THE UNIVERSITY OF MEMPHIS POST TRAUMATIC STRESS DISORDER EARLY INTERVENTION FOR OUR SOLDIERS LESLIE JAYROE 4/25/2011 HPRO 7720 Post Traumatic Stress Disorder and Our Soldiers- Providing Earlier Intervention History There is a significant amount of information out there on post traumatic stress disorder and the military, and this is mostly due to the fact that our combat soldiers were the ones observed over time to determine the effects war has had on them. Post traumatic stress disorder (PTSD) can be thought of as a "young" diagnosis. PTSD has been around for centuries, but it was n~t until 1980 that it was made an official disorder. However, throughout history, people have recognized that exposure to combat situations can have an intensely negative impact on the people who are involved in these situations. (Mathew Tull, 2009) PTSD has previously been described ia-410J e ~s "combat fatigue," "shell shock," or "war neurosis," and is defined by the American Psychiatric Association as an anxiety (emotional) disorder which stems from a particular incident evoking significant stress. (Bentley, 2005) PTSD is not limited to combat soldiers but can also be found among survivors of the Holocaust, of car accidents, of sexual assaults, and of other traumatic experiences. War has always had a severe psychological effect on people, and with the war our country is currently in, more and more of our soldiers are suffering from PTSD. After a traumatic experience, the mind and the body are in shock, but as the victim makes sense of what happened and processes his/her emotions, healing takes place leading toward normal function once again. With PTSD, one remains in psychological shock. The memory of what happened and their feelings about it are disconnected. In order to move on, it's important to face and feel those memories and emotions. One effective approach is through counseling. (Mathew Tull, 2009) The symptoms of PTSD can occur all of a sudden, progressively, come and go over time, or appear out of nowhere. Sometimes, symptoms are triggered by something that reminds a 31 Page person of the original traumatic event, such as a noise, an image, certain words, or a smell. While everyone experiences PTSD differently, there are three main types of symptoms: (Bentley, 2005) 1. Re-experiencing the traumatic event 2. Avoiding reminders of the trauma 3. Increased anxiety and emotional arousal According to the Graffiti of War Project, in 2007, the number of diagnosed cases in the military jumped 50%. One in every five military personnel returning from Iraq and Afghanistan has PTSD, and 20% of the soldiers who've been deployed since 2001 have PTSD which is over 300,000. More troops are serving their second, third or fourth tours of duty, which dramatically increases stress according to medical heath experts. Also, extended tour lengths from 12 months to 15 months were done to prov ...

1. THE UNIVERSITY OF MEMPHIS
POST TRAUMATIC STRESS
DISORDER
EARLY INTERVENTION FOR OUR SOLDIERS
LESLIE JAYROE
4/25/2011
HPRO 7720
Post Traumatic Stress Disorder and Our Soldiers- Providing
Earlier Intervention
History
There is a significant amount of information out there on post
traumatic stress disorder and the
military, and this is mostly due to the fact that our combat
soldiers were the ones observed over
time to determine the effects war has had on them. Post
traumatic stress disorder (PTSD) can
be thought of as a "young" diagnosis. PTSD has been around for
centuries, but it was n~t until

2. 1980 that it was made an official disorder. However, throughout
history, people have
recognized that exposure to combat situations can have an
intensely negative impact on the
people who are involved in these situations. (Mathew Tull,
2009) PTSD has previously been
described ia-410J e ~s "combat fatigue," "shell shock," or "war
neurosis," and is defined by the
American Psychiatric Association as an anxiety (emotional)
disorder which stems from a
particular incident evoking significant stress. (Bentley, 2005)
PTSD is not limited to combat
soldiers but can also be found among survivors of the
Holocaust, of car accidents, of sexual
assaults, and of other traumatic experiences. War has always
had a severe psychological effect
on people, and with the war our country is currently in, more
and more of our soldiers are
suffering from PTSD. After a traumatic experience, the mind
and the body are in shock, but as
the victim makes sense of what happened and processes his/her
emotions, healing takes place
leading toward normal function once again. With PTSD, one
remains in psychological shock.

