Case review: Problem Statement

In order to totally understand the dynamics behind any subject matter, one must understand its record. Hopefully that the history is positive marked by compassion, gentleness, and matter for most of humankind. However, when one looks at the history of mental health in america, it isn't characterized by the adjectives previously mentioned. Instead, it is characterized by fear, misunderstanding and inhumane treatment.

According to historian Gerald N. Grob, who authored some literature in 1983, 1991, and 1994, the annals of mental health practice in the United States is less than stellar. The roots of modern mental health treatment has a humble starting when mental health treatment was primarily accomplished in the house. Within the 1700s when a person suffered from what is now considered a mental illness, their treatment and did not take place in an institution but instead in the house. As the of populace of the country grew, mental health treatment shifted to society centers and into clinics such as in Philadelphia, also to asylums just as Williamsburg, Virginia. Those who were not fortunate enough to be looked after in the house, or in a clinic or within an asylum often found themselves in jails or in work properties.

With the advent of the 19th century, a movements towards "moral treatment" was in fashion spearheaded by reformers Dorothea Dix and Horace Mann. These reformers thought the best way to treat mental health issues was within an asylum. There the individual would get a mixture of somatic as well as psychosocial treatments in a managed environment. During this time, the understanding of "moral" supposed that the average person was treated in that fashion that these were in the end restored to full mental health and were considered no more chronically mentally sick (Grob, 1994 as cited in Chavez, Hayman, & Arons, 2009).

Following the Civil Battle, it was known that the knowledge of "moral treatment" was unrealistic and asylums became a refuge for the untreatable chronic patients. Due to the level of their illness, they truly became forgotten associates of modern culture and the quality of mental healthcare deteriorated. As a result to go overcrowding and lack of financing treatment became more inhumane.

It was during this time period that a new reform movements devoted to "mental hygiene" came into being. This new movements ultimately formed the Country wide Committee on Mental Cleanliness which eventually transformed into what is now known as the National Mental Health Association (NMHA). The committee on mental cleanliness advocated for early on treatment of mental health in the fact that early treatment would avoid the development of chronic mental health issues. As such, these reformers advocated for outpatient treatment as opposed to the standard at that time that was inpatient treatment in an asylum or medical center. It had been their belief that by dealing with patients early by means of outpatient treatment, that folks wouldn't normally develop serious mental health problems.

With the advent of World Battle II, excitement for early involvement grew. It finally culminated in the idea of community mental health programs, which we've today. The NMHA, thought prominently in this reform, since it recognized that earlier inpatient attention was often ineffective, neglectful, and even unsafe (Chavez, Hayman, & Arons, 2009). The idea surfaced that mental health outpatient treatment could be more effective and finally less hazardous than long inpatient medical therapy.

Since the terrorist harm on Sept 11, 2001, and the beginning of the conflict on terrorism, about 1. 64 million soldiers have deployed to Iraq and Afghanistan (RAND, 2008). Around 300, 000 troops returning from Iraq and Afghanistan deal with a variety of mental health issues often related to him Posttraumatic Stress Disorder (PTSD), which is the predominant mental ailment facing treatment providers who serve the military, at this time. However, for a number of reasons, which will be discussed later in this paper, only around 150, 000 troops have desired treatment (Bavolek, 2008).

In 2008, the RAND Organization conducted a study to look for the mental health status of returning military. They centered on three major areas PTSD, despair, and distressing brain damage (TBI). The analysis looked at the prevalence of these issues among troops returning from the conflict area as well as the programs and services designed to meet their needs and the price tag on those programs. The study centered on a section of returning service users and found that roughly 18. 5% satisfied the requirements for PTSD or despair, 19. 5% found the conditions for TBI, and another 7% met the requirements for combination of TBI and PTSD.

One of the significant problems that was discovered in the RAND study was the living of a huge space between those who need mental health services therefore of their battle experience and availability of services within the military. The reason for this distance often are available in two areas; limited specialist availableness as well as the cultural attitude within the military services framework regarding mental medical issues. Often servicemembers will discuss the identified negative consequences for individuals who seek mental health treatment. Troops attended to think that to get mental health treatment is to show weakness which finally influences how their product views their mission readiness capability eventually concluding the soldier's job.

Lack of available providers also effects the ability of the military to provide enough mental health services to the soldiers. While the government is positively recruiting and employing new providers, the proportion between those who need mental health services and those who can provide those services still remains quite large.

