Providing Effective and Evidenced Based Care in Collaborative Environments

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• 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

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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
•  

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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 membersaccess to clinicians who are
• Skilled in evidence based treatments for PTSD
• Understand the military culture

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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_str
  ess_disorder_ptsd.asp

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KEY POINTS OF THE CPGs

• 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

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KEY POINTS OF THE CPGs (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)

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Recommended Treatment Options

• Prolonged Exposure
• Cognitive Processing Therapy
• Stress Inoculation Training
• Eye Movement Desensitization and Reprocessing
  (EMDR)

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Additional Treatment Options

• Relaxation training
• Imagery Rehearsal
• Brief Psychodynamic Therapy
• Hypnotic Techniques

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Other Information Provided in CPGs

• Recommendations for early intervention
• Medication recommendations
• Symptom specific treatment recommendations
• Additional recommendations regarding triage,
  assessment, rehab, and treatment

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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

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Keys to Providing Evidenced Based PTSD Care
in Military Settings

• Clinical Competence
• Military Cultural Competence

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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

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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

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Application to Deployed Settings
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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

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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.

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

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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
  III, etc.)
• Mandatory briefings

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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

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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

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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

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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

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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

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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
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U.S. Army John F. KennedySpecial Warfare Center
and School Location Ft. Bragg, NC
95th Civil Affairs Brigade (Airborne) Location
Ft. Bragg, NC
4th Military Information Support Group Location
Ft. Bragg, NC
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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_at_soc.mil or LTC Jeff
  McNeil jeffrey.mcneil_at_soc.mil
• Directorate of Psychological Applications
• US Army Special Operations Command (Airborne)
• [phone]

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Questions