Bret A. Moore, PsyD, ABPP
Board-Certified Clinical Psychologist, San Antonio, TX
Dr. Moore has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: Dr. Moore, you have worked as both a civilian psychologist and in the field as an active duty member of a combat stress team. Please tell us about some of the clinical problems you observed on the front lines.
Dr. Moore: I would say that well more than half of my initial presentations were, interestingly enough, relationship-oriented. Especially with a group of primarily young men ages 18 to 24 that have young girlfriends and wives back home, being separated by thousands of miles for a year or more can cause quite a bit of disruption in those relationships. Another big part of what we dealt with were crises related to workplace conflict, like arguments or fights with coworkers. And of course we dealt with what we generally call combat operational stress: not only PTSD and acute stress disorder, but transient combat stress reactions that required some attention until they started to dissipate. This treatment often involved psychoeducation, sometimes sleep medication, and some short-term cognitive therapy.
TCPR: And then of course you did see PTSD.
Dr. Moore: Yes. This was especially common among individuals who suffered a traumatic event during their first or second tour, without developing symptoms of PTSD, but then came back for a third or fourth tour and developed PTSD at that time. As you might imagine, trying to manage PTSD in a combat environment is very tricky, especially when you are doing some type of exposure therapy and you have rockets and mortars going off in the background.
TCPR: What are some of the most common complaints that you see in this same group of individuals returning back home?
Dr. Moore: In the immediate short-term, you see readjustment issues: relationship problems, insomnia, other sleep problems, trying to adjust back to civilian life, trying to get back into a routine. As things progress, the vast majority of people tend to get better. But there’s also a subset who, at six months, still have issues with symptoms such hyperarousal and will eventually meet criteria for PTSD. You also see a good deal of traumatic brain injury (TBI) and depression.
TCPR: For those of us who do not work exclusively with returning veterans, what are some of the effective ways or tips that you might have for working with them?
Dr. Moore: It really depends on the clinician and the person. While I think that a structured interview is useful, service members are bombarded with formal interviews and checklists, so my recommendation is not to start off with a very sterile clinical interview or screening tool. Instead, try to get to know the soldier and understand his or her story. Don’t press; don’t ask too pointed questions if you don’t have to. I know that may not be practical because often we don’t have a lot of time to spend with our patients, but I think if you come off as too focused on symptoms, then you run the real risk of that person not coming back.
TCPR: Are there any do’s and don’ts of how to discuss patients’ experiences in battle and how they feel upon returning?
Dr. Moore: It’s important to understand that the military has a culture in which stoicism is rewarded. You don’t show emotions, and you don’t admit to failures, faults, or weaknesses, and oftentimes mental health issues are seen as weaknesses. Where you might trip up as a clinician is to try to overdiagnose, overpathologize, or reach a diagnosis too soon. If you put any one of us into a combat zone 12,000 miles away from family for a year, being shot at and potentially blown up, you are going to have some kind of psychological issues, some kinds of symptoms. So it is really important to try to understand the story, the individual’s symptoms, and reassure them that what they are experiencing is to some degree expected and normal. It is very important to acknowledge them and to thank them for making the first step of seeing a professional, because for many it’s a big deal just coming into your office.
TCPR: Is there a risk of going in the opposite direction and simply accepting that anybody’s experience would be a normal reaction to what they went through and then missing some bigger issues?
Dr. Moore: That is a very good point. It is important to realize that to normalize is one thing, but you definitely don’t want to marginalize or minimize what they’ve experienced. If a patient meets criteria for a certain disorder, then absolutely don’t hesitate to diagnose it, because with disorders come potential benefits down the road, especially in the VA system.
TCPR: Can you explain to us the process by which soldiers and active duty members are prepared for reacculturation or reintegration back into “normal” life?
Dr. Moore: Typically the preparation starts early, even prior to deployment, in a series of psychoeducational briefs and information about resources. They are told that there are some thoughts and feelings to expect for the first few weeks or months, and if these issues persist, then that is when you might want to consider getting more professional help. Chaplains usually come in and do a brief on reintegration with the family, and then there are a series of health assessments done down range in the combat environment at 30 days and six months after they return.
TCPR: Can you tell us a bit about military culture and the impact it has on the psychology of individuals in the military?