In addition to having less available providers, there is also some dilemma that surrounds the issues of PTSD and the need for treatment which, as mentioned before is a significant issue facing military services members today. For most, the confusion encircling PTSD focuses on why some military members are damaged and others are not. Perhaps the best way to comprehend PTSD is to first develop an understanding of injury itself. To state that all stress is the same would be ludicrous. However, it might be in the same way ludicrous to state that all trauma affects people in the same way. The impact of trauma often depends after an individual's perception of the function as well as their own sense of vulnerability. This is certainly true for individuals engaged in the warfare on terror. Whether a meeting becomes distressing for the average person or seldom depends on a number of things. First of all it depends upon the function itself, there are a few events that take place in war which are truly distressing and leave lifelong marks, including the loss of a kid because of hostile activities. However the cause of traumatic impact of other incidents aren't so clear. Often what makes an event distressing for just one person and not for another depends after the individual's understanding of this event in romantic relationship to their own sense of vulnerability as well as how carefully it may relate with or lead to remembrances of occasions from their former. Still, for others, their belief of the role they play in the overall conflict could determine whether or not the individual is traumatized by certain occasions. For example, an individual who perceives their role in the warfare on terrorism as an expression with their patriotism or simply simply as employment that should be done may also be less traumatized by a meeting instead of someone who sees himself involved with a discord or performing employment where there is absolutely no sense of mental attachment or dedication.

In addition to understanding the individual's belief with their role in the warfare on terror and the energy of stress to engender feelings of great shock, disbelief, dread, and helplessness. One must realize much like any event, it isn't the incident that triggers the response, but rather our reaction to the occurrence along with whatever so this means we might in person put on that event. McLean and Woody cite a report conducted by Peter J. Lang (1979), who developed a bio-informational theory of psychological imagery which consists of interconnected information about the characteristics of the psychological situation, the individual's a reaction to the situation, and the meaning of the problem to the individual (McLean & Woody, 2001). Chemtob et al. speculate that trauma survivors are prone to interpret situations that take place around them as intimidating thus triggering the recollection of the traumatic event (Chemtob et al as cited in McLean & Woody, 2001, p. 211). For many this sense of generalizing the emotional connection with the distressing event to every aspect with their life causes avoidance of certain areas of daily living such as large crowds in a shopping center. Thus, by keeping the impact of the injury alive of their memory, the person will keep reliving the distressing event resulting incapacitating consequences. Matching to Witvliet (1997), this information-processing theory accounts for the cognitive phenomena seen in PTSD. McNally et al. also speculated that the veterans who are having trouble recalling personal recollections are having this trouble because the preoccupation with intrusive recollections of injury consume a disproportionate show of cognitive resources, thus disrupting other styles of thinking. McNally et al. further conjectured that negative qualities dominate the self-representations of individuals with PTSD, in that way impeding access to positive self-representations (McNally et al as cited in McLean & Woody, 2001). These informational ideas all hypothesize a fear composition, or its comparable, of neuronal systems involved in psychological handling of fearful information. These theories suggest that adjustment of fear framework reactivity can occur through two programs: habituation and alteration of so this means (Foa & Kozak, 1986 as cited in McLean & Woody, 2001).

Purpose of the Study

At Fort Carson, Colorado where there is an upsurge in deployment responsibilities, the need arose for cure program that concentrated not only on handling PTSD, but also enabling the soldier to develop a larger resiliency to a variety of life situations which ultimately allows them to perform their mission with an increase of self confidence and competence.

To address this need, a rigorous Outpatient Program (IOP) was developed by Dr. Kenneth Delano. This program targets providing skills that assist the soldier in the development of greater resiliency to life stressors. While PTSD is usually a predominant issue for many of the individuals in this program, the IOP communities focus on allowing the soldier to build up a number of different skills that help them talk about variety of different problems such as marital problems as well as their failure to handle job related stress as well as the strain of a variety of personal issues.

