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The role of proximity, immediacy, and expectancy in frontline treatment of combat stress reaction among Israelis in the Lebanon War

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The authors examined the effectiveness of the prevailing treatment doctrine stressing the principles of proximity, immediacy, and expectancy for combat stress reaction among Israeli soldiers in the Lebanon War. Two treatment outcomes were measured: return to military unit and presence of posttraumatic stress disorder. All three treatment principles were associated with a higher rate of return to the military unit. The beneficial effect of frontline treatment was also evidenced by lower rates of posttraumatic stress disorder. The authors suggest that these principles can also be effective in treating other forms of posttraumatic stress disorder.
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ZAHAVA SOLOMON AND RAM! BENBENISHTY
Am JPsychiatry 143:5, May 1986 613
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The Role of Proximity, Immediacy, and Expectancy in
Frontline Treatment of Combat Stress Reaction
Among Israelis in the Lebanon War
Zahava Solomon, Ph.D., and Rami Benbenishty, Ph.D.
The authors examined the effectiveness of the
prevailing treatment doctrine stressing the principles
of proximity, immediacy, and expectancy for combat
stress reaction among Israeli soldiers in the Lebanon
War. Two treatment outcomes were measured:
return to military unit and presence of posttraumatic
stress disorder. All three treatment principles were
associated with a higher rate of return to the military
unit. The beneficial effect of frontline treatment was
also evidenced by lower rates of posttraumatic stress
disorder. The authors suggest that these principles
can also be effective in treating other forms of
posttraumatic stress disorder.
(Am JPsychiatry 143:613-617, 1986)
Acute combat stress reaction encompasses a variety
of combat-induced, polymorphous behavioral,
cognitive, and affective manifestations that result in
impaired functioning. Frontline treatment is the pre-
vailing military doctrine for treatment of this syn-
drome. Developed by the American psychiatrist
Salmon (1) and later rephrased by Artiss (2), the three
principles of frontline treatment are proximity, imme-
diacy, and expectancy. Afflicted soldiers should be
treated in close proximity to the combat zone, as soon
Received March 6, 1985; revised Aug. 16, 1985; accepted Nov.
26, 1985. From the Research Section in Mental Health, Medical
Corps, Israel Defense Forces; the School of Social Work, Tel-Aviv
University; and the School of Social Work, Hebrew University,
Jerusalem. Address reprint requests to Maj. Solomon, Research
Section, Department of Mental Health, Israel Defense Forces, Mili-
tary P.O. Box 02149, Israel.
Copyright © 1986 American Psychiatric Association.
as possible after the onset of symptoms, and with the
expectation of a quick return to combat. Treatment
focuses on replenishing depleted physiological needs
by satisfying the need for sleep, food, and drink for a
few days in relative safety. During this period minimal
psychiatric intervention is carried out, allowing the
soldier opportunities to ventilate his recent traumatic
experiences. Following this brief intervention, the sol-
dier is expected to be able to resume his military
assignment. Frontline treatment is a simple interven-
tion, believed to be potent in reducing the loss of
manpower and long-term psychiatric sequelae (3, 4);
therefore, it has been adopted by many Western
armies.
Unfortunately, despite the extensive use of frontline
treatment, empirical evidence regarding its effective-
ness is quite limited (5). Many methodological limita-
tions of the existing studies severely hinder their
generalizability. Available data are derived mostly
from personal impressions of medical staff and from
small-scale surveys (5). Time frames for follow-up are
generally unspecified. Outcome measures focus only
on rate of return to unit, apparently ignoring psychi-
atnic symptoms (6, 7). Since frontline treatment is the
currently recommended treatment for combat stress
reaction, empirical assessment of its effectiveness is
imperative.
The Israel Defense Forces officially implemented
frontline treatment for the first time in 1982, during
the Lebanon War. Conditions of war usually do not
provide a setting conducive to the systematic study of
treatment effectiveness; however, the unique circum-
stances in Lebanon did allow for such an assessment.
During the 1982 Lebanon War, combat stress reaction
casualties were treated either by the frontline method
COMBAT STRESS REACTION AMONG ISRAELIS
614 Am JPsychiatry 143:5, May 1986
or in civilian facilities at the rear. The location and
type of treatment were determined solely by logistic
constraints. Because frontline and civilian services
were geographically close, confounding by transfer
time is negligible.
