Providing Effective and Evidenced Based Care in Collaborative Environments

1. Providing Effective and Evidenced Based Care in Collaborative Environments LCDR Rick Schobitz, Ph.D., CDR Dennis Slate, Psy.D., LT Seth Green, Ph.D., & LT Andrew Lloyd, Ph.D Brooke Army Medical Center The comments expressed in this presentation reflect the opinion of the authors and not the Department of Defense, Brooke Army Medical Center, or the U.S. Army

2. Objectives • Identify PTSD treatments within DoD/VA clinical practice guidelines • Describe the value of prolonged exposure as a treatment for PTSD and acute stress disorder in deployed settings • Recognize the link between collaborative training and interoperability during deployment

3. Background • Scholarly research documents the prevalence of symptoms of PTSD and ASD among service members returning from combat (Milliken, et al., 2007) • The key to provide optimal care for affected service members—access to clinicians who are: • Skilled in evidence based treatments for PTSD • Understand the military culture

4. Care for PTSD • DOD/VA Clinical Practice Guidelines (CPGs) provide evidenced based recommendations for PTSD care • CPGs revised in 2010 • Available for further review at: http://www.healthquality.va.gov/post_traumatic_stress_disorder_ptsd.asp

5. KEY POINTS OF THE CPG’s • Triage and management of acute traumatic stress • Routine primary care screening for trauma and related symptoms • Diagnose trauma syndromes and co-morbidities • Evidence-based management of trauma-related symptoms and functioning • Collaborative patient/provider decision-making, education, and goal-setting

6. KEY POINTS OF THE CPG’s (cont.) • Coordinate and sustain follow-up • Identify major gaps in current knowledge base • Outline for psychological care in ongoing military operations • Proactive strategies to promote resilience and prevent trauma-related stress disorders • Standardized longitudinal care (DoD/VA, Primary Care/Mental Health)

7. Recommended Treatment Options • Prolonged Exposure • Cognitive Processing Therapy • Stress Inoculation Training • Eye Movement Desensitization and Reprocessing (EMDR)

8. Additional Treatment Options • Relaxation training • Imagery Rehearsal • Brief Psychodynamic Therapy • Hypnotic Techniques

9. Other Information Provided in CPGs • Recommendations for early intervention • Medication recommendations • Symptom specific treatment recommendations • Additional recommendations regarding triage, assessment, rehab, and treatment

10. Training to Provide Evidenced Based Care (EBC) • Army medical department (AMEDD) currently provides 2 – 5 day training on EBC • Question: Does short term training lead to implementation into clinical practice? • AMEDD has concern this may not be the case which leads Army psychology leadership to instruct Army training sites to develop plan to support implementation

11. Keys to Providing Evidenced Based PTSD Care in Military Settings • Clinical Competence • Military Cultural Competence

12. BAMC Evidenced Based PTSD Treatment Training Program • Created in 2010 at BAMC Psychology and Social Work training programs • Evidenced based PTSD treatment service created within existing clinic • Weekly seminar reviews current literature and discusses current cases • Focus on applying evidenced based models and working through complex cases

13. Requirements for Training Program • Trained supervisors with background in EBC and especially Prolonged Exposure • Audio and video recording equipment • Appointments that are of the appropriate length consistent with EBC models

14. Application to Deployed Settings

15. Evidenced Based Care in Deployed Settings • Preliminary evidence suggests abbreviated PE model may be of use in deployed settings (Cigrang, J., Peterson, A., and Schobitz, R. 2005) • Current investigation by Strong Star research consortium is evaluating 5 session model • Brief model could be applied during deployment if research supports it

16. Evidenced Based Care in Deployed Settings • Deployment “down time” may provide opportunity of treatment • Example: Marine on Navy Ship • Use as initial intervention while identifying resources for future care • We need additional longitudinal outcome data to inform about effectiveness, use as early intervention, etc.

17. Additional skill needed for providers wishing to work in the DoD: Cultural Competence

18. External Rotation • Psychology residents spend 2-3 months imbedded with medical staff of an Army maneuver unit • 4th Infantry Division, Fort Carson, Colorado • 1st Cavalry Division, Fort Hood, Texas • Shift in training focus • Deployment cycle (ARFORGEN) issues • Command consultation • Training, administrative, and organizational tasks

19. Deployment Cycle Issues • Soldier Readiness Processing • Pre-deployment (SRP) • Readiness screening (PHA) • Mandatory briefings • Determination of deployability for Soldiers in treatment • Post-deployment (rSRP) • Ensuring/managing continuity of care (“red” and “amber” Soldiers) • Post-Deployment Health Assessment (DRAT, SAT I&II, etc.) • Mandatory briefings

20. Command Consultation • Identifying and addressing problems within the unit (e.g., an increase in alcohol related incidents or poor morale) • Unit Behavioral Health Needs Assessment • “Walkabouts” • Developing and coordinating unit BH service delivery system and policies • Procedures for access to care, addressing acute safety issues, and ensuring compliance with DoD and other BH requirements • Developing training calendar

21. Training and Prevention • Managing required training events • Traumatic event management (psychological first aid), suicide prevention, Battlemind/resiliency • Delivering requested training • Stress management, teambuilding, sleep hygiene • Unit level peer advocate training

22. Examples of Training • Aeromedical Psychology Course • Center for Deployment Psychology • Expert Field Medical Training • Combat and Operational Stress Control Course • SERE Orientation Course • Field Medical Readiness Badge Training

23. U.S. Army Special Operations Command • Opportunities for USPHS psychologists • 8 Positions within USASOC • Clinical services exclusively with a Special Operation Force (SOF) population • Locations across the United States

24. 75th Ranger Regiment • Location: Ft. Benning, GA • Working exclusively with Rangers and families from three Ranger units co-located at Ft. Benning • Regimental Headquarters • Regimental Special Troops Battalion • 3rd Battalion

25. Special Forces Locations 1st Special Forces Group (Airborne) Location: JBLM, WA 3rd Special Forces Group (Airborne) Location: Ft. Bragg, NC 5th Special Forces Group (Airborne) Location: Ft. Campbell, KY 7th Special Forces Group (Airborne) Location: Eglin AFB, FL

26. U.S. Army John F. KennedySpecial Warfare Center and SchoolLocation: Ft. Bragg, NC 95th Civil Affairs Brigade (Airborne) Location: Ft. Bragg, NC 4th Military Information Support Group Location: Ft. Bragg, NC

27. Application Process • Interested candidates will be screened and interviewed by each individual unit Commander and Command Psychologist. • POC for more information • LTC Paul Dean paul.dean1@soc.mil or LTC Jeff McNeil jeffrey.mcneil@soc.mil Directorate of Psychological Applications US Army Special Operations Command (Airborne) (910) 432-6833

28. Questions ~ A Partnership Built on Trust