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Nature-based therapy as a treatment for veterans with PTSD: what do we know?

March 2017
Journal of Public Mental Health 16(1):15-20

DOI:10.1108/JPMH-08-2016-0039

Authors:

University of Copenhagen

Purpose The purpose of this paper is to provide a comprehensive argument for nature-based therapy (NBT) for veterans with post-traumatic stress syndrome. It is the aim to generate an overview of the evidence for NBT to the target group. A review of available scientific literature within the field, has been comprehensively conducted. This work is the foundation for the recommendations to decision makers and politicians. Design/methodology/approach This paper provides a conceptual analyses and a general review of the literature. Following steps have been conducted. Based on the research question, relevant work (scientific papers) have been identified using search terms in English within the three areas the target group (veterans), the diagnosis (post-traumatic stress disorder, PTSD) and treatment (NBT). Study-quality and evidence level have been assessed and discussed. Findings The findings show a wide variation according to the interventions the nature setting, the length and frequency of the NBT session as well as the health outcome measures. The studies demonstrated a positive impact on the PTSD symptoms, quality of life and hope. None of the studies found negative impact of the interventions. Being in a group of other veterans facing the same problems was highlighted as well. Some studies measured the ability to return to workforce for the veterans and found NBT beneficial in that process. Research limitations/implications The limitation of the research due to the methods of identifying studies. The purpose of this was to give an overview of existing literature, and there can be studies, that are not found in this process. Including qualitative and quantitative methods are useful in a process of understanding the impact of NBT for veterans with PTSD. The quantitative studies, which unfortunately are few, can give information of the extent to which the treatment affects the symptoms of PTSD. Seen in the perspective of the burden for the veterans suffering from PTSD and the economic burden for society, the process of synthesizing the research in the field in order to generate a fundament seems necessary. Practical implications This policy papers are useful in order to make recommendations for politicians and decision makers as well as practitioners. Social implications The burden of suffering from PTSD is heavy for the veterans and their family. The society must drive forward the development of new and better evidence-based treatment programs for veterans with PTSD. NBT might be a step in the right direction of this. Originality/value It is well-known that there are an increase in the number of veterans diagnosed with PTSD. Generally the drop-out rate of the veterans is high in conventional treatment and it is found that veterans experience some side effects from medical treatment. NBT is, in existing research, found to have a positive impact on the veterans, and therefore, it should be part of future treatment programs for veterans with PTSD.

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Nature-based therapy as a treatment for

veterans with PTSD: what do we know?

Dorthe Varning Poulsen

Abstract

Purpose –The purpose ofthis paper is to provide a comprehensive argument for nature-based therapy (NBT)

for veterans with post-traumatic stress syndrome. It is the aim to generate an overview of the evidence for NBT

to the target group. A review of available scientific literature within the field, has been comprehensively

conducted. This work is the foundation for the recommendations to decision makers and politicians.

Design/methodology/approach –This paper provides a conceptual analyses and a general review of the

literature. Following steps have been conducted. Based on the research question, relevant work (scientific

papers) have been identified using search terms in English within the three areas the target group (veterans),

the diagnosis (post-traumatic stress disorder, PTSD) and treatment (NBT). Study-quality and evidence level

have been assessed and discussed.

Findings –The findings show a wide variation according to the interventions the nature setting, the length and

frequency of the NBT session as well as the health outcome measures. The studies demonstrated a positive

impact on the PTSD symptoms, quality of life and hope. None of the studies found negative impact of the

interventions. Being in a group of other veterans facing the same problems was highlighted as well. Some studies

measured the ability to return to workforce for the veterans and found NBT beneficial in that process.

Research limitations/implications –The limitation of the research due to the methods of identifying

studies. The purpose of this was to give an overview of existing literature, and there can be studies, that are

not found in this process. Including qualitative and quantitative methods are useful in a process of

understanding the impact of NBT for veterans with PTSD. The quantitative studies, which unfortunately are

few, can give information of the extent to which the treatment affects the symptoms of PTSD. Seen in the

perspective of the burden for the veterans suffering from PTSD and the economic burden for society, the

process of synthesizing the research in the field in order to generate a fundament seems necessary.

Practical implications –This policy papers are useful in order to make recommendations for politicians and

decision makers as well as practitioners.