As a natural quasi-experimental design, coupled
with careful documentation, these circumstances en-
abled us to evaluate the effectiveness of frontline
treatment empirically. The present study assessed the
contributions of each of the three frontline treatment
principles-proximity, immediacy, and expectancy-
to two outcome measures, return to the military unit
and the presence of posttraumatic stress disorder.
Return to the unit represented a concern for man-
power loss; the presence of posttraumatic stress disor-
der determined the existence of long-term psychiatric
sequelae.
METHOD
Subjects
The target population encompassed all Israeli sol-
diers with known combat stress reaction during the
1982 Lebanon War. Subjects numbered several hun-
dred; exact figures cannot be disclosed due to strict
security regulations. Data reported here pertain to
82% of the target population. No significant differ-
ences were found between study subjects and nonre-
sponders for all examined sociodemographic variables.
The majority of subjects (64%) were born in Israel;
20% were of African or Asian origin, and the rest were
of European or American descent. Seventy-five percent
of the subjects ranged in age from 1 8 to 33 years; the
median age of all subjects was 28.5 years. Approxi-
mately two-thirds were married. Twenty percent had
completed eighth grade, 26% had had at least some
high school, 35% had completed high school, and
19% had studied beyond high school. Forty-three
percent were of above-average and 29% of below-
average economic standing.
Measures
Soldiers’ medical files provided information regard-
ing proximity of treatment. Based on this, subjects
were divided into four groups: two groups were given
frontline treatment and two were given alternative
treatment. The first frontline group encompassed all
soldiers who had received treatment for combat stress
reaction on Lebanese terrain. The second frontline
group contained all soldiers treated in military mental
health facilities located in northern Israel, near the
border with Lebanon. Since this group had been
treated close to the combat zone, it was considered a
frontline group. All of the soldiers in the two alterna-
tive treatment groups had been treated in facilities at
the rear. The first group consisted of soldiers who had
been airlifted to general hospitals in Israel; the second
group was composed of soldiers who had sought
psychiatric help while at home on leave in Israel.
Information regarding immediacy and expectancy
was obtained by means of questionnaires filled out 1
year after the first ceasefire. Subjects were asked how
much time had passed from the onset of their symp-
toms until they received treatment. Based on this,
subjects were divided into five immediacy groups:
those who received treatment immediately, within
several hours, in fewer than 2 days, in 2 or more days,
or after the ceasefire. Subjects were asked to indicate
their perceptions of treatment goals. The following
choices were presented: return to unit at all costs,
return to unit if capable, resume previous level of
functioning regardless of return, or treatment expecta-
tions unclear.
Two measures of outcome were used-return to unit
and the presence of posttraumatic stress disorder.
Return to unit was determined from soldiers’ written
reports. The presence of posttraumatic stress disorder
was assessed by a questionnaire based on DSM-III
criteria. Relying on DSM-III, we defined a respondent
who met four criteria as suffering from posttraumatic
stress disorder. First, the subjects must have experi-
enced a traumatic event of an intensity greater than
they experienced in everyday situations and that would
arouse distress in most people. Because all subjects
were combatants who had actively participated in the
Lebanon War, they all met this first criterion.
For the assessment of the three remaining criteria,
subjects were presented with a DSM-III-based inven-
tory containing 13 items describing posttraumatic
stress disorder symptoms related specifically to war
trauma. Symptoms were grouped in three categories:
1)reexperiencing the trauma, as evidenced by such
symptoms as recurrent and intrusive recollections of
the event, recurrent dreams, or suddenly behaving or
feeling as if the event were recurring; 2) numbing of
responsiveness or reduced involvement with the exter-
nal world, as evidenced by diminished interest in
important activities, feelings of detachment from oth-
cr5, or constricted affect; and 3) additional symptoms,
including hyperalertness, sleep disturbances, memory
or concentration difficulties, survivor guilt, guilt feel-
ings about behavior during the war, avoidance of
activities that triggered recall of the event, and inten-
sification of symptoms by exposure to events that
symbolized the trauma.
Posttraumatic stress disorder was diagnosed when at
least one symptom from each of the first and second
categories and at least two symptoms from the third
category were reported.
Reliability. The posttraumatic stress disorder inven-
tory was administered twice within a 1-week interval
to a small group of 20 soldiers. The rate of agreement
was 82.3%, indicating high test-retest reliability.
Concurrent validity. The posttraumtic stress disor-
den inventory for the entire sample was correlated with
the Impact of Event Scale, a measure designed specif-
ically to assess the impact of traumatic experiences (8).