3. The memory of what happened and their feelings about it are
disconnected. In order to move
on, it's important to face and feel those memories and emotions.
One effective approach is
through counseling. (Mathew Tull, 2009)
The symptoms of PTSD can occur all of a sudden,
progressively, come and go over time, or
appear out of nowhere. Sometimes, symptoms are triggered by
something that reminds a
31 Page
person of the original traumatic event, such as a noise, an
image, certain words, or a smell.
While everyone experiences PTSD differently, there are three
main types of symptoms:
(Bentley, 2005)
1. Re-experiencing the traumatic event
2. Avoiding reminders of the trauma
3. Increased anxiety and emotional arousal
According to the Graffiti of War Project, in 2007, the number of
diagnosed cases in the military
jumped 50%. One in every five military personnel returning

4. from Iraq and Afghanistan has
PTSD, and 20% of the soldiers who've been deployed since
2001 have PTSD which is over
300,000. More troops are serving their second, third or fourth
tours of duty, which dramatically
increases stress according to medical heath experts. Also,
extended tour lengths from 12
months to 15 months were done to provide enough troops for
buildup, but is another factor that
has caused extra emotional strain. {The Graffiti of War Project,
2007)
Statement of Purpose
The purpose of this paper is to provide an early intervention for
first time deploying soldiers from
Arkansas by applying the Precede/Proceed Model in hopes of
preventing post traumatic stress
disorder brought on by combat. The Precede/Proceed Model
consists of 9 phases which were
applied for the sack of this intervention. The first five phases
are within the Precede part of the
model: 1) social assessment 2) epidemiological assessment 3)
behavioral and environmental
assessment 4) educational and ecological assessment 5)
administrative and policy assessment.

5. The last four phases are within the Proceed part of the model: 6)
implementation of the program
7) process evaluation 8) impact evaluation 9) outcome
evaluation. (Edberg, 2009) By following
these phases in order, I was able to create a successful
intervention while applying the Theory
41 Page
of Planned Behavior. The Theory of Planned Behavior, simply
stated, is about the associ
of attitudes and behaviors.
Phase 1: Social Assessment
A person's quality of life is greatly impacted by post traumatic
stress disorder, and can cause
serious social, emotional, and psychological problems for
soldiers returning to the civilian life .
Twenty soldiers made up the study group for this program. They
were selected through the
recruitment office in Little Rock, Arkansas at random and had
to meet the following criteria:
• First-time deploying soldier
• An Arkansas resident

6. Age, sex, and ethnicity were not deciding factors for being part
of the study. The main social
problems that were documented in medical and work records
from this group of soldiers after
post-deployment were an increased number of absences from
work, lack of sleep, and domestic
problems. Prior to their first deployment, they were each
assessed for any social disorders, work
records were noted, and medical records were evaluated so a
baseline could be established for
the study. There were no soldiers before deployment with these
issues. This information was
obtained through the recruitment office in Little Rock, Arkansas
to determine each soldier's
deployment status and medical records from their personal
physicians as well as former
employee records were used for the sake of the intervention.
Phase 2: Epidemiological Assessment
Of the twenty soldiers being studied, the most common health
problems documented from
medical records were alcohol abuse, the use of narcotics, and
post traumatic stress disorder.
The pre-assessment also evaluated them for these issues before

7. the first deployment, and
SI Page
again, none of the soldiers exhibited these issues before the
deployment. Of the three issues,
post traumatic stress disorder is the most important and most
changeable for the given
population. If PTSD can be prevented, then the other issues
should also resolve. Pre and post
deployment medical records were used to make this evaluation
for these soldiers and a national J
health database was used for comparison as well as reviewing
the literature on this particular
issue.
Phase 3: Behavioral and Environmental Assessment
There are behavioral and environmental factors that contribute
to PTSD in soldiers .
Environmental factors: (Corporation, 2008)
• combat
• deployments longer than 12 months at a time
• multiple deployments
• suicide bombers

