Posttraumatic Stress Disorder (PTSD) is the most prevalent mental health disorder reported amongst members of the Australian Defence Force (ADF) (McFarlane et al. 2011). In the Mental Health Prevalence Wellbeing study (McFarlane et al. 2011) which surveyed 49% of current ADF members, found that 22% of the ADF population had experienced a mental health disorder in the past 12 months. The most prevalent disorder was PTSD with 8.6% of ADF males experiencing the disorder compared to 5.2% of the general population (McFarlane et al. 2011). Managing PTSD in the ADF population represents a major challenge for the Australian Department of Defence (DoD) and the Australian Department of Veterans affairs (DVA) due to the associated high risk of suicide, alcohol and substance use, relationship break downs and the propensity to develop co-morbid disorders that are linked to a diagnosis of PTSD (McFarlane et al. 2011). These risk factors significantly impact on the individual, the family, the organisation and society (Forbes et al. 2007).
Prospective studies have shown that most trauma survivors display a range of PTSD reactions in the initial weeks after a traumatic event, but that most of these people adapt effectively within approximately three months (Koren, Arnon, & Klein, 1999). Those that fail to recover by this time are at risk for chronic PTSD (Koren, Arnon, & Klein, 1999). Further underscoring the risk for chronicity in PTSD, Kessler et al. (1995) found that one-third of people with PTSD fail to recover after many years, in many cases after years of mental health treatment.
Whilst the DoD and DVA recognise PTSD as major issue with the implementation of national studies and funding to co-ordinate therapeutic responses, there are obstacles to the achievement of effective and timely treatments, from identifying those at risk of PTSD to using the best evidence-based treatments including psychotherapy and pharmacotherapy (Forbes et al. 2007). The current literature review aims to address the latter in regards to reviewing the efficacy of the current gold standard treatments used by both departments which include Eye Movement Desensitisation and Reprocessing (EMDR) and trauma-focused Cognitive Behavioural Therapy (CBT). The following review is a summary of the current literature of PTSD in the ADF population and the efficacy of the current gold standard treatments that are employed. The literature review used Google Scholar as its main database in searching for articles related to PTSD, CBT, EMDR, ADF.
Traumatic events are profoundly stressful. The stress that results from traumatic events precipitates a spectrum of psycho-emotional and physiopathological outcomes (Iribarren et al. 2005). PTSD is the mental disorder that can result from the experience or witnessing of traumatic or life-threatening events such as terrorist attack, violent crime and abuse, military combat, natural disasters, serious accidents or violent personal assaults (Iribarren et al. 2005). Individuals report difficulty in sleeping, nightmares, flashbacks, intrusive thoughts, physiological arousal and increasingly detached or estranged behaviour (Iribarren et al. 2005). Co-morbid disorders such as depression, substance abuse and problems of memory and cognition are common (Iribarren et al. 2005). The disorder soon leads to impairment of the ability to function in social or family life, which more often than not results in occupational instability, marital problems and divorces, family discord and difficulties in parenting (Iribarren et al. 2005). The disorder can be severe enough and last long enough to impair the person’s daily life and, in the extreme, lead the patient to suicidal tendencies (Iribarren et al. 2005).
The Australian Gender Indicators study revealed that in 2007, Anxiety disorders, affecting 14% of all people aged 16-85 years, were the most common mental disorders reported in the 12 months prior to interview (NSMHW 2007). The most common Anxiety disorder for both men and women was PTSD, but women were almost twice as likely as men to experience this disorder (NSMHW 2007). Females were more likely than males to have experienced Anxiety disorders both in the 12 months prior to interview (18% and 11% respectively) and in their lifetime (32% compared to 20% for men) (NSMHW 2007).