ZAHAVA SOLOMON AND RAM! BENBENISHTY
Am JPsychiatry 143:5, May 1986 615
TABLE 1. Relationship Between Treatment Principles and Treatment Outcomes for Israeli Soldiers With Combat Stress Reaction During
1982 Lebanon Wara
Treatment
Return to Unit Posttr aumatic Stres s Disorder
Percent of Percent of
Principle Soldiers x2 df p Soldiers 2 df p
Proximity 17.47 3 <.000 7.43 3 <.07
At the front 43 52
Near the border 59 48
Airlifted to rear 21 66
At the rear 28 66
Immediacy 9.49 4 <.05 10.03 4 <.04
Immediate 44 54
After several hours 35 65
Within 1 day 26 73
Within 2 days or
more 29 56
After the war 24 74
Expectancy 20.25 3 <.000 12.37 3 <.01
Return at a!! costs 53 55
Return if capable 40 62
Recover if unable
to return 23 67
Not clear 26 75
aData given in percents rather than exact figures due to strict security regulations.
The posttraumatic stress disorder inventory correlated
with the factors of intrusion (r.62, p<.Ol) and
avoidance (r=.40, p<.Ol) of the Impact of Event
Scale, supporting concurrent validity for the posttrau-
matic stress disorder measure. Moreover, the clinical
validity of the 13-item inventory was assessed by
concurrent clinical interviews of a sample of 118
soldiers randomly selected from the subjects who
completed the questionnaire. Clinicians experienced in
diagnosis of posttraumatic stress disorder assessed the
existence of each symptom in the inventory and also
determined whether soldiers suffered from the syn-
drome. Concordance rates calculated for each of the
13 items ranged from 69% to 80%. For the final
diagnosis of posttraumatic stress disorder, agreement
between clinicians’ assessment and diagnosis based on
the inventory was 75%. Therefore, there was consid-
erable agreement between the self-report inventory
and the clinical diagnosis of posttraumatic stress dis-
order.
Procedure
Subjects were ordered to report to the headquarters
of the Surgeon General of the Israel Defense Forces
approximately 1 year following the ceasefire. The
order was accompanied by a personal letter explaining
that the subject had been selected to participate in a
routine periodic health assessment conducted as part
of the Medical Corps’ concern for the well-being of
soldiers. On arrival, subjects were seated in groups of
seven to 19 while they individually filled out a battery
of questionnaires. They were informed that participa-
tion was voluntary and were assured that all data
would remain confidential, in no way affecting their
military or civilian status.
RESULTS
Since subjects had not been purposely assigned to
treatment groups, we needed to assess whether assign-
ment in effect was random. Close scrutiny of medical
files revealed no discernible differences between the
initial clinical pictures of combat stress reaction casu-
alties who were treated at the front and those removed
to the rear. In a series of statistical analyses, no
significant associations were found between treatment
group membership and sociodemographic charactenis-
tics, including age, education, economic status, living
conditions, and country of origin. Members of the four
treatment groups also did not differ in military ratings
of intelligence, motivation, rank, or corps member-
ship. Finally, debniefings of mental health officers
conducted immediately following the ceasefire mdi-
cated that, due to logistical constraint, allocation to
treatment groups was not systematic. Hence, we as-
sume that there was no bias operating in the selection
of treatment location.
Table 1 presents the relationships between each of
the treatment principles and each of the outcome
variables. Return to unit and proximity showed a
strong association. Soldiers treated at the front or near
the border between Israel and Lebanon returned to
their units more frequently than did those who were
airlifted to the rear or treated initially at the rear.
Return to unit was also associated with immediacy.
Soldiers who had been treated immediately showed the
highest rate of return to the unit; soldiers who had
started treatment after the ceasefine showed the lowest
rate.
The strongest association occurred between return
to the unit and expectancy. For soldiers with the
perceived expectation that they would return at all
COMBAT STRESS REACTION AMONG ISRAELIS
616 Am JPsychiatry 143:5, May 1986
TABLE 2. Relationship Between Number of Treatment Principles
Applied and Treatment Outcomes for Israeli Soldiers With Combat
Stress Reaction During 1982 Lebanon Wara
Treatment Outcome
Posttraumatic
Number of Treatment Return to Unit Stress Disorder
Principles Applied (percent)t’ (percent)c
0 22 71
1 23 64
2 48 59
360 40
aData given in percents rather than exact figures due to strict security
regulations.
bx223.7, df=3, p<.000.
Cx27.7, df=3, p<.O6.
costs, the rate of return was double that for soldiers
who did not understand their therapists’ expectations.
