Book Review: Treating PTSD in Military Personnel: A Clinical Handbook

Treating PTSD in Military Personnel: A Clinical Handbook
Bret A. Moore & Walter E. Penk (eds). (2011). New York: The Guildford Press.

This book claims to meet 'a critical need' by reviewing the 'full range of effective treatments for posttraumatic stress disorder', enabling readers to develop their skills in working with military clients. The editors and other contributors approach mental disease in general, and PTSD in particular, from a medical perspective. The terms 'gold standard in research' and 'randomised controlled trials' are used unquestioningly, and the book is situated firmly within the paradigm of natural science. While some of the content has relevance for those working with military personnel outside the US, it is essentially 'US-centric'. Its legislative and cultural foundations, and the assumptions it makes about the values and beliefs of both military personnel and practitioners, have most relevance to those living and working within its borders.

The first chapter makes the case for the military being a unique cultural entity with its own customs, values and language, and argues that therapists need to develop cultural competence to work ethically with this group.

Chapter 2 looks at issues relating to the accurate assessment of PTSD in military personnel. Drawing upon research sponsored by the Veterans Administration, it talks about PTSD prevalence rates of between 5 and 40 per cent amongst veterans of recent military operations. The chapter touches upon some of the fundamental ethical issues facing practitioners who work with military personnel, including confidentiality (the limits of which are explicitly addressed in US military legislation, but are far less clear for therapists working with UK service personnel). It also draws attention to the real practical difficulties military personnel may face if they admit to any psychological ill health. A diagnosis of depression, for example, renders the individual, at least temporarily, non-employable and non-promotable (with attendant financial loss). The chapter concludes by suggesting that a multi-method assessment process involving both clinical interviews and self-report measures be used in assessing for PTSD.

Cognitive Processing Therapy (Resick, Monson & Chard, 2008) is the subject of Chapter 3. The key strength of this approach is said to be that it can accommodate different life events or traumas in one treatment. Surprisingly, although CPT is endorsed by the Veterans Health Administration, the authors acknowledge that its use with actively serving personnel is not yet supported by any relevant research, and that it might not be suitable for serving personnel who have to contain these emotions in order to get their job done.

Chapter 4 looks at Eye Movement Desensitisation Therapy (EMDR) (Shapiro, 2001). Shapiro herself admits that the theory behind the therapy she founded is a work in progress, and controversy continues over its inability to prove the functional mechanism behind its effectiveness. This chapter ignores this controversy, but recognises that EMDR alters peoples' memories of traumatic events and is therefore not a treatment that can be used with military personnel who are subject to court martial, or are witnesses in court martial proceedings, in which accurate recall of events is essential.

Chapter 5 describes Virtual Reality Exposure Therapy (VRET). Virtual reality technology allows for the creation of stimuli that closely match the original trauma (the client's description of events are used by the therapist to recreate a virtual version of them). The therapist and client then work on processing the memory, identifying hot spots and alternative ways of understanding the situation, etc. The author speculates that VRET may, because of its technological and hands-on nature, be a culturally acceptable form of therapy in the military, but acknowledges the risk of cyber sickness and the unsuitability of heavy head equipment for clients with injuries to the neck/back.

The historical relevance of Freud's theories to the concept of PTSD are explored in Chapter 6. In the context of this long and distinguished history, the author laments it is regrettable that psychodynamic treatment receives 'at best, a second-tier recommendation in clinical practice guidelines for PTSD'(Forbes, et al, 2010). He goes on to propose that psychodynamic therapy may be particularly useful for clients with complex PTSD (a concept that, surprisingly, the rest of this book does not address) due to its focus on interpersonal relationships.

Chapter 8 moves the focus on to therapeutic modalities and presents a useful review of recent studies on group therapy for the treatment of PTSD. The key strengths of this approach are summarized as efficiency and cost effectiveness, reduced stigma, familiarity (most military training takes place in groups) and social support, with the key potential risk being re-traumatisation due to others recounting their experiences.

Chapter 9 acknowledges the impact that PTSD can have on the family members of military personnel. The theoretical foundation of the chapter lies in systems theory, but the authors also explore the use of 'supportive' therapies including Emotion-Focused Therapy and Strategic Approach Therapy. They note the regrettably low participation rates for couples or family therapy in military studies.

In Chapter 10 the authors take a rather uncritical look at the use of pharmacological means of alleviating the symptoms of PTSD, concluding that at least three different drug groups need to be involved – those designed to address anxiety, affective symptoms and re-experiencing symptoms. What is most helpful about this chapter is its acknowledgement of the challenges presented by the use of psychotropic drugs in a military environment.