PTSD in the ADF
Members of the ADF are at risk of developing mental disorders, as they are exposed to a range of occupational stressors – for example, exposure to traumatic events and extended periods of time away from their primary social support networks (Mental Health of ADF Members and Veterans Senate Report 2016). Between July 2013 and June 2014, 896 ADF personnel were referred to the ADF Rehabilitation Program with a primary diagnosis of a mental health disorder. Of these, 33.6 per cent were identified as being 'deployment related' (Mental Health of ADF Members and Veterans Senate Report 2016). In this period, 206 of the 896 personnel were referred with a specific diagnosis of PTSD, of which 84 per cent were identified as being 'deployment related'. Since 2000, 108 ADF personnel are suspected or confirmed to have died as a result of suicide, of which 47 had previously deployed. (Mental Health of ADF Members and Veterans Senate Report 2016).
The prevalence of PTSD in Gulf War Veterans assessed at 10–15 years after deployment was 5.4%. Many of those who required treatment did not receive it (Pietrzak 2011). The most common barriers to treatment included limited access to mental health professionals, living in remote or underserved areas, economic and time constraints, stigma associated with mental illness, privacy/confidentiality issues and lack of confidence with mental health professionals (Pietrzak 2011). Up to 20% of those who had sought mental health care were dissatisfied (Pietrzak 2011). The key indicators and factors that contribute to treatment effectiveness are related to disease severity and presentation, treatment effectiveness and psycho‐social condition of the person undergoing treatment (Pietrzak 2011).
Treatment of military veterans with combat‐related PTSD has specific challenges. Military culture and training are designed to produce effective combatants through promoting emotional shut‐down. When this is combined with high levels of anger which is common in PTSD the development of therapeutic alliance can be impaired. The therapeutic alliance is pivotal when engaging with trauma‐related fear during exposure treatments (Pietrzak 2011). This barrier may prevent habituation to fear, which inhibits self‐ reflection and leads to premature termination of treatment (Pietrzak 2011).
Combat veterans with PTSD may report large amounts of survivor guilt, perpetrator guilt, grief, and anger. Combat veterans are often reluctant to discuss their experiences for reasons ranging from fear of appearing weak to admitting to perpetrator behaviour to difficulty articulating complex experiences affecting them in many different ways (Sprang 2001).
Shapiro (1989) argues that EMDR helps individuals reduce or remove the negative affect associated with traumatic memories by activating a neurophysiological process that permits a form of relearning. The eye movements are presumed to activate brain chemistry that permits changes in memory structures and related emotional responses (Shapiro 1989). The basic application of EMDR involves eight phases of treatment (Table 1) with the number of sessions needed varying from one to many, depending on the individual (Shapiro 1989).
Shapiro (1995) proposed a theoretical framework, called Accelerated Information Processing (AIP) which forms one basis for the EMDR treatment strategy. The AIP model is based on the assumption of a "neurological balance in a distinct physiological system that allows information to be processed to an 'adaptive resolution'" (Shapiro 1995). Shapiro (1995) posits that "the eye movements or alternative stimuli used in the EMDR procedure trigger a physiological mechanism that activates the information processing system to an adaptive resolution." Shapiro's main premise about traumatic memories is based on the apparent imbalance which occurs in the nervous system when a person experiences severe psychological trauma, manifested by changes in neurotransmitters and adrenaline. The memories are encoded neurologically in the neurobiologically altered state. Shapiro (1995) hypothesizes that the original material, which is held in this distressing, excitatory state-specific form, continues to be triggered by a variety of internal and external stimuli and is expressed in the form of nightmares, flashbacks, and intrusive thoughts.
There is substantial evidence indicating the efficacy of EMDR against waitlist, pill placebo, supportive counselling, relaxation or treatment as usual (Hogberg 2007 & Kolk et al. 2007). Meta-analyses (Cloiter 2009) indicate that EMDR is an efficacious treatment with outcomes not significantly different from exposure-based therapies in both civilian and military populations. EMDR has been deemed efficacious by the International Society for Traumatic Stress (Shapiro & Maxfield 2002) and is recommended by the DoD and DVA treatment guidelines.