Although the data suggest that the association be-
tween proximity and posttraumatic stress disorder was
not significant, the percentage of soldiers who were
treated at the front who developed posttraumatic
stress disorder was lower than the percentage of sol-
diers who were treated at the rear.
The relationship between posttraumatic stress disor-
den and immediacy was significant. The two groups
with the lowest rates of the disorder were those treated
immediately and those treated 2 or more days after
onset of symptoms.
A strong relationship existed between presence of
posttraumatic stress disorder and expectancy. A linear
trend was observed, with the lowest rate of posttrau-
matic stress disorder in the soldiers who perceived the
therapist’s expectation as their return at all costs.
To assess the cumulative effect of the application of
the treatment principles, we examined the multivariate
relationship between each outcome measure and the
three treatment principles. As table 2 shows, the more
principles applied, the stronger the effect on outcome.
To assess the relationship between the two outcome
measures, we compared the rates of posttraumatic
stress disorder among soldiers who returned to their
units with those of soldiers who did not. A strong
association existed between the two outcome measures
(2=42.19, df=1, p<.OO1). Only 38% of the soldiers
who returned to their unit reported posttraumatic
stress disorder one year after the ceasefire, compared
with 74% of those who did not return.
DISCUSSION
The present study assessed the contributions of the
three frontline treatment principles of proximity, im-
mediacy, and expectancy to the outcome measures of
return to unit and presence of posttraumatic stress
disorder. Return to unit showed a strong association
with all three treatment principles; the presence of
posttraumatic stress disorder, a somewhat less strong
association. Results apparently demonstrate the effec-
tiveness of frontline treatment for combat stress reac-
tion.
Several interpretations help explain these findings.
Treatment provided in close proximity to the front
facilitates continuing contact with comrades and com-
manders, strengthening the soldier’s commitment to
his peers and reinforcing his military identity (9, 10).
Proximate treatment also facilitates contact with mil-
itary officials, resulting in fewer physical and adminis-
trative obstacles to a prompt return to the unit.
Further, treatment near the front actively exposes the
soldier to stimuli similar to those which precipitated
his condition. Soldiers with combat stress reaction
continue to wear their uniforms and are treated in
military camps on or near the battlefields, within range
of the sound of shellfire. As a form of desensitization,
such conditions minimize fear of fighting and render
the soldier ready for return to his unit.
Location is important for the therapist as well. A
clinician engaged in treatment in the battle zone iden-
tifies not only with the needs of the individual afflicted
soldiers but also with the needs of the combat unit as
a whole (1 1). He may therefore attempt to minimize
manpower loss and to return to combat as many
soldiers as possible.
The benefit derived from expectancy in frontline
treatment appears to be due to its implications for both
the soldier and the therapist. Use of frontline treatment
assumes that the soldier’s response is not evidence of
an underlying illness but merely a temporary crisis-a
natural, appropriate response to the extreme stresses
of war (3, 5). Thus, the therapist treating a soldier with
combat stress reaction on or near the battlefield is
more likely to communicate his expectation that, since
the soldier is experiencing only a transient crisis, he is
capable of resolving this crisis and resuming his miii-
tary role within his unit.
Immediate treatment on or near the battlefield trans-
mits to the soldier the expectation that he is continuing
to maintain his role as a soldier. His assignments in the
unit have not been permanently cancelled, and he is
still regarded by both peers and commanders as an
integral part of the unit (8-10). It is as though he is
merely on temporary leave, and his return is both
expected and desired.
The effects of proximity, immediacy, and expect-
ancy seem to be interrelated. In fact, the findings of this
study clearly demonstrate the cumulative effect of
implementing all three treatment principles. Together,
they serve to reinforce the soldier’s military identity
while providing him with the means to overcome a
temporary, stress-induced crisis, resulting in prompt
return to military duties.
The effectiveness of frontline treatment was also
assessed with regard to long-term psychiatric distur-
bances. Although the presence of posttraumatic stress
disorder showed some association with each of the
three treatment principles, the strongest was with
expectancy. Similar to Bnickman et al.’s compensatory
model of helping (12), frontline treatment does not
ZAHAVA SOLOMON AND RAMI BENBENISHTY
Am JPsychiatry 1 43:5, May 1986 617
hold the soldier responsible for his combat stress
reaction; his problems are considered secondary to
combat stress, not something inherent in his personal-
ity. He is expected, however, to mobilize his inner
resources in order to resume his pretrauma level of
functioning. As a result, the aura of guilt over breaking
down is removed and the soldier’s self-esteem en-
hanced, preventing crystallization of symptoms with
resultant chronicity.