Social implications –The burden of suffering from PTSD is heavy for the veterans and their family.

The society must drive forward the development of new and better evidence-based treatment programs for

veterans with PTSD. NBT might be a step in the right direction of this.

Originality/value –It is well-known that there are an increase in the number of veterans diagnosed with PTSD.

Generally the drop-out rate of the veterans is high in conventional treatment and it is found that veterans

experience some side effects from medical treatment. NBT is, in existing research, found to have a positive

impact on the veterans, and therefore, it should be part of future treatment programs for veterans with PTSD.

Keywords PTSD, Recommendations, Veterans, Nature-based therapy, Post-traumatic stress syndrome

Paper type General review

Introduction

This paper describes society’s obligation to provide appropriate treatment to military personnel

who are suffering from post-traumatic stress disorder (PTSD) following war service. Furthermore,

the paper reviews nature-based therapy (NBT) as a relevant component of an overall treatment.

PTSD can occur after experiencing or witnessing traumatic events (American Psychiatric

Association, 2013). Combat-related PTSD is a condition that has huge personal implications for

the individual and his family, and poses an economic burden for society. The prevalence of PTSD

among the US troops returning from Afghanistan and Iraq has been reported at 14-15 per cent

(Gates et al., 2012), and for UK troops the number is 3-5 per cent (Fear et al., 2010; Richardson

Received 29 August 2016

Revised 17 October 2016

Accepted 17 October 2016

Dorthe Varning Poulsen is an

Assistant Professor at the

Department of Geosciences

and Natural Resource

Management, University of

Copenhagen, Frederiksberg,

Denmark.

DOI 10.1108/JPMH-08-2016-0039 VOL. 16 NO. 1 2017, pp. 15-20, © Emerald Publishing Limited, ISSN 1746-5729

JOURNAL OF PUBLIC MENTAL HEALTH

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et al., 2010). Furthermore, the number of soldiers with symptoms compatible with PTSD in the

USA and the UK has increased (Atkinson et al., 2009; Tanielian and Jaycox, 2008). An important

part of this story is that veterans are diagnosed several years after having experienced the

traumatic events and not, as previously, within six months after the onset of symptoms. A Danish

cohort study of veterans from the war in Afghanistan found an increase in the percentage of

soldiers with PTSD symptoms; the figure increased from 3 per cent at the time of homecoming to

9.4 per cent three years after the time of homecoming (Andersen et al., 2013).

The treatment offered to war veterans often consists of either psychological treatment or

pharmacotherapy, or a mix of these two treatment forms. Exposure therapy and cognitive

therapy are recommended in clinical treatment guidelines in several countries (Forbes et al., 2010;

Castillo et al., 2014; Resick et al., 2015). In spite of these recommendations, a percentage of the

veterans deselect the treatment offered; Hoge found that up to 44 per cent of veterans in the USA

do not receive the recommended treatment or drop out of their treatment programme (Hoge

et al., 2014). Therefore, it seems urgent to seek out alternative treatments that work, are

acceptable to war veterans with PTSD, and that have a positive impact on the individual’s overall

life. In this regard, NBT is a promising option.

The aim of this paper is to summarize the existing evidence of the benefits of NBT for veterans

with PTSD, to identify strengths and weaknesses in the research conducted, and, based on this,

to make recommendations with regard to how to incorporate NBT as a part of the treatment

offered to war veterans with PTSD.

NBT

NBT covers a variety of interventions in which the nature setting (designed or natural) and the

therapeutic programs constitute a relationship that is adjusted to the need of the target group

(Stigsdotter et al., 2011). The treatment is based on the theory that environmental psychology

and natural environments are seen as supportive for human health (Stigsdotter and Grahn, 2003;

Stigsdotter et al., 2011). Moreover, it draws on Kaplan’s (1995) theory suggesting that nature can

help to replenish our mental and attentional capacity. Fatigue of the brain can occur when the

brain’s capacity to focus on a specific task has reached its limit. Though the interaction between

the ambient environment, i.e. green activities that have a therapeutic effect, and knowledge of the

special needs of the target group, NBT offers a very real and relevant form of treatment.