Skill development for individuals in the IOP program is accomplished through Cognitive Behavioral Remedy (CBT) techniques, which is the suggested treatment model, and has been successful in coping not only with trauma, but also permitting the participant to build up greater resiliency over the table (Taylor, 2004). The potency of CBT as cure modality has been evidently demonstrated with a variety of populations. It is a recommended treatment for a number of mental disorders including ambiance disorders, obsessive-compulsive disorder, eating disorders, substance abuse, and trauma. The effectiveness of CBT was validated in a 2001 research conducted by Muck, Zempolich, Titus, & Fishman, when a evaluation was made between your success of behavioral therapy to that of any supportive counselling modality. The consequence of the study confirmed that the number of participants using drugs reduced by 73% for those in the behavioral group in comparison with a decrease of only 9% for those in the supportive remedy group. These conclusions were substantiated in a 2006 study conducted by Rupke, Belcke, & Renfrow who discovered the mixture of cognitive remedy and antidepressants was proven to effectively manage more serious or chronic despair. The creators concluded of their research together with a meta-analyses, that cognitive behavioral remedy works more effectively than other treatment options to include pharmacotherapy for slight forms of melancholy.

In addition to CBT, Cognitive Handling Remedy (CPT) is shown to be effective in dealing with anger, which frequently is a an additional problem for a person who lacks resiliency skills (Cahill, Rauch, Sheila, Hembree & Foa, 2004).

In a report conducted by Resick (2008), and her acquaintances sought to show efficiency CPT as an efficient treatment for PTSD, by utilizing a prolonged publicity (PE) remedy model. CPT entails two basic components: cognitive remedy aimed at challenging distorted cognitions, altering this is of the distressing event and written accounts (WAs) where the client writes comprehensive accounts of the distressing event and repeatedly reads the information both at home and in program in order to habituate to the anxiety provoked by reminders of the trauma. The question that Resick and her co-workers (2008) wished to answer was if the full standard protocol of CPT was the most effective way or whether specific the different parts of treatment would offer equally promising results. The results of the study showed that each group, in their own way, acquired an impact on reducing the effect of PTSD. However, what was surprising was not that the organizations were successful, but that the categories were successful relative to each other. In other words, each group was in the same way successful as the other in its right.

In the IOP program, each soldier determined for the group is chosen because they may have a significant psychiatric impairment that, if not cured adequately may require a medical evaluation board and separation from the Army. The mission is to use these highly enthusiastic soldiers who desire to progress remain in the Army, and provide them the opportunity to get treatment which allows them to return to mission able status.

The IOP program is mostly for soldiers who have not made adequate progress in daily habit outpatient behavioral health treatment they want more extensive treatment with no constraints of the psychiatric inpatient setting. Often, these troops could also have been recently discharged from an inpatient treatment program, and based on further examination it is determined that additional treatment is needed in order to accomplish their treatment goals.

Soldiers are identified for IOP by their treatment service provider who pertains the soldier to the program based upon their clinical assessment of the soldier's need for further, more extreme treatment. The selection of soldiers is also endorsed by the Battalion Commander, who provides the support for the soldier by allowing them time through the normal duty time to attend the program.

Significance of the Study

A critical concern facing Fort Carson is the limited number of behavioral health treatment providers as well as the providers' supply to get sufficient amount of time in their treatments program if to therapeutically addresses the problems facing lots of the soldiers allocated to the Post. With all the increase in operations tempo, a significant number of military have develop the need for skills that permit them to develop greater resiliency never to only the injury experienced while on deployment that the normal stressors of daily living. Prior to the initiation of the IOP program, many of the soldiers coping with behavioral health issues, often found treatment coming in the form of pharmacotherapy with limited or no exposure to individual or group remedy. However, studies have been reported by reported by the Institute of Medication, that has shown that group remedy has proven efficacious in treating patients with a variety of behavioral health issues (Legislations, 2008).

Behavioral health providers at Fort Carson known the valuable role that group remedy, predicated on cognitive behavioral techniques, can play in assisting soldiers develop better resiliency to the stressors these are experiencing. The therapeutic techniques found in this program are helping troops develop the coping skills essential to offer with the tensions they experienced because of this of combat, as well as their standard life experience. Research continues to support the idea that group therapy is as an effective treatment modality for soldiers who are working with a variety of behavioral health issues. Foy et al. (2002) proven the effectiveness of Trauma Focused Group Remedy (TFGT) on military dealing not only with fight PTSD but other life stressors.

It is expected that through the IOP program, troops will figure out how to develop new skills that to help them cope better with day-to-day stress issues hinder their ability to perform their mission. The outcome of the treatment process is the fact soldiers are able to return to their units totally mission capable. It is also predicted that with recently obtained skills, the troops can demonstrate their ability to handle crisis events through the week because they are educated to generalize those skills in their daily activities. The following is a model of this program.