8. Behavioral factors:
• Worried about medication side effects
• Feel that friends and family can help more than counseling
• Fear that there will be damage to career
• Fear of peers lacking confidence in him/her
The environmental factors cannot be changed for soldiers at war
unless they change
cC)reers, but the behavioral factors can be changed. With more
education on PTSD, and the
acceptance of the disorder by the military, soldiers could
alleviate the behavioral barriers.
fii P;:lP'P
Goal and Objectives
Goal: The goal of this program is to provide early intervention
to twenty Arkansas soldiers
before their first deployment to Afghanistan as to prevent the
development of post traumatic
stress disorder before and after their second deployment with
success rate set at 85% after 48
months of the start of the intervention. /

9. Objective 1: To increase awareness of post traumatic stress
disorder among twenty soldiers by I
100% within two weeks before their first deployment to
Afghanistan.
Objective 2: To provide four sessions of post deployment
counseling to the twenty soldiers aft/
each deployment, at 85% counseling attendance rate.
Phase 4: Educational and Ecological Assessment
For this phase, three areas are looked at: Predisposal,
Reinforcing Factors, and Enablers .
Predispose: Unlike major depression and other psychological
disorders, PTSD shows
biochemical changes in the brain and body. Individuals
diagnosed with PTSD have a higher
response to a dexamethasone suppression test than individuals
diagnosed with clinical
depression. Most people with PTSD also show a low secretion
of cortisol and high secretion of
catecholamines in urine, with a norepinephrine/cortisol ratio
compared to people who do not
have the disorder. Low cortisol levels may predispose
individuals to PTSD. Because cortisol is
important in restoring homeostasis after the stress response,
trauma survivors with low cortisol

10. tend to be distressed more over the situation(s) and suffer from
it longer, setting the stage for
PTSD. (RWMC, 201 0) Each soldier was evaluated for low
cortisol levels through a urine test
before deployment. Of the twenty soldiers, only one showed a
markedly low level.
71 PrJilP
Reinforce: Factors that are reinforced for the possible
development of PTSD include the
environment that these soldiers are placed in and also the
military's policies on length of time
and redeployment. The environment that they are in puts them
under a great deal of stress and
most of which can't be altered . Combat, suicide bombers, long
hours without sleep, lack of
communication with loved ones, the loss of fellow soldiers, and
the possibility of killing innocent
people are all part of what they have to go through on a daily
bases while deployed . The
military policy for deploying soldiers for longer than 12 months
at a time and multiple
deployments are factors that could be altered.

11. Enable: Enabling factors include a lack of knowledge of what
exactly post traumatic stress
disorder is , lack of counseling for the disorder either due to
lack of knowledge or not seeking
treatment because the military tends to look down upon soldiers
with PTSD, and also the lack of
healthcare facilities where these soldiers can go to receive help.
The military does administer
post deployment testing to determine if a soldier has any
physical or psychological problems I
once they are back, but some cases still go undiagnosed .
Soldiers know that if they answer
certain questions honestly, it may keep them from getting to go
home sooner.
Phase 5: Administration and Policy Assessment
With Arkansas not having a program established for the
prevention of Post Traumatic Stress
Disorder for soldiers prior to this intervention, policies and
administration had to be developed .
With the help of Veterans Affairs, personnel from the military
recruitment office in Little Rock,
and The University of Arkansas for Medical Sciences Hospital
(UAMS), a board was appointed ,
polices were made and presented to the House for approval.