In NBT, the therapeutic approach varies from, e.g. mindfulness-based methods, cognitive

therapy or, the development of special skills in relation to nature and horticulture. Even though the

overall goal is to enhance the veterans’self-confidence and ability to deal with everyday life

situation, the therapeutic aspect is an inseparable part of NBT. Thus it is very important to

differentiate between NBT and outdoor activities. Outdoor activities have a purpose in themselves

and are not directly related to healing; they might have a positive impact on the participants’

mental and physical being in the moment, but they are not designed to lead to the individual’s

recovery. And therefore they should not be included in the assessment of a treatment for veterans

with PTSD.

Below is an overview of existing research within the area of NBT for war veterans with PTSD.

Based on this overview, important matters as well as issues that need further research will be

identified with a view to preparing an evidence-based guideline for NBT for veterans that will

benefit both the veterans and society.

Overview of the existing research

The purpose of this literature review is to give an overview of research concerning NBT for

veterans with PTSD. This review uses the term “NBT”defined by Corazon et al. (2010) as “a

therapeutic intervention targeting the need of a special population, where the natural environment

is specially designed or specially chosen for the particular therapeutic activity”. NBT can be seen

as an umbrella-term for different types of therapy also referred to as ecotherapy, horticultal

therapy and therapeutic horticulture.

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A search strategy was developed inspired from The Cochrane Centre; The Cochrane Handbook

for Systematic Reviews of Interventions (Higgins and Green, 2008).

Search terms within the field of the three foci (“Therapy”,“Target group”and “Diagnose”) were

developed (Table I).

Looking at the field as a whole, there is a huge contrast between the commonness of treatment

programmes for veterans with PTSD involving “nature”(a Google search generated more than

800,000 hits) and the lack of scientific studies of NBT programmes.

A broad search of papers published from 1995-2016 based on English search terms within the field of

“NBT”,“veterans”and “PTSD”was conducted. Two reviews including, respectively, 19 (Poulsen

et al., 2015) and eight studies (Bird, 2014) was found. Additionally, six studies were identified. The

quality of the studies was assessed using recommendations from Cochrane Handbook (Higgins and

Green, 2008). RCT studies are recommended in reviews of medical intervention, because they test

the effectiveness of various types of medical intervention (Higgins and Green, 2008; Popay et al.,

1998). In spite of this, only few RCT studies have examined NBT for veterans with PTSD. A systematic

review (Poulsen et al., 2015) included only two RCT studies published in the period from 1996 to

2015. The same picture was seen in a review focussing on treatment of Australian veterans in which

the author concluded that research in this area is based mainly on “small self-selected sample sizes

and a lack of randomised controlled groups”(Bird, 2014). The two reviews found a greater number of

qualitative designed studies: (Poulsen and Stigsdotter, 2015) included 17 of such studies and Bird

included eight papers in his review. Qualitative studies are often used in social research because of

their value with regard to investigating complex and sensitive issues (Bryman, 2015), but as described

above, they are not usually part of reviews of medical interventions. The consequences of not

including this type of research in this particular field might be that rigorous data that are relevant to

policy are not included in review studies. A transparent assessment of the methodology’squality

before analyzing the data, as done by Poulsen (Poulsen and Stigsdotter, 2015) is required. So what

may be seen as a weakness from a medical methodological perspective can instead be viewed as a

quality in research within the social research, and bring deeper insight into the participants’experience

of the treatment and life perspective. This paper argues for a biopsychosocial approach (Borrell-Carrio

et al., 2004; Engel, 1989) and therefore, the qualitative as well as the quantitative studies are reviewed.

Results

In general, the interventions varied especially with regard to the setting, the length and frequency

of intervention and also the health outcome measures. A measurement in the studies is the

individual’s ability to return to the workforce. This is an interesting measurement, because of

the high rate of unemployment among veterans (Resnick and Rosenheck, 2008; Smith et al.,

2005) and the resulting economic consequences for the individual and society. Concrete skills

such as horticulture and gardening give the veterans competences that are described as

transferable from the context of the garden to the personal life of the veterans (Poulsen and

Stigsdotter, 2015). In spite of the differences between the studies, there is a tendency that an

extended treatment period of one month instead of shorter compressed intervention periods

(days or a week) has an impact in the long term (Poulsen et al., 2015). Some studies describe

improved physical health as a consequence of the physical demands of green activities. Physical

health is an important measure because of the known negative impact of PTSD on general health.

