The statistics on PTSD in veterans keeps increasing according to the author Matthew Tull, in his article he emphasizes how Iraq and Afghanistan soldiers experience many conflicts in regards to their mental health. Therefore, Tull discusses the statistics on soldiers who experienced traumatic events. For example, Tull presents that 94.5% of veterans witness dead bodies, 92% are attacked and ambushed, soldiers who witness or get injured and killed, and about 95% of soldiers are shot at as well. This case study will be focusing on the effect on soldiers who experienced traumatic events while being in Iraq and Afghanistan. During this proposal, it will discuss how veterans who are males and females living in New Jersey in Atlantic County are able to reduce their PTSD through Cognitive Behavioral Therapy, in order for veterans to increase their healthier lifestyle.
Introduction and Problem Statement
Many PTSD studies have been conducted in Iraq and Afghanistan veterans over the last few years as the author Charlotte Tucker states in her article. Therefore, Tucker argues that as the disorder becomes more common and known among veterans and their doctors, researchers are enhancing their treatments as well as comprehending what PTSD consists of to better assist veterans. However, the author explains that PTSD is a condition that is triggered by terrible events and the symptoms of this condition include anxiety, traumatic flashbacks, behavioral changes, nightmares, and uncontrollable thoughts about the event experienced. Although, PTSD can be reduced if it is treated properly though therapies and medications. This disorder should not wait to be treated because the longer an individual waits to treat it the more chronic it can become. In this proposal, the independent variable (intervention) will be the use of Cognitive Behavioral Therapy, which will measure the outcome (dependent variable). By exposing the intervention (independent variable) to veterans it can be able to reduce PTSD symptoms in veterans.
Recent studies have established many symptoms of PTSD in Iraq and Afghanistan soldiers. It is a well known disorder and commonly known in most veterans therefore, according to the Journal of Military and Veterans Health it concludes that “more than half of the 3,000 American soldiers wounded in Iraq and Afghanistan have suffered from brain damage and, unfortunately, the trauma will have a permanent effect on their memory, mood, and behavior as well as their ability to think and work (Blech, 2006)”.
This proves how traumatic events can trigger PTSD symptoms like mood changes in veterans due to what they have experienced throughout their deployment. In addition, the research by Hundt, Natalie Ecker, Anthony Thompson, Ashley,Smith, Tracey Stanley, Melinda Cully, (2018) present two types of treatments for the reduction of PTSD symptoms the researcher’s discuss that, “trauma-focused psychotherapies, such as prolonged exposure and cognitive processing therapy, are the most effective forms of treatment for posttraumatic stress disorder. These treatments are commonly delivered in the Veterans Health Administration; however, dropout means that some veterans fail to benefit”.
Although there is evident research on how to overcome PTSD symptoms in many veterans, some do not seek for help according to researcher’s Tracey Stecker, Gregory McHugo, Haiyi Xie, Katrina Whyman, and Melissa Jones (2014) “the unfolding story suggests that the prevalence of PTSD among returning service members is high, treatment utilization is low, and those who do seek treatment are unlikely to stay in treatment. Although it would be reassuring to know that those who make it to treatment and stay in treatment get good treatment, research suggests that they are unlikely to get minimally adequate treatment (18,19).
Without adequate treatment, returning service members will likely continue to suffer from symptoms of PTSD throughout their lives”. Due to the lack of improvement for some individuals as stated by the researcher’s, in the U.S. Department of Veteran Affairs website the researcher’s Hamblen, Schnurr, Rosenberg, & Eftekhari (2018) consider that, “clinicians and researchers are interested in finding new ways to advance PTSD treatment, accessibility, and delivery for certain populations and for patients who fail to respond to current evidence-based treatments.
These advances include alternative delivery strategies, engagement strategies, combining treatments, and flexible applications of manualized treatments”. Prior research investigations have established that there are therapies for veterans that they can receive to reduce their PTSD symptoms as well as substance use. For example, researcher’s Christy Capone, Candice Presseau, Elizabeth Saunders, Erica Eaton, Jessica Hamblen and Mark McGovern (2018) all aim to project a treatment that will help decrease PTSD and substance use on Iraq and Afghanistan veterans, “integrated Cognitive Behavioral Therapy (ICBT) is a manual-guided intervention designed to improve both PTSD symptoms and substance use. ICBT focuses on three primary areas:
- psychoeducation regarding PTSD symptoms, substance use, their interrelation and treatment;
- breathing retraining, a combination of centering and breathing techniques; and
- flexible thinking, a cognitive restructuring approach and functional analysis of the links among activating events, beliefs, and emotional or behavioral consequences”.