Carlson et al. (1998) found 12 sessions of EMDR with combat veterans resulted in a 77% remission of PTSD with no dropouts. Positive effects were reported on multiple measures at posttest, and effects were maintained at 3- and 9-month follow-up. In a non-randomized retrospective study of treatment outcomes for veterans receiving EMDR, biofeedback, or relaxation training, EMDR was found to be superior to the other two treatments on seven of eight measures (Silver, Brooks, & Obenchain, 1995). This and the Carlson et al. (1998) studies are the only two studies of EMDR with PTSD-diagnosed combat veterans treated across multiple traumatic combat experiences using a sufficient number of sessions rather than a single session or two. The veterans in both of these studies were suffering from chronic PTSD.
According to both the International Society for Traumatic Stress Studies (Chemtob et al. 2000) and the Departments of Veterans Affairs and Defence Joint Clinical Practice Guidelines for PTSD (2004), other randomized studies of EMDR with veterans are flawed because of insufficient treatment doses, offering only two sessions and/or component analyses treating only one memory. Corroborating the need for multiple treatment sessions, a recent analysis of the treatment of 63 war veterans by newly trained EMDR clinicians suggested that wounded combat veterans needed 8.5 sessions of treatment and non-wounded needed 3.8 sessions to eliminate disturbances associated with war-related traumatic memories (Russell et al. 2007). Given EMDR’s in-session rapid effects and the lack of need for homework, it appears particularly suited for frontline treatment, for instance, as an immediate intervention for recently and severely wounded casualties shortly after evacuation (Russell, 2006).
Whilst there is support for EMDR there remains controversy over its mechanisms and delivery. Shapirio (1989) firsts discussed EMDR as a one session treatment in which all 8 phases could be delivered and a positive effect gained. This has been argued by Davidson & Parker (2001) in a meta-analysis conducted into the efficacy of EMDR, it was found that EMDR often needed 12 sessions to take effect (Feske 1998). The same meta-analysis also revealed no evidence for the use of eye movement or alternating stimuli as near zero effect sizes were found between control groups and experimental groups who were exposed to the eye-movements and not exposed to the eye-movements (Davidson & Parker 2001).
Limitations that have been cited into the studies conducted on EMDR include that due to the misguided instructions of EMDR being completed over 1 – 3 sessions which were later retracted by Shapiro (1995), much research is inconclusive due to the limited session numbers. Another limitation in the study of EMDR is the heavy reliance on the process measures (SUDS & VoC) as the predictors of success. Outcome studies which are heavily used in CBT studies are needed and indicate smaller effect sizes than what has previously been reported (Davidson & Parker 2001).
CBT in the context of PTSD is comprised of Psychoeducation about trauma, relaxation training, and identification and modification of cognitive distortions (Maercker et al. 2006). Trauma focused CBT can also involve imaginal reliving of the trauma memory, imaginal exposure, in vivo exposure, facilitation of post-traumatic growth, stress inoculation, graduated exposure to avoided situations and trauma re-experiences, and rescripting/imagery rescripting (Maercker et al. 2006 & Williams et al. 2003) (Table 2). CBT duration in typical clinical practice is determined by the patient’s response to treatment (Foa et al., 2005).
Various cognitive distortions are seen in PTSD, depending on the traumatic experience and the nature of the psychological state of the person. Common cognitive distortions include perceiving the world as dangerous, seeing oneself as powerless or inadequate, or feeling guilty about outcomes that could not have been prevented (Friedman 2006). Many survivors feel guilty, thinking that they could have done more to limit the damage, or prevent injury or death, and may have suicidal ideation (Kar 2010). A study has also indicated that PTSD is associated with negative beliefs about self that may influence self-esteem and interpersonal relationships (Christensen 2004). PTSD often co-occurs with depression, and they may share common risk factors. One possible common cognitive risk factor is hopelessness. In a study of female survivors of interpersonal violence, relationships between hopelessness and symptoms of PTSD were due almost entirely too shared variance with depression (Scher & Resick 2005).