Most of the researched papers mentioned the veterans’experience of being part of a group with

Table I The table gives an overview of the search strategy

Search topic Therapy Target group Diagnose

Search terms

(only in English)

Nature-based therapy,

ecotherapy, horticultural

therapy

Veterans, soldiers, military

personnel, servicemen

Post-traumatic stress disorder

(PTSD), combat disorder,

war-related trauma

Databases Medline, Pubmed, Cochrane Library, CINAHL, PILOTS, Google Scholar

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other veterans who face the same type of problems. This feeling of belonging to a group breaks

down the feeling of being stigmatized and isolated (e.g. Atkinson, 2009; Detweiler et al.,2010).

Two studies found a significant reduction in PTSD symptoms and depression, an improvement in

functioning, in hope, and sense of control of the symptoms of PTSD (Duvall and Kaplan, 2013;

Gelkopf et al., 2013; Hyer et al., 1996), whereas Hyer et al. (1996) only found this in the qualitative

part of their study. A recent study (Detweiler et al., 2015) that used cortisol levels and questionnaires

as a measurement of the severity of PTSD in veterans, found no significant difference in the cortisol

levels for the two treatment groups (one group was treated with horticultural therapy (HT) and the

other group was treated with occupational therapy (OT). However, the qualitative part of the study

did show that the majority of participants benefitted more from HT than OH. Only one study

followed the participants after the intervention (Poulsen et al., 2015). This qualitative study examined

a ten-week NBT programme; after one year the veterans were found to have benefited from the

therapy in that their PTSD symptoms were less severe and their sense of control had improved.

Furthermore, the majority of the group had returned to work or education.

Conclusion and recommendations for policy makers

Society is facing an increasing number of war veterans experiencing symptoms of PTSD after

serving in war zones. Added to this, a number of studies indicate there is a connection between

PTSD and an increased rate of physical health issues, substance abuse, and unemployment.

Treatment most often focusses on medical treatment and trauma-focussed psychological

therapy. The literature discusses whether medical treatment can cure PTSD or merely offers

symptom relief. Studies show that many veterans do not seek help or drop out of the

programmers offered. This leaves a group of veterans and their families with the burden of dealing

with the PTSD symptoms in their daily lives.

Even though the majority of the studies have a qualitative approach and only a few RCT studies

have been identified, the results with regard to the effect of NBT are consistently positive and no

negative impact from NBT has been reported.

The qualitative studies of NBT provided to veterans contribute with knowledge regarding the

complex condition of living with PTSD. More well-structured RCT studies are needed in the area.

Such studies, combined with relevant transparent qualitative studies must be the foundation for

developing clear guidelines for NBT. Therefore, the following steps are recommended:

■Development of a set of measurement tools with a multi-method approach that captures the

different challenges the veterans are facing, and provides a basis for comparing the results of

different projects;

■Clear and transparent description of the therapeutic approach and interaction with nature

enabling practitioners (therapists) to use this approach, to make the treatment transparent

and transferable to the practice sector; and

■Clear distinctions between outdoor activities and NBT. Outdoor activities do not involve

a specific therapeutic effort, and are therefore not a treatment even though it appears so

in the literature.

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Corresponding author

Dorthe Varning Poulsen can be contacted at: dvp@ign.ku.dk

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Impact of the Natural Environment on Individuals’ Psychological Well-being

Article

Full-text available

Mar 2024

Qiannan Guo

This article explores the intricate relationship between the natural environment and the human psyche. The article examines how exposure to nature can have a positive influence on mental health, increase life satisfaction, and promote the development of positive personality traits. By reviewing research on naturopathy, the outdoors, and personality development, the article emphasizes the profound impact of nature on human mental health and leads to the importance of integrating the natural environment into urban development. As a result, the article proposes the concept of Biophilic and discusses how Biophilic concepts can be integrated into future urban development from the perspective of landscape design to ensure the sustainability and accessibility of natural spaces in cities so that human beings can achieve psychological well-being through daily contact with natural environments. Natural environments are not only beneficial for human mental health but also for future urban sustainability as well as ecological diversity. Therefore, by prioritizing nature in future urban design and development, it is possible to create healthier, more resilient, and liveable cities that ultimately benefit human well-being and the environment.