Dr. Moore: One of the biggest issues related to military culture and clinical treatment is the issue of stigma. In the military you are trained to be tough and strong, and told that you can overcome whatever is thrown at you. It is seen as weakness to ask for help. The military has made a lot of strides in trying to counter that and to normalize seeking psychological care. A big help is that some Special Forces generals have come out and declared, “I suffered from problems, so I got help, and it is okay for you to do that, too.” Also, the military is a closed society and to an extent they really trust their own, so it takes time to develop that trust with an outside clinician. I always encourage clinicians to try to learn as much as they can about the culture, the rules, the regulations, the ranks, and how the hierarchy works. (Eds note, see sidebar for tips and resources on understanding military culture.)
TCPR: Can you comment on the management of PTSD in combat veterans?
Dr. Moore: I think it is abundantly clear that psychotherapy is the number one approach for PTSD. Psychotherapy is really the only way to get at the global symptoms of PTSD, as opposed to pharmacology, where you really just target certain symptoms like nightmares or insomnia. In my experience, it also seems that soldiers tend to struggle more than other trauma survivors with nightmares, which are very difficult to treat.
TCPR: Is there a particular psychotherapy that is best?
Dr. Moore: Yes, prolonged exposure (PE) therapy and cognitive processing therapy (CPT). PE therapy involves exposure to real-world situations and imaginal exposure, or talking about the trauma over and over with your therapist. CPT involves learning one’s thoughts and feelings about the trauma and challenging them. I am a strong proponent of integrative treatment—including psychopharmacology for specific symptom management and psychotherapy for global symptom reductions.
TCPR: You said nightmares are real problem for combat veterans. Is there a particular treatment that is best for those?
Dr. Moore: Fortunately, there are a couple of good treatments. Prazosin (Minipress) has been shown to be really effective for reducing nightmare frequency and intensity. However, in my experience, once you stop the medication, the nightmares come back. Then there is a treatment called imagery rehearsal therapy or imagery rescripting that was pioneered by Barry Krakow in Albuquerque. This is a short-term cognitive behavioral therapy with a lot of really great research using randomized trials showing that it is very effective in eliminating nightmares with only two or three sessions.
TCPR: Can you share with us some of the criteria used for acceptance into one of the armed services? In particular, are people with preexisting psychiatric illnesses allowed in the military?
Dr. Moore: It depends on what the military needs. It ebbs and flows. One of the theories behind why there has been an increase in suicide is that there was a period of time where the military relaxed its standards to let more people in, possibly allowing more people with preexisting psychiatric conditions to enter with a waiver. It’s believed by some that the military may now be too large, which means it may be more difficult for those with preexisting conditions to join.
TCPR: How big of a problem is suicide among veterans?
Dr. Moore: Suicide is an important issue for both veterans and active duty personnel. It has been on the rise in recent years. We see around 24 suicides per 100,000, which is above the age-matched demographic of 18 or 19 per 100,000 in the civilian population. The prevailing theory is that risk is related to combat deployments—the more deployments, the greater the risk of suicide. However, a large study showed that suicide was not related to the length of deployment or the number of deployments (Leardman CA et al, JAMA 2013;310(5):496–506). Instead, it may be related to the intensity of the combat in a deployment.
TCPR: Are there warning signs that are different among veterans than among civilians?
Dr. Moore: We know that often those who commit suicide struggle with relationship problems. Substance abuse and financial issues are also important factors. Thomas Joiner, a suicidologist, developed the interpersonal psychological theory of suicide, which might explain why service members are at greater risk. One of the factors he talks about is an acquired capacity or capability to commit suicide. For soldiers who are in a combat environment and constantly being faced with danger and the potential for death, dying becomes less taboo; it becomes just part of a normal life. Another piece that factors into that acquired ability to kill yourself is that so many of our men and women are dealing with chronic pain, and the irritability and agitation that go along with it.
TCPR: Thank you, Dr. Moore.
Don’t Know DFAC from MRE?
Where to Learn More About Military Culture and Acronyms
One of the best ways to develop rapport and trust with military patients is to learn more about their culture, and admit when you don’t understand something and ask for clarification, says Dr. Moore.
It can go a long way to learn the differences between the four uniformed armed services (Army, Air Force, Navy, and Marines) and to learn the basics of the military occupational specialties in each branch. Plus, googling the most common military acronyms can help you learn the terms these patients might use often.
In addition, Dr. Moore suggests the following books to expand your knowledge:
Treating PTSD in Military Personnel: A Clinical Handbook, by Bret A Moore and Walter E Penk, eds. The Guilford Press; New York, NY:2011.
Military Psychologists’ Desk Reference, by Bret A. Moore and Jeffrey E. Barnett, eds. Oxford University Press; New York, NY:2013.