Summary of Methodology

Data Collection and Instrumentation

The data will be accumulated by using a quantitative research approach involving the use of several tools. These devices are: the Posttraumatic Stress Disorder Checklist-Military (PCL-M), Key Treatment Post Traumatic Stress Disorder (PC-PTSD), Alcoholic beverages Use Disorders Id Test (AUDIT), Drug Abuse Verification Test (DAST), OQ - 45. 2, Beck Nervousness Inventory (BAI), Beck Depressive disorder Index-II (BDI-II), Locke Wallace Marriage Inventory (LW), and a job performance inventory based mostly upon the Army's Noncommissioned Officer Effectiveness Record (NCOER). Furthermore to these equipment, this study can look at and compare the individual's involvement in pre-and post-administrative happenings such as DUIs and home violence episodes which are generally reflect a lack of resilience to daily stressors.

Design Procedures

The study will involve group and individual therapy conducted by certified providers in the Team of Behavioral Health. The IOP group is mostly for soldiers who have not made sufficient progress in boring outpatient behavioral health treatment and need more intense treatment with no limitations of the psychiatric inpatient setting up. These soldiers may have been just lately discharged from an inpatient treatment program. However, it is set through additional analysis methods that further treatment is needed in order to accomplish their treatment goals. Military will be discovered for the IOP by their treatment company who pertains the soldier to the program based upon their clinical diagnosis of the troops need for further, more strong treatment. Selecting military is also endorsed by the Battalion Commander, who supplies the support for the soldier by allowing them time through the normal duty hours to attend this program. Inside the IOP group, folks are chosen for the group based on established requirements by an individual provider. Furthermore, the procedure providers in the IOP program will be constant throughout the treatment process.

Data will be accumulated at baseline with the program's finish. Each individual will be given the tools and results will be analyzed to determine if there is a statistically factor between pre-and post-scores. Furthermore, the individual's commander with get the work performance inventory at baseline with 90 days post treatment to determine if there is a statistically significant degree of improvement in obligation performance.

This study will include the next chapters: Chapter 2 will give attention to a critical review of the books. The books review will focus on IOP treatment and typical outpatient modalities such as pharmacotherapy as well as various treatment modalities such as CBT, CPT, and DBT and their overall performance especially within the military services population.

Chapter 3 will focus on the methodology used in the IOP program. It'll look at the instrumentation being used, the choice process for the soldier, the procedure process that occurs in the teams for the 4-6 weeks of treatment. It will will take a look at the validity of the equipment and the strategy used to determine the overall efficiency of the procedure program. The results which is discussed in Chapter 4. Section 5 will Review the IOP program as a treatment modality, in comparison to traditional Army IOP and its own give attention to PTSD. Furthermore, it will examine the unique concentration of this IOP program and its own give attention to resiliency and return to responsibility (RTD). This section will likewise incorporate a dialogue of the results and the impact the IOP program has had on the soldier and his/her increased quest capabilities. Finally, there will be a debate of the study restrictions and thoughts about future studies.

Research Questions

The key questions because of this study give attention to soldier resiliency. Is the soldier increasing in his/her ability to manage crisis events that take place during the week? Are they learning skills in treatment which they can generalize with their daily life?


It is assumed that the entire effectiveness of the IOP will be showed statistically and empirically through the data gathered as well as IOP individuals' self-report. It really is further believe that the benchmarks for selection of individuals for participation in the IOP will be employed equally to all individuals being considered.

Definition of Terms

Resiliency has been thought as "an individual's capacity to tolerate stressors rather than manifest mindset dysfunction, such as mental condition or consistent negative disposition" (Neill, 2006). In other words, the ability of an individual to have the capacity to cope with difficult life issues without developing some type of psychopathology.

According to Neill (2006), psychological stressors or "risk factors" are often considered to be experiences of major severe or chronic stress such as loss of life of someone else, chronic illness, erotic, physical or emotional abuse, dread, unemployment, and community assault. In case of the military people we would have with their fight stress, increased product tension anticipated to increased operations tempo, and quest responsibilities.