12. The program took place at The University of Arkansas for
Medical Sciences Hospital (UAMS) in
Little Rock. With the administrative and financial support
provided by this hospital, an office with
81 Page
a conference room, counseling rooms , secretary, counselors,
computers, printers, office
supplies, educational material, and office furniture were all
provided, and 1 was appointed as the
Director of the program .
Once the staff was hired, policies and procedures were reviewed
by all, and everyone
underwent post traumatic stress disorder training in order to
have an understanding of the
people they would be working with .
Phase 6: Implementation of the Program
Along with the application of the Precede/Proceed Model, I will
apply the Theory of Planned
Behavior (TPB). TPB is a theory about the link between
attitudes and behavior. The attitude
toward a particular behavior is determined by a person's

13. assessment of what the consequences
of their actions are. If the consequences are negative, the less
chance there is for a person to
behave a certain way. In regards to this intervention, if a soldier
feels that they may lose their
job, lose respect, or be treated differently for admitting they
have PTSD and receive treatment
for it, they are less likely to admit they have a problem and seek
help.
In order to select soldiers for this program , the recruitment
office in Little Rock, Arkansas was
asked for referrals . Once the twenty soldiers were selected
based on their deployment status,
they were evaluated by a counselor to determine any underlying
psychological disorders.
These initial evaluations were added to their charts .
A test was given at the beginning of the program to determine
the knowledge these soldiers had
on PTSD before starting the program. Afterwards, educational
material was distributed and
reviewed two weeks before initial deployment. Educational
material consisted of handouts ,
DVDs, and guest speakers who discussed with the soldiers their
experience with PTSD. During

14. I Pae:e
I
this time, the soldiers were also introduced to the counselors
they would be working with upon
completion of the deployment.
Counseling sessions will start once post deployed soldiers
return from their first tour of duty.
Every three months they are required to meet with the
counselors on staff at UAMS, and
express their feelings and emotions. If additional sessions are
recommended by the counselor,
the soldier will submit to treatment, and continue individual
counseling sessions until the
counselor feels that the soldier is no longer at risk for PTSD.
Content of Counseling Sessions:
The sessions will take place during a specified three day
weekend every three months for a total
of four sessions (totaling 12 months). Every three months, the
soldiers will return to UAMS for
the counseling sessions and the same structure will be followed.

15. Day 1: Counseling will begin as a group therapy session the
first day where each
soldier talks about his/her experiences from the deployment.
The purpose of starting
with group sessions is for the soldiers to have a support group,
hear other soldier's
stories that might bring back memories they may have tried to
block, and to get them
talking about the issues they are dealing with after their first
deployment. The
counselors will be present and leading the session which will be
recorded for
documentation purposes and evaluation. The session will last
four hours with two 30
minute breaks incorporated within that time . Participants will
sit in a circle and the
group sessions will be conducted in a casual atmosphere.
Day two: Each soldier will meet with a counselor individually
in a professional setting
and will be encouraged to express their feelings and emotions
through discussion.
10 I Pari e
I

16. The individual session will last two hours, and the counselor
will keep records during /
the meeting which will be placed in the soldier's program
intervention file. V
Day 3: The weekend counseling session will conclude with
questionnaires that will
assist in determining if there were any changes mentally,
socially, or psychologically,
j and then be compared to the questionnaires given before
deployment. Waiting until
day three for the questionnaires will allow for a more accurate
evaluation, allowing for
incidences that were previously blocked to surface . Review of
the questionnaires,
counseling session, and group session will establish if there is a
need for further
treatment.
After the second tour of duty, each soldier will undergo four
more counseling sessions which will
also be held on a specified three day weekend every three
months (total of 12 months). If
additional sessions are recommended, soldiers will submit to
additional treatment which will be

17. individual counseling sessions where they will continue to
express feelings and emotions until
the counselor feels that the soldier is no longer at risk for
developing PTSD.
Content of Counseling Sessions:
Day 1: Like the first post-deployment sessions, day one will
consist of group
counseling where each soldier will share their experiences from
the previous
deployment. Counselors will be present as before, and they will
be in charge of
leading the session while it is being recorded for documentation
purposes and
evaluation. This session will last four hours total with two 30
minute breaks
implemented in.
Day 2: The second day will be devoted to individual counseling
sessions where each
soldier will meet with a counselor and express their feelings and
emotion through
111 P;JP'P
discussion. The individual session will last two hours, and the