Cognitive therapy is based on an underlying theoretical rationale that an individual’s affect and behaviour are largely determined by the way they think and structures the world around them (Garakani et al 2004). Victims generally begin to experience improvement in symptoms and behaviour as they begin to think and act more realistically and adaptively with regard to their situational and psychological difficulties (Smith et al. 2007). In adults, children, and adolescents with PTSD, the effects of CBT have been observed to be partially mediated by changes in maladaptive cognitions, as predicted by cognitive models of PTSD (Smith et al. 2007). It has been proposed that successful processing of traumatic events involves emotional engagement with the trauma memory, organization of the trauma narrative, and correction of dysfunctional cognitions that often follow trauma (Hembree & Foa 2000). One study investigating trauma processing during and after CBT consisting of imaginal exposure combined with rescripting suggested that imaginal reliving during CBT is not crucial for symptom reduction, but it may promote conceptual processing, which in itself predicts a better treatment outcome for PTSD (Kindt et al. 2007).
Table 1. 8 Phases of EMDR Therapy
Client history and treatment planning
The clinician gathers information about the client's current level of functioning, current symptoms, stimuli that trigger symptoms, and assessment of the client's stability and life circumstances. With this information, the clinician establishes targets for treatment that encompass the original trauma, subsequent secondary triggers, and adaptive behaviours that will be desirable in the future
Tasks in this phase include rapport-building, teaching relaxation procedures, informed consent to treatment, and discussion with the client about the potential loss of secondary gains that might be occurring because of the symptoms
The assessment phase entails the clinician clarifying components of the target and provides a pre-treatment baseline. The client identifies an image that accurately represents the memory sequence, as well as the concomitant maladaptive self-evaluation he or she uses when recalling the event. The degree of emotional distress associated with the memory is quantified using Subjective Units of Distress (SUDS) (Wolpe 1991), in which the client assigns a numerical rating to the intensity of the disturbing feelings as he or she recollects the trauma. The client is asked to generate a more adaptive self-evaluative statement that also creates an internal locus of control. The degree to which the client believes the adaptive self-evaluative statement is quantified using the Validity of Cognition (VoC) (Shapiro 1989). A rating of 1 means the client acknowledges the accuracy of the rational self-statement, but the statement does not feel valid, while a 7 indicates emotional congruence with what one knows is true on an intellectual level
The purpose of this phase is reduction of negative affect as indicated by the SUDS rating. In this phase the client engages in repeated horizontal eye movements at the rate of about one per second, for about 24 eye movements. The rate of speed for the movements as well as the number of eye movements necessary to induce accelerated processing varies between clients. Some clients cannot engage in horizontal eye movement; vertical or diagonal eye movement is also acceptable in this treatment protocol. Other forms of stimulation besides eye movements can also induce accelerated reprocessing. Alternative stimuli used by clinicians and found in the research include alternating hand taps on clients' left and right hands and alternating sounds in the clients' left and right ears
Installing" is the process of restructuring the critical or otherwise negative self-evaluative statement that had accompanied the distressing memories. The negative self-statements are replaced with more positive, adaptive self-evaluative cognitions. If the client already had some constructive self-statements, those statements are further strengthened during this phase
The client holds the target memory and positive cognition in mind then searches through his or her body for anybody sensations suggesting tension. If the client identifies any, the bodily sensation becomes the target of subsequent sets of eye movements
It is critical that the client re-establishes a sense of stability and equilibrium by the conclusion of the session, regardless of whether or not the reprocessing was successfully completed. The client is also directed to keep a journal or log of associated thoughts, images, or dreams that occur between treatment sessions
This is done at the beginning of each new session. The purpose is for the clinician to ascertain whether treatment effects are being maintained
Prolonged exposure has been reported to be effective for improving post-traumatic stress symptoms in 60%–65% of trauma victims suffering from PTSD (Grunert et al. 2007). However, a simple habituation model (on which prolonged exposure is based) is observed to be insufficient to address non-fear emotions (eg, guilt, shame, anger) in PTSD. In contrast, by adding an imagery-based, cognitive restructuring component (imagery rescripting and reprocessing therapy) to the treatment of individuals of PTSD who have failed to improve with prolonged exposure alone, 78.3% of clients showed full recovery from their PTSD symptoms and no longer met criteria for PTSD after 1–3 sessions of imagery rescripting and reprocessing therapy (Grunert et al. 2007). It suggests that individualised trauma assessments should be conducted for each patient to identify the predominant trauma-related emotions and cognitions which will help to find the best CBT “treatment fit” for the specific trauma characteristics of each patient (Grunert et al. 2007).