Exploring Changes in Depression and Meaning in Life through River Rafting for Veterans with PTSD

Article

May 2022

As part of a larger research program examining the impacts of nature-based experiences on veterans with Post-traumatic Stress Disorder, this study focused on changes in their depression and meaning in life after participating in a four-day river rafting experience. Results showed that there were statistically significant improvements over time for both depression scores and meaning in life scores. Results also indicated a weak statistically significant, negative association between depression and presence of meaning in life. The study’s results are useful for practitioners who may be considering nature-based programs for their clients, as well as researchers seeking to better understand the psychological health benefits of river rafting.

Helping people and planet: Clinical psychology in a time of climate change

Article

Oct 2021

Joe Rehling

Drawing on recent qualitative research, this paper argues that increasing access to small-group, nature-based, ecologically-protective activities (i.e. green prescribing) constitutes the most direct and effective way for clinical psychology to help planet and people in a time of climate change.

The Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Program: A Responsive Mixed-Methods Protocol for Evaluating a Multi-site Agricultural Pilot Program (Preprint)

Article

Full-text available

Jun 2022

Background Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes. Objective The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs. Methods This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program’s content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran’s entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans’ experiences, and short-term participation outcomes. Results Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022. Conclusions This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs. International Registered Report Identifier (IRRID) DERR1-10.2196/40496

Handbuch zur Entwicklung von zertifizierten Kur-und Heilwäldern in Bayern

Technical Report

Full-text available

Jul 2022

Die Ergebnisse eines dreijährigen Forschungsprojekts wurden in einem deutschsprachigen Handbuch zusammengefasst, um die strukturellen Anforderungen an Wälder für Prävention (Kurwald) und Therapie (Heilwald) zu definieren. Neben der Literaturrecherche wurden in 15 Regionen Ortsbegehungen in verschiedenen Wäldern Bayerns, Deutschland, durchgeführt, um die Qualität des Waldes zu beurteilen. Ebenfalls wurde ein Kriterienkatalog und ein Screening-Tool zur Bewertung der Waldstruktur für Gesundheitsinterventionen (präventive und therapeutische Maßnahmen) entwickelt sowie eine professionelle Weiterbildung für ein Wald-Gesundheitstraining bzw. Waldtherapie durchgeführt. Nun kann jede Gemeinde, jeder Waldbesitzer oder jede Gesundheitseinrichtung in der Nähe eines Waldes den Ausweisungsprozess für einen Kur- oder Heilwald in Bayern starten. The results of a three-year research project were summarized in a German-language manual to define the structural requirements of forests for prevention (Kurwald or recreational forest) and therapy (Heilwald or therapy forest). In addition to the literature reviews, site visits were conducted in 15 regions in various forests in Bavaria, Germany, to assess the quality of the forest. Also, a criteria catalog and a screening tool for assessing forest structure for health interventions (preventive and therapeutic measures) were developed, and professional training for forest health training or forest therapy was conducted. Now, any community, forest owner or health facility near a forest can start the designation process for a recreational or therapy forest in Bavaria.

Development of the nature-based therapy concept for patients with stress-related illness at the Danish Healing Forest Garden Nacadia

Article

Full-text available

Jan 2010

Horticultural Therapy: A Pilot Study on Modulating Cortisol Levels and Indices of Substance Craving, Posttraumatic Stress Disorder, Depression, and Quality of Life in Veterans.