Neill believes that the central process involved with building resilience is the training and development of adaptive coping skills. The essential circulation model (called the transactional model) of stress and coping is: A stressor (i. e. a potential way to obtain stress) occurs and cognitive appraisal occurs (deciding set up stressor symbolizes something that can be readily handled or is a way to obtain stress because it may be beyond one's coping resources). In case a stressor is considered to be a danger, coping reactions are brought on. Coping strategies are usually either be outwardly focused on the problem (problem-solving), inwardly focused on feelings (emotion-focused) or socially centered, such as psychological support from others.

Neill expresses that, "in humanistic psychology, resilience refers to a person's capacity to flourish and accomplish their potential despite or simply even because of such stressors. Resilient individuals and neighborhoods are more likely to see problems as opportunities for growth" (Neill, 2006). Stated plainly, people who show resilience not only offer effectively with stressful experiences they see them as an effort and use the complete event as an opportunity ror a learning experience and progress development.

While a lot of people may seem to establish themselves to be more resilient than others, it should be known that resilience is a active quality, not a long term capacity. In other words, resilient individuals display strong self-renewal, whereas less resilient individuals end up worn down and negatively influenced by life stressors.

John Dewey (1859-1952 as cited in Neill, 2006), the renowned 20th century American educational philosopher, details this sense of continuance through energetic self-renewal

A natural stone when struck resists. If its level of resistance is higher than the pressure of the blow struck, it remains outwardly unchanged. In any other case, it is shattered. While the living thing may easily be smashed by an excellent drive, it nonetheless attempts to carefully turn the energies which react upon it into means of its own further existences. . . It's the very dynamics of life to make an effort to continue in being. Since this continuance can be secured only by continuous renewals, life is a self-renewing process.

Post Traumatic Stress Disorder, in line with the Mayo Groundwork for Medical Education and Research (2009), has been defined a type of anxiety disorder that's triggered by way of a distressing event. You can form post-traumatic stress disorder when you experience or witness an event that causes strong dread, helplessness or horror.

Intensive Outpatient Program (IOP) as defined by the American Society of Obsession Treatments (ASAM) as treatment which contains anything higher than 9 time of therapy weekly. Furthermore, an IOP can be an alternative to inpatient hospital treatment or partial hospitalization of certain psychiatric or chemical type dependency conditions as determined by patient's symptoms and degree of performing. An IOP must provide a comprehensive intake assessment including both mental health and substance dependency. An IOP must offer multi-modal, multi-disciplinary organised outpatient treatment that is a lot more intensive than outpatient psychotherapy and medication management. Intensive outpatient programming is mentioned for patients, often in crisis, who require structured, multi-modal treatment (specific therapy, group therapy, family and/or multi-family as appropriate and unless contraindicated, and psycho-education) to achieve alleviation of symptoms and improved level of functioning. This program will have a varying amount of treatment and will be capable of reduce each participant's consistency of attendance as symptoms are alleviated and the average person can continue more of his/her regular life commitments. All treatment strategies must be individualized, concentrating on stabilization and transition to community established outpatient treatment and/or organizations as needed. The IOP must be administered by a certified professional and sufficiently staffed to allow for speedy professional assessment of your change in mental position which could warrant a move to a more intensive level of treatment or change in medication (North Carolina Point out Health Plan, 2007).

Noted Limitations

While this review will be thorough, there are several limitations that will impact the final results. People who are preferred for the IOP are also necessary to be engaged in weekly specific therapeutic time. While this analysis will verify overall success of the IOP, it does not consider the confounding impact that the average person therapy may have on the IOP restorative results. Furthermore, soldiers mixed up in IOP will likewise have the chance to receive family and relationship remedy which can also impact the info gathered on the IOP program. Furthermore, unit support or the shortage thereof can be considered a critical concern in the entire effectiveness of the outcome of treatment from the soldier's perspective. Yet another limitation is usually that the standards for access into the IOP are subjective in character and therefore may not be equally apply to all individuals requesting entrance in this program.


There are numerous initiatives to help soldiers successfully give back from combat experience in the Battle on Terror. However, the impact of the Iraq and Afghanistan issue has been always obvious because lots of the soldiers came back with wounds that can't be seen but nevertheless present. So, these wounds will be felt by soldiers and their families for many years to come. Therefore, it is important that we provide the best treatment plans open to assist the military in their recovery and return these to society and the entire world they in order going and serve their country. Through the IOP it is hoped that soldiers can develop better resiliency that allow them to offer effectively using their combat experiences and a daily stressors they need to deal with while in garrison.

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