The first part of this book finishes with an examination of the history of psychosocial rehabilitation, from the work of St Benedict in the sixth century through to the programmes offered by the US military today to troops trying to make the transition between deployment and home. Basing their thoughts on Bandura's (2006) theory of Human Agency, the authors speculate on the importance of helping clients to become active agents and not just onlookers of the events they experience.

Onto Part 2 of the book, which highlights specific clinical issues said to be associated with PTSD. Chapter 12 looks at co-occurring affective and anxiety disorders and contains some interesting speculation as to the relative contributions of genetics and personality to the overlap between these disorders and PTSD. The authors highlight the way in which co-occurring disorders can, if not tackled, dramatically reduce the effectiveness of treatment for PTSD, and recommend an integrated treatment in which all disorders are treated at the same time, ideally by the same therapist.

Chapter 13 focuses on substance use disorders, summarising the occurrence rates of PTSD with substance use, evaluating assessment tools, and reviewing some published treatment strategies and, again, propose the use of integrated treatment strategies that address both the PTSD and the substance use concurrently. The authors acknowledge, however, the lack of research on military populations, and restrict themselves to recommending areas for further study rather than specific treatment programmes.

In Chapter 14, the authors examine the issue of traumatic brain injury and explore the challenges inherent in distinguishing between the psychological and organic roots of PTSD symptoms. The focus is on cognitive rehabilitation through, for example, attention process training or psychoeducation, but the authors accept that the best treatment approaches for PTSD in cases of traumatic brain injury are not yet well understood and that all they can state is that there is no evidence that current treatments for PTSD would be contraindicated in such patients.

Chapter 15 starts with the story of the Tailhook Convention in Las Vegas in 1991. Reportedly 83 women and 7 men were sexually assaulted at the convention, which was attended by 4000 Navy and Marine Corps service members (The Navy Blues, 1993). This led to the concept of 'military sexual trauma' (MST) becoming enshrined within the Veterans Health Care Act of 1992. The chapter examines risk factors for MST and concludes that PTSD as a result of MST is more common than PTSD from combat exposure, with men and women equally at risk.

The focus of Chapter 16 is sleep disorders. Disappointingly, much of this chapter looks at evidence to support the thesis that war and sleep are not compatible, rather than examining the way PTSD can affect sleep or the way that sleep disturbances, as a feature of PTSD, can impact on military personnel in particular. The authors' treatment approaches are similarly generic – with a lot of time spent on very basic sleep hygiene techniques.

Chapter 17 explores the link between PTSD and suicidal behaviour. Joiner's (2005) interpersonal-psychological theory of suicide (IPTS) is described as the key tool for predicting suicidal behaviour, though the chapter also includes guides to clinical interviewing in cases where suicidal ideation is present. Specific treatment approaches for suicidal behaviours are explored at a fairly basic level but there are some interesting reflections on the specific challenges presented by suicide in the military.

In Chapter 18, the authors highlight the issues of anger and aggression, and point out that the level of anger experienced by veterans with PTSD is a robust predictor of poorer PTSD treatment efficacy and increased rate of dropout (Forbes, et al, 2008). The need for the clinician to assess the risk of specific aggressive behaviours by considering their clients' experience of family violence, the existence of other psychopathologies and the stability of their past and current relationships is emphasized.

The book concludes with a chapter on resiliency building, which begins by describing some of the research on resilience in 'returning warriors'. The chapter includes debate on what characterises resilient individuals, including a section on 'How to develop persistent PTSD and related adjustment problems'.

Reading this book was a pretty mixed experience. Starting with the positives:

• Somewhat unusually for an edited volume, the book forms a very coherent and rather easily digested whole, largely due to the structured format for each of chapters – as it says on cover, this book has been 'tightly edited'.
• It contains a vast amount of diverse and useful research for anyone interested in PTSD in military personnel.
• It examines many of the relevant cultural issues and challenges likely to face therapists working with this client group.

On the negative side:

• Each chapter quotes different studies on, for example, the prevalence of PTSD in military personnel, making the lack of a concluding chapter summarising the data into a coherent whole a serious omission.
• The selection of treatment orientations appears somewhat random, given that many of them did not have the type of evidence supporting them that editors claim was the basis of their inclusion in the book in the first place.
• The book raises awareness of different treatment options but fails to deliver on its promise to help clinicians to develop their skills in working with military personnel. Most of the treatment orientations described require therapists to undertake additional training or purchase additional equipment. In short, this book is of more value as a starting point for researchers looking at PTSD (in general, and within a military setting) than it is as a

Susan Iacovou