Article

Full-text available

Jul 2015
Alternative Ther Health Med

Context • Horticultural therapy (HT) is a subgroup of occupational therapy (OT). Both HT and OT have been successful as adjunctive treatment modalities in substance abuse treatment. Studies have indicated that gardening promotes neuroendocrine and affective restoration from stress. Objectives • The study intended to assess the effect of HT versus nonhorticultural OT on cortisol levels, depression, symptoms of posttraumatic stress disorder (PTSD), alcohol cravings, and quality of life. Methods • The research team designed a randomized pilot study. Setting • The study was open for participation from July 2012-October 2012. It took place during multiple occurrences of a 28-d treatment programs for substance use disorder at a Veterans Affairs medical center. Participants • Participants were 49 veterans, averaging 46.4 y old (SD = 11.9); the dropout rate was 37%. Intervention • Participants were randomly assigned to the HT or the OT group. They attended supervised HT and OT groups 5 h/d for 3 wk. Outcome Measures • Pre- and posttreatment, participants completed the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), the Alcohol Craving Questionnaire (ACQ-NOW), the Posttraumatic Stress Disorder Checklist Civilian Version (PCLC), and the Center for Epidemiologic Studies Depression Scale (CES-D). Salivary cortisol samples were taken at wk 1, 2, and 3. Results • A repeated measures analysis of variance (ANOVA) (F2,20 = 0.878) revealed that the HT performed was associated with a 12% reduction in salivary cortisol levels from wk 1 to wk 3, but the difference was not statistically significant (P = .43). Separate 1-way analyses of covariance (ANCOVAs) revealed no statistically significant differences in the self-administered tests, although both the Q-LES-Q-SF and CES-D showed a trend toward improving quality of life and depressive symptoms in the HT group compared with the OT group. Additional analysis of the nonbiologic tests suggests that most participants in the HT and OT had some benefit from the programmed activities. Conclusions • The trends suggest that HT may modulate stress in veterans, as evidenced by decreased cortisol levels and depressive symptoms, and may improve quality of life more than the programs in which the OT group participated. Further investigation with larger samples, including a nontreatment control group, is needed to determine whether the observed trends are treatment effects or due to abstinence.

A Randomized Clinical Trial of Group Cognitive Processing Therapy Compared With Group Present-Centered Therapy for PTSD Among Active Duty Military Personnel

Article

Full-text available

May 2015

To determine whether group therapy improves symptoms of posttraumatic stress disorder (PTSD), this randomized clinical trial compared efficacy of group cognitive processing therapy (cognitive only version; CPT-C) with group present-centered therapy (PCT) for active duty military personnel. Patients attended 90-min groups twice weekly for 6 weeks at Fort Hood, Texas. Independent assessments were administered at baseline, weekly before sessions, and 2 weeks, 6 months, and 12 months posttreatment. A total of 108 service members (100 men, 8 women) were randomized. Inclusion criteria included PTSD following military deployment and medication stability. Exclusion criteria included suicidal/homicidal intent or other severe mental disorders requiring immediate treatment. Follow-up assessments were administered regardless of treatment completion. Primary outcome measures were the PTSD Checklist (Stressor Specific Version; PCL-S) and Beck Depression Inventory-II. The Posttraumatic Stress Symptom Interview (PSS-1) was a secondary measure. Both treatments resulted in large reductions in PTSD severity, but improvement was greater in CPT-C. CPT-C also reduced depression, with gains remaining during follow-up. In PCT, depression only improved between baseline and before Session 1. There were few adverse events associated with either treatment. Both CPT-C and PCT were tolerated well and reduced PTSD symptoms in group format, but only CPT-C improved depression. This study has public policy implications because of the number of active military needing PTSD treatment, and demonstrates that group format of treatment of PTSD results in significant improvement and is well tolerated. Group therapy may an important format in settings in which therapists are limited. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Effectiveness of Group-Delivered Cognitive Therapy and Treatment Length in Women Veterans with PTSD

Article

Full-text available

Mar 2014

The effectiveness and length of group-delivered cognitive treatment for Posttraumatic Stress Disorder (PTSD) was examined in a sample of women veterans. The sample included 271 primarily non-Hispanic white (61%) and Hispanic (25%) women veterans treated in 8-, 10-, or 12-group length sessions with manualized cognitive therapy for PTSD. Outcome was measured with the PTSD Symptom Checklist (PCL) in an intention-to-treat analysis (N = 271), in completer subjects (n = 172), and with group as the unit of analysis (n = 47 groups). Significant decreases in PTSD were found in the full sample (effect size [ES] range = 0.27 to 0.38), completers (ES range = 0.37 to 0.54), and group as the unit of analysis (ES range = 0.71 to 0.92), suggesting effectiveness of cognitive group treatment for PTSD. PCL scores significantly improved in the 8, 10, and 12 group lengths, with no differences between each. Clinical improvement showed a third decreasing 10 or more PCL points and 22% no longer meeting PTSD diagnostic criteria, with the best results in the 10-session group. The results suggest group-delivered cognitive therapy is an effective, efficient, time-limited treatment for PTSD.

