May 11, 2004 -- WASHINGTON - One unavoidable fact about military action is that service members will have to deal with traumatic stress. The Department of Defense is working to find the best way to help troops deal with the harmful effects of the stress people face in combat. One part of that effort is a treatment trial called Project DE-STRESS.
Project DE-STRESS - Delivery of Self Training and Education for Stressful Situations - is an attempt to improve early care for victims of traumatic stress, according to Army Lt. Col. (M.D.) Charles Engel, director of the Deployment Health Clinical Center in Washington, D.C., where the treatment trial is taking place.
"We were interested in something that ultimately could be implemented in a primary care environment, where people could be screened and diagnosed early and some care could be provided for them without having to visit the specialist," Engel said.
Doctors at the Deployment Health Clinical Center at Walter Reed Army Medical Center in conjunction with the Boston University School of Medicine and the National Center for PTSD Research developed this innovative approach to trauma-related stress. The research study is a randomized clinical trial investigating two different computer assisted approaches to treat post traumatic stress symptoms. It is designed to compare two different kinds of treatment: stress inoculation training and supportive counseling.
Victoria Bruner, coordinator for Project DE-STRESS, said that supportive counseling is the intervention most often used by both military doctors and by the Department of Veterans Affairs to help veterans.
"Standard care, sometimes called supportive counseling, involves allowing the person to vent, to identify feelings, to focus on the here and now, and to haave their experiences validated," Bruner said.
She said that the alternative approach, stress inoculation training, has also been around for a long time.
"This training is widely used in the military," Bruner said. "If you know a person is going to be exposed to something harmful, like extreme stress, you teach them the skills to deal with that exposure. It's just like getting an inoculation against a disease."
The study is comparing these two well-documented interventions to find out which is best for reducing the long-term consequences that people may experience after their exposure to military trauma and whether these treatments can be delivered over the Internet.
What makes this treatment trial innovative is that it makes use of cutting edge technology. By using Web-based training, the researchers introduce a degree of portability and ease of access that would otherwise be impossible.
"Computer based interventions give the person the opportunity to work on their own, with guidance, in the privacy of their own home," Bruner said. "And our project is set up so that each participant is monitored every day by a trained therapist."
Engel added that computerizing the process helps service members to avoid the stigma associated with going to a psychologist or psychiatrist for help.
"It provides the service member with a chance to make their own gains in their own way before having to seek specialty care," Engel said. "Many people are reluctant to seek specialty care. In the military setting, there's a lot of concern that if they visit specialists with these sorts of problems that it will affect their careers."
The study is open to beneficiaries of the Department of Defense health care system who are experiencing mild to moderate symptoms as a result of military-related trauma. Patients who are bothered by memories or dreams of trauma or experiencing anxiety, depression or trouble sleeping may also be accepted into the program. Bruner says everyone in the program starts with a confidential introductory meeting with a trainer.
"If eligible, each participant gets an in-depth two hour assessment, and a two hour training session on stress management, traumatic stress and the instructions on the web site," Bruner said. "Afterward they work on the web site, but are closely monitored."
The secure and confidential Web site offers each patient eight weeks of independent study exercises. Participants are randomly assigned to one of two treatment groups. People in both groups monitor their symptoms every day based on eight measurement scales on which they rate their stress level and general mood. Professionals, including Bruner herself, monitor these self-evaluations.
"Not only do they have a daily awareness, but I look at it every day, and if their stress scores are high I call them to discuss what's happening. This way they can have someone to vent to or to apply the skills that they are learning."
Burner is well qualified for monitor duty, and to coordinate the treatment trial. A registered nurse and licensed clinical social worker, she's a board certified expert in traumatic stress with a couple of decades worth of experience in her field. On Sept. 11, 2001, she was helping survivors of the attack on the Pentagon, and weeks later became involved with a project assisting survivors of the attack. That project eventually led to Project DE-STRESS. Today, she thinks that Americans in general have a better understanding of stress injuries than they did before the events of 9-11.
"All of us in this country suffered exposure and it deepened our awareness of the terrible hardships that our military has been coping with since the beginning of this country."
Engel, the principal investigator for the project, thinks traumatic stress could be worse for those currently deployed to Iraq than it was for those who went in 1991.
"There are indications that the level of distress related to trauma will be higher this time than it was after the Gulf War, because this is a longer war involving more extended and intense combat. There is also the uncertainty associated with the peacekeeping role that comes into play."
That's a strong motivation for experts to find the best way to help those who suffer from traumatic stress. But, Bruner says, patients in both groups will receive help. In the supportive counseling group people have access to educational material. They are provided with non-directive stress management tips and trauma education, and they can e-mail or call their trainer at any time for reflective listening, supportive counsel and validation. Historically, this supportive counseling approach has helped a lot of people, but Bruner says some people need more, such as the active ingredients in stress inoculation training.
"These people are taught skills in deep diaphragmatic breathing, progressive muscle relaxation and how to change their self talk to address the errors in their thinking," Bruner says. "They can apply these skills to situations that cause them trouble."
For example, driving in convoys has turned out to be one of the most hazardous activities during Operation Iraqi Freedom. Weeks or months after such an experience, a soldier's brain might not shut down the defensive reactions that helped to protect the person in that situation. Therefore, the soldier might become extremely agitated or feel a sense of panic driving on a highway in the United States. At that point, Bruner says they might apply deep breathing, and remind themselves that the danger is over and that driving on American highways is relatively safe. While this example is oversimplified, it indicates how stress inoculation training can help combat veterans to control their behavior.
"Behaviors become habits, habits become lifestyles and life styles determine the quality of life we have," Bruner said.
Bruner said the training could increase an individual's stress hardiness, and likened it to other military training.
"Sort of like doing push-ups, except this can build up your stress defensive muscles," she said.
Project DE-STRESS is scheduled to continue until August of 2005. Aside from the introductory session, patients will receive private evaluations at the end of the program, three months after it ends, and again six months afterward. Bruner wants 100 participants, and at time of publication, 30 had already signed up. Enrolling in the treatment trial is a way for patients to help others while they help themselves.
"If someone participates, not only is it good for them but they will be contributing to a knowledge base that will help many other people who come after them," Bruner said.
Burner feels that Project DE-STRESS could be a working model for the future. If it is made widely available throughout the military system it could help to increase resilience, force health protection and soldier readiness. And she says our service members deserve the best health protection possible, be it physical or behavioral.
"We have an obligation to people who choose to raise their hand and swear to defend their country so that all of us can live in peace. To me, the least we can do is provide them with the opportunity to learn how to assist themselves with the kinds of techniques that will help them have a high quality of life after those experiences."
For more information or to learn about how to participate in Project