The traumas of war have long been associated with PTSD. In addition, soldiers exposed to combat remain at high risk for developing the disorder (Miyahira et al. 2010). Multicomponent CBT showed promise in a group of male combat veterans with severe and chronic PTSD for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement and interpersonal functioning (Miyahira et al. 2010). CBT with brief virtual reality exposure has been found to be beneficial in treating PTSD in war veterans (Miyahira et al. 2010). A 12-session integrated treatment using components of cognitive processing therapy for PTSD, and CBT for chronic pain management in veterans with comorbid chronic pain and PTSD, suggested not only the feasibility of this treatment approach but also clinical benefit (Miyahira et al. 2010).
CBT vs EMDR
Various forms of therapies have been compared with CBT in the treatment of PTSD, namely supportive psychotherapy, problem-solving therapy, present-centred therapy, psycho-dynamic therapy, hypnotherapy, acupuncture, and structured writing therapy (Cottraux et al. 2008). However, more consistent comparison has been with EMDR. A systematic review of 23 clinical trials on the efficacy of CBT in comparison with other psychotherapies suggested that CBT had better remission rates than EMDR or supportive therapies. CBT was comparable with exposure therapy and cognitive therapy in terms of efficacy and compliance. These findings suggested that specific therapies, such as CBT, exposure therapy, and cognitive therapy are equally effective, and more effective than supportive techniques in the treatment of PTSD (Mendes et al. 2008).
Another systematic review of 33 randomized controlled trials compared all psychological treatments for adults suffering from traumatic stress symptoms for three months or more. Types of interventions studied were trauma-focused CBT/exposure therapy, stress management, other therapies (supportive therapy, nondirective counselling, psychodynamic therapy, and hypnotherapy), group CBT, and EMDR. With regard to reduction of clinician-assessed PTSD symptoms measured immediately after treatment, trauma-focused CBT did significantly better than other therapies and wait-list/usual care. There is no significant difference between trauma-focused CBT and stress management, trauma-focused CBT, and EMDR. Group trauma-focused CBT was significantly better than wait-list/usual care. It was concluded that individual and group trauma-focused CBT, EMDR, and stress management are effective in the treatment of PTSD. There was some evidence that individual trauma-focused CBT and EMDR are superior to stress management in the treatment of PTSD at 2–5 months following treatment (Bison & Cochran 2007)
In six studies comparing EMDR directly to trauma‐focused CBT, results were mixed. Three studies found an advantage for EMDR as compared to exposure alone and to exposure plus cognitive therapy. Three studies found exposure or its combination with cognitive restructuring and SIT was superior to EMDR (McFarlane et al. 2011).
The Australian Guidelines recommend trauma‐focused psychological therapy, delivered during 90‐ minute sessions, as the best evidence treatment for PTSD (ACPMH 2007). This type of treatment can be easily delivered in a community setting, given the availability of suitably trained therapists. Findings of more than 30 well controlled studies indicate that trauma‐focused Cognitive Behavioural Therapy (CBT), as well as Eye Movement Desensitization and Reprocessing therapy (EMDR) in addition to in vivo exposure, are the treatments of choice for PTSD (Pietrzak 2011). These treatments were found to be effective, not only in the treatment of PTSD symptoms, but also of co‐morbid anxiety and depression, as well as achieving improvements in broader quality of life (Pietrzak 2011).