Therefore even though the main focus on this study is about the effect of Cognitive Behavioral Therapy, substance use is widely common in veterans and that is where ICBT comes into play. However, little research has been conducted to show that the use of Benzodiazepines is not as well recommended to treat symptoms of PTSD. In recent studies by the U.S Veteran Affairs it analyzes that Benzodiazepines can lead to patients depending on it excessively. In addition, the U.S Veteran Affairs discuss that Benzodiazepines must be prescribed by Doctors only and it may lower anxiety and sleep problems but it is not a medication that is reliable for PTSD. As stated in the article of the U.S Veteran Affairs, “Benzodiazepines provide short term relief from distressing feelings but can become a problem in the long run.
You can become dependent on the medication and end up feeling like you cannot face stressful situations without it. If you use benzodiazepines to escape reminders of your trauma, you never truly learn to manage your stress. This makes it harder to recover from PTSD. Effective treatments for PTSD, like talk therapy, help you stop avoiding distressing situations and memories” (2018). However, other types of therapies have proven to be more effective in veterans with severe PTSD. Previous studies by researcher’s Juliette Mott, Natalie Hundt, Shubhada Sansgiry, Joseph Mignogna, and Jeffrey Cully (2014) have promoted the effectiveness of psychotherapy in veterans with PTSD in their case study and they emphasize the “data from this study also indicate improvements related to psychotherapy exposure, with an increasing proportion of patients receiving eight or more psychotherapy sessions”. Therefore this type of psychotherapy treatment illustrates that it is effective after a few sessions.
However, during this study the researcher’s express how psychotherapy can be taken via telephone for those patients who may have issues traveling to therapy sessions, and it is just as effective for them. Lastly, another form of treatment that is proven by researcher’s Denise Sloan, Michelle Bovin, and Paula Schnur (2012) suppose that “group treatments for PTSD are assumed to involve a number of mechanisms that offer benefit beyond those provided by the individual therapy format. Group treatment provides a safe environment for patients with PTSD to become more socially connected with others and offers the opportunity to build trust”. Therefore, the researcher’s of this study consider that group therapy can be effective because patients tend to open up about their feelings when others are sharing similar experiences and trauma.
Aims and Hypotheses
Will Iraq and Afghanistan veterans who suffer from PTSD symptoms, who participate in Cognitive Behavioral Therapy as opposed to veterans who only receive group therapy reduce PTSD symptoms? The hypotheses of this research study are to prove how male and female veterans from New Jersey who suffer from PTSD symptoms have a greater chance of receiving lower scores on the Clinician-Administered PTSD scale (CAPS) by attending to Cognitive Behavioral Therapy compared to veterans who only receive group therapy.
Therefore veterans who start to show improvement with Cognitive Behavioral Therapy will be able to have healthier and mentally stable lives. One of the main purposes of this study is to give veterans a chance to learn how to cope with their emotions such as anger, sadness, and guilt by opening up and talking to their therapist in regards of these emotions. Although the independent variable of this study is the intervention which will be Cognitive Behavioral Therapy and it will be introduced to the patient as soon as they are selected randomly from a group of veterans. Influenced by the independent variable (intervention) the dependent variable is the outcome that is supposed to prove the effectiveness of reduction in PTSD symptoms through Cognitive Behavioral Therapy
The target population of this research study will be Iraq and Afghanistan male and female veterans suffering from PTSD. The sampling frame is the veterans who are a part of the Veterans of Foreign Wars (VFW) in Atlantic County. Therefore the researcher will be visiting the Atlanticare Behavioral Health outpatient clinic in Egg Harbor Township to aim for a list of potential participants who are veterans in Atlantic County. The use of these lists will allow the researcher to pull 200 participants from the target population of Atlantic County.
A random generator will be used during this research study that will randomly assign the group into two different groups. The first group will be 100 participants and they will be receiving the intervention of Cognitive Behavioral Therapy and the other 100 participants which is the control group be assigned into group therapy. In this study since it is only for veterans in Atlantic County specifically, it may encounter an issue with external validity because it is not as generalized to all populations. In order to establish a more successful external validity the age range of this case study will range from 21-70 year old of veterans from all education levels, income levels, all race, and all race and ethnicities.