AN EVALUATION OF THE GARDENING LEAVE PROJECT FOR EX-MILITARY PERSONNEL WITH PTSD AND OTHER COMBAT RELATED MENTAL HEALTH PROBLEMS

Article

Full-text available

Jacqueline M Atkinson

An evaluation of the Gardening Leave project for ex-military personnel with PTSD and other combat related mental health problems.

Peer Outdoor Support Therapy (POST) for Australian Contemporary Veterans: A Review of the Literature

Article

Mar 2014

Kendall Bird

Peer outdoor support therapy (POST) is one approach utilised in Canada, the United States and the United Kingdom to address mental illness and distress amongst contemporary veterans. In the current paper several areas of veteran psychological therapeutic treatment are reviewed. Current standard practice and research studies for therapist-led treatments from Australia are summarised and critiqued and placed within the literature context examining military and veteran unique needs and challenges to treatment including responsiveness, reluctance and retention. Research review results regarding peer support interventions and outdoor therapy interventions for non-veteran and contemporary veteran populations are outlined, alongside an overview of known POST programs for veterans. The implications of the reviewed literature and research are discussed, particularly the need for further research into the role outdoor peer support may play for the Australian veteran population alongside other veteran mental health services.

Whatever happened to the soldiers? Nature-assisted therapies for veterans diagnosed with post-traumatic stress disorder: A literature review

Article

Apr 2015

Tanielian, T. & Jaycox, L.H. (Eds.) (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND MG-720.

Book

Jan 2008

Lisa Jaycox

PTSD Treatment for Soldiers After Combat Deployment: Low Utilization of Mental Health Care and Reasons for Dropout

Article

May 2014
PSYCHIAT SERV

Objective: Limited data exist on the adequacy of treatment for posttraumatic stress disorder (PTSD) after combat deployment. This study assessed the percentage of soldiers in need of PTSD treatment, the percentage receiving minimally adequate care, and reasons for dropping out of care. Methods: Data came from two sources: a population-based cohort of 45,462 soldiers who completed the Post-Deployment Health Assessment and a cross-sectional survey of 2,420 infantry soldiers after returning from Afghanistan (75% response rate). Results: Of 4,674 cohort soldiers referred to mental health care at a military treatment facility, 75% followed up with this referral. However, of 2,230 soldiers who received a PTSD diagnosis within 90 days of return from Afghanistan, 22% had only one mental health care visit and 41% received minimally adequate care (eight or more encounters in 12 months). Of 229 surveyed soldiers who screened positive for PTSD (PTSD Checklist score ≥50), 48% reported receiving mental health treatment in the prior six months at any health care facility. Of those receiving treatment, the median number of visits in six months was four; 22% had only one visit, 52% received minimally adequate care (four or more visits in six months), and 24% dropped out of care. Reported reasons for dropout included soldiers feeling they could handle problems on their own, work interference, insufficient time with the mental health professional, stigma, treatment ineffectiveness, confidentiality concerns, or discomfort with how the professional interacted. Conclusions: Treatment reach for PTSD after deployment remains low to moderate, with a high percentage of soldiers not accessing care or not receiving adequate treatment. This study represents a call to action to validate interventions to improve treatment engagement and retention.

Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: A randomized control trial

Article

Mar 2013

Chronic combat-related posttraumatic stress disorder (CR-PTSD) is a condition with many treatment barriers. Nature Adventure Rehabilitation (NAR) as a second line or as a supplemental intervention has the potential to overcome some of these barriers and incorporate aspects of successful treatment modalities for PTSD within an experiential learning paradigm. In a pre-post controlled trial, CR-PTSD veterans (n=22) underwent a 1-year NAR intervention compared to a waiting list (WL) control group (n=20). Posttraumatic symptoms (PTS), depression, functional problems, quality of life, perceived control over illness (PCI) and hope were measured by self report measures. PTS, emotional and social quality of life, PCI, hope and functioning improved significantly. Change in PTS was contingent upon change in PCI. The current study is the first to present NAR as a promising supplemental intervention for chronic CR-PTSD. NAR seems to work through a process of behavioral activation, desensitization, gradual exposure to anxiety evoking situations and gaining control over symptomatology.