, P. A., & Schnicke, M. K. (1992). Cognitive Processing Therapyfor sexual assault victims. Journal of Consulting and ClinicalPsychology, 60, 748–756.

Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatmentof complicated grief: A randomized controlled trial. Journal of theAmerican Medical Association, 293, 2601–2608.

Singer, M. (2004). Shame, guilt, self-hatred, and remorse in thepsychotherapy of Vietnam combat veterans who committedatrocities. American Journal of Psychotherapy, 58, 377–385.

Stapleton, J. A., Taylor, S., & Asmundson, G. J. G. (2006). Effects ofthree PTSD treatments on anger and guilt: Exposure therapy, eyemovement desensitization and reprocessing, and relaxationtraining. Journal of Traumatic Stress, 19, 19–28.

Watson, C., Kucala, T., Juba, M., Manifold, V., Anderson, P., &Anderson,D. (1991). A factor analysis of theDSM-III posttraumaticstress disorder criteria. Journal of Clinical Psychology, 47, 205–214.

Wong, M. R., & Cook, D. (1992). Shame and its contribution to PTSD.Journal of Traumatic Stress, 5, 557–562.

Address correspondence toMaria M. Steenkamp, Boston University, 648Beacon Street, 5th Floor, Boston, MA 02215; e-mail: [email protected].

Received: January 22, 2009Accepted: August 17, 2009Available online 24 April 2010

mailto:[email protected]

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A Brief Exposure-Based Intervention for Service Members With PTSD