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The Use of Complementary Therapy in Military Personnel with PTSD
Ashly Elias, Kechna Laurent, Kevin Mathew and Tess Cagenello
Table of Contents
Objectives: There is an alarming rate of PTSD in active military personnel and war veterans. In recent years, the use of complementary therapies has been utilized in addition to traditional treatment in aims of finding more ways to treat PTSD and decrease the symptoms. This integrative review describes emerging complementary interventions for PTSD and how they may potentially be beneficial to military personnel suffering from the disorder.
Methods: This integrative literature review followed the following stages: 1) problem identification 2) literature search 3) data evaluation 4) data analysis and 5) results. Research was conducted using various evidence-based-databases. Ten articles met the inclusion criteria for this review.
Results: Yoga, meditation, pet, and, music therapy may all serve as complementary therapies to potentially decrease the severity of PTSD symptoms and improve the quality of life of military personnel
Conclusions: It important that military personnel and veterans receive the necessary care for the traumatic experiences they may have endured during combat. Providing complementary interventions to those with PTSD will allow soldiers and veterans a wide variety of treatments that may be individualized to their wants and needs, in addition to traditional services. These therapies may not substitute standard care but may act as an additional form of treatment that aims to decrease the symptoms of PTSD while improving the overall quality of life.
Scope of the problem. With the many physical wounds active military personnel return with after war, there is one hidden wound that continues to haunt their minds. According to the United States Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder [USDVA] (2010), posttraumatic stress disorder (PTSD) is identified as an anxiety disorder that develops after experiencing or witnessing a traumatic event. The USDVA (2015) reports that the National Comorbidity Survey Replication, conducted between 2001 and 2003, estimated a lifetime prevalence of PTSD amongst Americans is estimated to be 6.8%. Currently, there are veterans from World War II, the Korean War, the Vietnam War, the Gulf War and Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) suffering from PTSD in the U.S. The estimated lifetime prevalence of PTSD amongst Vietnam veterans estimated 30.9% for men and 26.9% for women. Eleven to 20 out of every 100 veterans in OIF and OEF are being diagnosed with PTSD in a given year, which is becoming a growing issue in the veteran and active military population (USDVA, 2015).
Population. There are currently 21, 369, 602 veterans living in the United States according to the U.S. Census Bureau 2009-2013 American Community Survey. Females comprise 7.3% of this population. The unemployment rate for veterans is currently 5.3% nationally, and the number of homeless veterans in the U.S. is estimated to be 49,865. Currently, 6.0% of the veteran population in the U.S. is uninsured and 16.4% have a service connected disability. Nearly 30% of the population uses VA Health Care. When looking at the period of service, 11.5% served in the second Gulf War, 12.1% served in the first Gulf War, 33.4% of veterans served in the Vietnam War, 10.3% of veterans served in the Korean War and 7.8% of veterans are from World War II (USDVA, 2015). There are 1,356 Department of Veterans Affairs facilities throughout the country. The majority of veterans in the U.S. are 65 years old and older, at 43.7%, with ages 55 to 64 years being the second highest range of veteran age, with a percentage of 23.1% (USDVA, 2015). The median household income of veterans is $61,884 nationally. When looking at the period of service, 11.5% served in the second Gulf War, 12.1% served in the first Gulf War, 33.4% of veterans served in the Vietnam War, 10.3% of veterans served in the Korean War and 7.8% of veterans are from World War II. In relation to educational attainment, 26% hold a bachelor’s degree or higher and 4.5% are enrolled in college (USDVA, 2015).
Etiology. Posttraumatic stress disorder is a condition that affects the psychic-emotional system of the body (Piotrowski & Range, 2016). It is caused by experiencing a trauma or stress related event that may include direct or indirect exposure to near death, sexual assault and violence, or serious injury. Vieweg et al. (2006) states that after experiencing trauma, there are three dimensions of PTSD that occur. This includes re-experiencing the traumatic experience with intrusive memories, dreams, flashbacks and physical distress of the event, persistent avoidance of the cause of trauma, and increased arousal. PTSD is driven by pathological changes in the amygdala and the hippocampus. As for treatment, various methods are utilized to relieve PTSD symptoms, such as non-pharmacological therapies and pharmacological therapies (Vieweg et. al., 2006).
Physical, mental and social impact. PTSD has a lasting effect physically on those who experience it. Pacella, Hruska and Delahanty (2013) note that PTSD is a failure to adapt to stressors in which long-term activation of pathways in the brain, such as the hypothalamic-pituitary-adrenal (HPA Axis) place individuals at risk for developing certain medical issues. Goldberg et al. (2014) found that PTSD was linked to decreased health functioning and increased disability amongst veterans from the Vietnam War. The decrease in function included facets of physical and mental health. PTSD and comorbidity of other illnesses are often common with these individuals. Angkaw et al. (2015) identified alcohol use as a disorder that is comorbid to PTSD. The authors have found that PTSD symptoms are associated with decreased mental health related quality of life, facilitated by alcohol related consequences.