Our results also show that soldiers who returned to
duty exhibited a lower rate of posttraumatic stress
disorder. There are several possible explanations for
this finding. Return to the unit may mirror prognosis.
Soldiers with combat stress reaction who had a more
encouraging prognosis were returned to their units; in
contrast, those who had a less favorable prognosis
were referred to the rear for further treatment. Return
to the unit in itself could be both an outcome and a
therapeutic tool. It is possible that sending soldiers
with combat stress reaction back to their units actually
contributed to a better outcome, resulting in fewer
signs of posttraumatic stress disorder.
The detrimental consequences of psychiatric label-
ing are well documented (13). Because the soldier is
returned to his unit, his episode of combat stress
reaction is not labeled a major psychiatric disorder and
such consequences are less likely to occur. Finally,
social support has been shown to aid recovery from
psychiatric crises (14). Within the military, where
support derived from ties with comrades is of para-
mount importance, this is especially relevant. The peer
and officer support soldiers with combat stress reac-
tion receive during treatment on or near the battlefield
and after their return to the unit contributes to their
better prognosis.
Despite the negative association observed between
return to unit and presence of posttraumatic stress
disorder, a considerable number of soldiers who re-
turned to their units after treatment suffered from this
disorder one year after the ceasefire. This finding raises
a number of questions. How was their return to the
unit experienced by these soldiers? What was their
level of functioning after return to their units? How
many of these soldiers left their units at a later time due
to problems related to combat stress reaction? These
questions are currently being addressed in ongoing
research.
The data reported here encourage the application of
frontline treatment for combat stress reaction. If one
considers combat stress reaction only one of many
precursors for posttraumatic stress disorder, then it is
possible that, with some modifications, the three pnin-
ciples of frontline treatment could also successfully be
applied to other, non-war-related psychiatric trau-
mata, such as automobile accidents, rape, or severe
illness.
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... close proximity, immediate care and an understanding that the goal of the treatment was to return them to their unit), with a reduced but protective effect even if they received only one of those components. 8 A follow-up study 13 conducted 20 years later among these same soldiers showed sustainability of this finding, with a lower proportion of PTSD symptoms, loneliness and higher social functioning among those who had received one or more components of care at the time of the original event. However, the sample size was small, and despite the numerical difference, there was no statistically significant difference in PTSD symptoms and some other measures (e.g. ...
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Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.
... En contextos operativos y bélicos los trastornos y reacciones de estrés conforman una respuesta psicofisiológica normal a situaciones extremadamente anormales (Deahl, Gilham, Thomas, Searle & Srinivasan, 1994;Solomon & Benbenishty, 1986). Esta respuesta suele tener carácter transitorio, de modo que la mayoría de los militares que la experimenta se recupera poco tiempo después, reincorporándose al servicio sin secuelas. ...
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... During the Vietnam War, military psychiatrists began promoting postbattle meetings to analyse soldiers' emotional responses and to support their combat stress. The purpose of this form of debriefing was to allow soldiers to externalize thoughts, memories and emotions related to a potential traumatic experience in order to understand and normalize them [6,7]. ...
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Post-aggression debrief is the practice of reviewing an aggressive event in order to process the experience and learn from it. Debriefing aims at addressing the emotional impact of aggression and its consequences on the people involved (both service users and staff) and at analysing each incident in order to identify practice issues and organizational and system problems and ultimately to prevent recurrences. Debriefing should be routinely offered to both patients and staff involved in aggression and restraint episodes: it can be provided according to different focuses and timing, depending on whether the targets are the patients or the staff members. The debriefing process should consist in a rigorous analysis of objective facts, followed by an open discussion about subjective feelings, thoughts and suggestions about potential changes in service organization and practice. Empirical research has focused on post-aggression debriefing mostly as a part of broader programs of intervention. However, debriefing by itself can reasonably play a crucial role in improving the quality of clinical practice and reducing aggressive episodes in psychiatric wards. Debriefing represents a chance to comprehend the patient’s psychopathological world, to restore a narrative coherence beyond the traumatic and violent event and to keep a safe and trustable therapeutic environment. In conclusion, post-aggression debriefing should be considered a valuable tool for clinical practice, since it can transform potentially traumatic experiences into occasions for understanding, rethinking and improving the everyday therapeutic work.
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