18. counselor will record
information to add to the soldier's program intervention file.
Day 3: It will be devoted to the questionnaires that evaluate
social, psychological , and
emotional changes, and these will be compared to the previous
questionnaires as
well as the group and individual counseling sessions in order to
determine if
additional counseling is needed.
Phase 7: Process Evaluation
Process evaluation was done by examining the program's
components and if they were carried
out the way they were stated initially. Before each soldier's
initial deployment, they were each
educated on post traumatic stress disorder, the signs and
symptoms, and the need for
I
J
treatment if he/she or someone they knew started to develop any
of the symptoms. Four
counseling sessions were completed after each deployment by
each soldier that remained in
the program, and the counselors along with the medical exam

19. staff completed documentation of
changes in the soldiers with particular regard to psychological
changes.
Phase 8: Impact Evaluation
The impact evaluation shows the program's effectiveness by
observing the objectives that were
set for the program. Soldier's medical records, counseling
records, and work records were
reviewed periodically and at the completion of the 48 months .
Objectives for this intervention
were:
Objective 1: To increase awareness of post traumatic stress
disorder among twenty soldiers
by 100% within two weeks before their first deployment to
Afghanistan.
12 I P a Q e
Objective 2: To provide four sessions of post deployment
counseling to the twenty soldiers after
each deployment, at 85% counseling attendance rate.
Objective one was at 100%. The twenty soldiers all received
education on PTSD two weeks prior

20. to being deployed, and there was a 100% increase of awareness
among the soldiers of this
disorder which was determined by comparing pre and post
PTSD testing.
Objective two was met at 90% which was 5% above the goal
set. Of the twenty soldiers who
participated in the program, one was killed in action during the
first tour of duty, and another
soldier was killed in action during the second tour of duty. Of
the eighteen soldiers remaining,
1 00% compliance was met with the counseling sessions over
the 48 months.
Phase 9: Outcome Evaluation
The overall goal of this program was to provide early
intervention to twenty Arkansas soldiers
before their first deployment to Afghanistan as to prevent post-
traumatic stress disorder from
developing before and after their second deployment with the
success rate set at 85% after 48
months of the start of the intervention. Upon completion of the
48 month intervention, the
outcome evaluation revealed that our goal and objectives were
met. Of the twenty soldiers who
began the program, eighteen completed the program, two lost

21. their life in combat, and one
developed PTSD. 85% of the 20 soldiers in the program did not
develop PTSD after the 48
months which met the goal of the intervention.
With the program's success, UAMS has decided to continue this
intervention program and offer
it to more first time deploying soldiers in Arkansas. The
recruitment office will still be
responsible for referrals, and an assistant director will be
appointed to assist with the
implementation of the future programs.
Sources:
Bentley, S. (2005, March/April). Helpguide.org. Retrieved from
A Short History of PTSD : From
Thermopylae to Hue Soldiers Have Always Had A Disturbing
Reaction To War :
http:/
/www.vva.org/archive/TheVeteran/2005_03/feature_HistoryPTS
D.htm
Corporation, R. (2008, April17) . One In Five Iraq and
Afghanistan Veterans Suffer from PTSD or Major
Depression . Retrieved from http :/

22. /www.rand.org/news/press/2008/04/17 .html
Edberg, M. (2009). Essential Readings in Health Behavior
Theory and Practice. Sudbury, MA: Jones &
I
Bartlett Learning. //
Mathew Tull, P. (2009, January 25) . About. com. Retrieved
from Overview of PTSD and the Mili~try:
http:/ /ptsd.about
.com/od/ptsdandthemilitary/a/Mii_Overview.htm •
RWMC. (2010). Post- Traumatic Stress Disorder Effecting
Those WHo Protect Us And Those Who ive
Beside You. Retrieved from
http://www.supportforptsd.com/WhatCausesPTSD.aspx
The Graffiti of War Project. (2007). Retrieved from http:/ /www
.graffitiofwar.com/ptsd-facts--stats.htm l
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