The first group in this study will receive Cognitive Behavioral Therapy, as opposed to the second group which is considered the control group and that is only group therapy. However, to evaluate the effectiveness of this treatment, participants will be attending Cognitive Behavioral Therapy or Group Therapy for a total of six months. The researcher will be collecting data after every two months. This will predict the internal validity by illustrating the reduction of PTSD symptoms in the two groups.
The intervention that will be used in this case study will be Cognitive Behavioral Therapy as well as Group Therapy. Iraq and Afghanistan veterans will all participate in the intervention sessions each Monday, bi-monthly, for six months. The impact of the intervention will be measured immediately following the intervention and again every two months for four months. Therefore the interventions will be taking place at the VFW in Egg Harbor Township because it is an even distance between the cities of Atlantic County. There will be licensed professional Therapists conducting these interventions with assessments, questionnaires, and the application of the interventions.
There will be 40 Therapists that will divide into two groups of the interventions both Cognitive Behavioral Therapy and Group Therapy. They will be assisting participants throughout their interventions and they will collect the information given of five participants for a total of 200 participants. Once the participants meet with their assigned therapist they will begin their first session which will be about an hour long and a half long because this is where the therapist will gather important personal information of the participant. As well as the Therapist will be able to understand the participant’s ongoing problems, emotions, concerns, symptoms, and strengths. In comparison to other studies, the VFW where the interventions are taking place will be providing snacks and beverages during therapy sessions and they have also have raised money for fifteen dollar gift cards to local gas stations with the help of other VFW’s in Atlantic County as a courtesy for participating in the study.
Instrument and Measurement Techniques
During this study, the groups who are receiving the intervention which is the independent variable will be measured by the rates of intensity and frequency before the interventions are held and another three times after the intervention. Though therapies it will increase the reliability of the results. The scale that will be used while conducting this study is the Clinical Administered PTSD Scale (CAPS). According to the International Society for Traumatic Stress Studies, research demonstrates how Inter-reliability is excessive, reaching from 0.92 to 1.00 for frequency ratings and 0.93 to 0.98 for strength ratings; the worldwide extremity correlation was 0.89. (Hovens et.al., 1994). Kappa for a categorical PTSD diagnosis is frequently 1.0 (i.e., 100% agreement; e.g., Mueser et.al., 2001).
In conjunction Test-retest reliabilities very from .77-.96 for the three symptom clusters and from .90-.98 for 17-item core symptom scale (Blake et.al., 1995). Using the standard 1/2 scoring rule reported previously, test-retest reliability (kappa) for a CAPS PTSD diagnosis was .63, with 83% agreement. Therefore the CAPS illustrates elevated internal consistency, including alphas for the three symptom clusters reaching from .85-.87, and .94 for the final total score (Blake et.al., 1995). Powerful concurrent validity has been illustrated in disagreement with the Structured Clinical Interview for DSM-IV (SCID) PTSD module (.83) and the PSS-I (.73) (Foa & Tolin, 2000). The concluded final concurrence between a clinician-rated diagnosis and CAPS diagnosis was 79%; sensitivity was .74, while specificity was .84 (Hovens et.al., 1994). Many research studies announced a vigorous agreement between various PTSD self-report scales and the CAPS.
The researcher has decided to utilize group interviews because of the lower costs in collecting data. It is also known as being a form of a focus group which is most common in treatment groups that are being exposed to the study. One of the many advantages of this form of data collection is that the structure varies and it can be used for qualitative and quantitative research. All participants will meet at the VFW in Egg Harbor Township, New Jersey. By arranging participants to go to the VFW at the same time it will save the researcher time and less potential recording errors compared to in-person interviews. However one of the major disadvantages with group interviews tends to be confidentiality among participants. Therefore a consent form will be handed to every participant and they will need to sign it.
Informed Consent Form
In this study an informed consent will be provided to all voluntary individuals participating, the form will include an explanation of the purposes of the research and the expected duration of the participants engagement, a statement that the study involves research, a description of the procedures to be followed, and identification of any procedures which are experimental. Participants must also be aware that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the participant is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitled. The following consent form is listed below:
Iraq and Afghanistan Veterans and PTSD
You have been selected and invited to participate in a research study about Cognitive Behavioral Therapy or Group Therapy in regards to the reduction of PTSD symptoms in veterans from Iraq and Afghanistan.