Seidler & Wagner (2006) suggest that in the treatment of PTSD, CBT and EMDR tend to be equally efficacious. Seidler & Wagner (2006) stated that future research should not restrict its focus to the efficacy, effectiveness and efficiency of these therapy methods but should also attempt to establish which trauma patients are more likely to benefit from one method or the other.
Considering the available literature it is clear that there is evidence for the efficacy of both CBT and EMDR in treating PTSD in the civilian and military population. What is less clear is which therapy is suitable to individuals who present with a specific set of variables and circumstances. The argument that EMDR is able to deliver results in a timely manner which can suit the “let’s get things done now” attitude of ADF members would appear invalid as the recommended session length of 8-12 is comparable with CBT. As both forms of therapy have proven effect and therefore are the current gold standard’s and recommended treatments for PTSD by the DoD and DVA, studies should now focus on dropout rates and assessment. Grunert et al. (2007) discussed the importance of individualised trauma assessments to assist the therapist in discerning a treatment fit for the trauma characteristics being presented. This is especially important for ADF members who are more likely to be exposed to complex multiple traumas. Further dismantling studies as to the effectiveness of CBT and EMDR components would also be useful in identifying presenting characteristics and effectiveness of specific interventions. This could lead to a multi-faceted treatment which is tailored to the specific needs of the ADF member promoting remission and completion of therapy.
Table 2. CBT techniques used in treating PTSD
Education offered to individuals with a mental health condition and their families to help empower them and deal with their condition in an optimal way. For PTSD this includes education on trauma and psychological and physiological reactions to trauma.
Relaxation training involves instructing the individuals in various relaxation exercises, which are used at times of anxiety or distress. Relaxation its effects by reducing hyperarousal symptoms. Once hyperarousal is reduced, the patient may be less distressed by trauma-related stimuli and, therefore, less avoidant (Taylor et al, 2001)
Cognitive Restructuring with PTSD involves challenging maladaptive cognitions of helplessness, hopelessness and worthlessness to reduce fear. This is achieved through questions such as “What is it about this situation that makes you weak?’’, ‘‘How is it that you are to blame?’’, and ‘‘What would you say to a friend in this situation? (Ehlers & Clark, 2000)
In Imaginal Reliving individuals are asked to relive the traumatic experience in the presence of the therapist, starting from the beginning and continuing to the point when they were safe again, while putting the experience into words (Foa & Rothbaum, 1998)
In Imaginal Exposure individuals are asked to recall the details of the traumatic event while focusing their attention on any occurring sensory feelings, thoughts, and emotions. Exposure to such memories results in reduction of fear and avoidance. The presumed underlying mechanism is the loosening of the association between unconditioned and conditioned stimuli (Foa et al., 1999)
In vivo Exposure
In vivo exposure involves planned confrontations with situations or objects associated with the trauma and that are therefore anxiety-evoking (Richards et al. 1991)
Post-Traumatic Growth is the subjective experience of positive psychological change reported by an individual as a result of the struggle with trauma. Some theorize it is a coping style, while others think of Post-Traumatic Growth as an outcome of coping with traumatic stress (Sheik 2008)
Stress Inoculation Training
Stress Inoculation Training involves teaching coping skills to manage stress and anxiety. This may include training in deep muscle relaxation, cognitive restructuring, breathing exercises, assertiveness skills, thought stopping, role playing, and guided self-dialogue. Stress Inoculation Training is often used in conjunction with other therapy techniques, such as CBT (Meichenbaum, D & Deffenbacher 1996)
Therapists assist the client to construct an exposure fear hierarchy, in which feared objects, activities, or situations are ranked according to difficulty. They begin with mildly or moderately difficult exposures, then progress to harder ones (Opdyke, Williford & North 1995)
in Imagery Rescripting expression of inhibited responses is facilitated as well as new information provided during evocation of the traumatic memory (Arntz & Weertman 1999)
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