If you are willing to participate in this research study, you will be asked to attend intervention sessions each Monday, bi-monthly, for six months. You will also be asked to answer a series of questions in regards to your symptoms of PTSD as well as the intensity and frequency of the symptoms of PTSD. You will need to report to the VFW center in Egg Harbor Township, New Jersey for all sessions. After two months you will be asked to report back on the fourth month to measure how the PTSD symptoms have changed for the last part of the data collection for a final result in the research study. This study will be a total of six months long.
During this study you will not have to worry about any risks due to all the information given by participants staying confidential between the therapist and yourself because you may be addressing any conflicts, emotions, symptoms in regards of PTSD, and overall personal history. Your name will also not be shared in any publications and further research. Many minimal discomforts due to participants opening up to their therapists.
The advantage of this study is to prove the effectiveness of Cognitive Behavioral Therapy compared to Group Therapy in veterans with severe PTSD symptoms. This will allow researchers to help all veterans from all over the world combat their PTSD symptoms.
Participants will not receive any compensations of money during the study and after the study. This research study is voluntary. If at any point in the study you decide to not keep going you may drop out without any consequences since it is voluntarily. For example, if you do not feel comfortable answering questionnaires of expressing yourself you do not have to engage in the study. If any questions come to mind feel free to contact Ted Alter, Ph.D., Principal Investigator and Advisor at Stockton University. Stockton University Institutional Review Board Health Sciences and Behavioral Sciences have confirmed that this research study is excused from IRB control.
The researcher believes if this study is effective that it will help many veterans reduce their PTSD symptoms and establish a healthier lifestyle. Cognitive Behavioral Therapies, as well as Group therapies, will end up being the reason PTSD symptoms are reduced. Therefore the researcher believes that the Professional therapists did an adequate job in assisting and taking the time to listen to all the veterans who participated in the sessions. This research also was helpful for participants because they have learned to manage their coping skills, emotions, and they also were influenced by their therapists to problem solve situations and emotions in a healthy and proper way. During this study, the internal validity was presented as the difference in the reduction of PTSD symptoms due to the interventions that were randomly assigned to participants.
Strengths and Limitations
After conducting this study there will be a greater chance of PTSD symptoms being reduced in Iraq and Afghanistan veterans who attended all Cognitive Behavioral Therapies in comparison to Group Therapy. Therefore, in regards to the American Association Psychology, it emphasizes, how a therapist is able to alter the patients negative thinking can lead to the improvement of their emotion regulation as well as healthier behaviors through Cognitive Behavioral Therapies.
However, much attention has been drawn to some strengths and limitations that can occur in this research study, for example, one of the major strengths in this study was obtaining a large 200 sample because it is can reduce any sample errors while conducting the study. Another strength during this study was the random selection of participants because it has an equal chance of selection, data analysis is less likely to encounter sampling errors, and it is also an easier and faster way of collecting data.
Some limitations of this case could be that it may not be applicable to everyone due to the fact that this study is only for Iraq and Afghanistan veterans and it may not be as generalized to individuals suffering from PTSD symptoms that are outside of this target population. Another limitation of this research case can also be that the participants receiving group therapy instead of cognitive behavioral therapy may feel as if it is not as effective and could end up dropping out from the study and this can affect the sample size because of the decrease in participants. Although the research design that is being used is successful because the researcher is able to truly measure the effectiveness of therapies before the intervention and after the intervention.
Overall this research study has been effective in many ways starting off by the reduction of PTSD symptoms through the interventions that were given. This research case is able to educate veterans of what PTSD is and the actions that can be taken to reduce the symptoms. However, this case study can also promote policies that further research can be done to find significant observations of the long term effects of the interventions. To discuss some of the positive outcomes of this study is that more therapists have the opportunity to assists the veteran population and this can create more jobs for licensed therapists and even therapists who are bilingual because some participants may not speak fluent English.
It is also a way for veterans to have a set place to better their health with the interventions provided. Social workers are able to raise awareness of PTSD to the public through these programs that benefit veterans as well as their health. Social workers can also benefit from this study by learning new material from therapists that they may not be familiar with. Also, a Social worker utilizes research studies to measure the effectiveness of the practice in which they capture and the programs they administer.