There is much social stigma in the veteran culture in regards to PTSD. Many studies offer insight on how veterans with mental health issues are perceived in the military and their own perceptions of having mental health illnesses. Hipes, Lucas and Kleykamp (2015) found that in their study with veterans, there was a status advantage of being in the military but status disadvantage associated with having been deployed and being afflicted with PTSD. Mittal et al. (2013) also conducted a study on how treatment-seeking veterans perceived themselves being diagnosed with PTSD. The authors found that the veterans believed that the public stigmatizes them for having PTSD. The veterans also perceived that the public labels them with stereotypes such as “dangerous or violent” or “crazy”. This condition and terms affect a veteran’s entire life and family. Suffering from these conditions can also impair relationships, disrupt marriages, aggravate the difficulties of parenting, and cause problems in children that may extend the consequences of combat experiences across generations (Tanielian & Jaycox, 2008). If veterans do not receive interventions and help from society, their PTSD can easily be exacerbated in many ways. Aggressive individuals behave in ways that beget aggressive responses, and withdrawn individuals behave in ways that exacerbate their isolation. As a result of this form of continuity, the interpersonal relationships of both types of individuals tend to suffer and become worse over time (Tanielian & Jaycox, 2008).
Economic consequences. Active military personnel and veterans suffering from PTSD face financial burdens as a result of the disorder and associated mental consequences. In the span of two years, post-service, active military personnel and veterans are projected to lose thousands of dollars. When excluding the cost of lives to suicide, active military personnel and veterans are estimated to spend around $5,900 a year as a result of PTSD (Tanielian & Jaycox, 2008). However, removing the exclusion criteria of suicide for this population is projected expenses brings losses to an estimated $10,298 a year (Tanielian & Jaycox, 2008). While caring for veterans, the health care system is economically strained as well. During 2004 through 2009, the Congressional Budget Office (CBO) estimated that the veterans’ health administration (VHA) spent as much as $1.4 billion in a five-year span, on veterans with PTSD (Bass & Golding, 2012).
Current treatments. In the active military personnel and veteran population, post-traumatic stress disorder differs in comparison to civilian PTSD. For active military personnel and veterans with PTSD, maladaptive physiological arousal occurs due to a continuous state of hyperactivity needed for survival in combat (Chemtob et al., 1997). Due to the unique presentation of PTSD in active military personnel and veterans, current treatments for PTSD include cognitive processing therapy (CPT) and pharmacological approaches.
The basis for using CPT stems from implications in the emotional processing theory associated with PTSD. In this theory, PTSD is assumed to arise from the creation of fear networks in memory that cause irrational tendencies of escaping and avoiding behavior (Resick, Nishith, Weaver, Astin, & Feuer, 2006). Such fear networks can be activated by numerous stimuli associated with the trauma and resultantly cause ill behaviors associated with PTSD (Resick et al., 2006).
CPT works by manipulating stimuli associated with trauma leading to PTSD. The traumatic memories associated with the trauma are repetitively exposed to the patient in a safe environment (Resick et al., 2006). According to the emotional processing theory, this intervention will help patients decrease their response to stimulating triggers of trauma and cause long term positive modification of their fear networks (Resick et al., 2006).
Pharmacological therapy works on the basis of ameliorating the biological determinants of PTSD. According to the U.S Department of Veterans Affairs (2016), the biological determinants in PTSD have been noted to be a “dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and the balance between excitatory and inhibitory brain neurocircuitry” (USDVA, 2016, para. 6). Consequently, patients with PTSD have a dysregulation of the adrenergic mechanism that controls the flight or fight response (USDVA, 2016).
By understanding the dysfunctional biological determinants of PTSD, researchers have identified a specific class of drugs that are effective when treating PTSD symptomology. Current supporting evidence for pharmacological treatment of PTSD symptomology is for selective serotonin reuptake inhibitors (SSRI’s). SSRI’s are effective for PTSD patients because they modify deficient levels of amygdala serotonin transport (5-HTT), an inhibitory neurotransmitter (USDVA, 2016). Deficiencies of 5-HTT have been found to evoke panic attacks and trauma related flashbacks in PTSD patients (Murrough et al., 2011). Therefore, use of SSRIs to increase levels of amygdala serotonin transport is beneficial to control excitatory symptoms in PTSD patients.
Both CPT and pharmacological therapy have been found to be useful treatments for PTSD patients. However, many war veterans do not attain sufficient relief from solely using traditional therapies. Such an instance was noted after the Israeli Defense Forces Medical Corps caused poorer PTSD symptom outcomes for war veterans undergoing CPT based exposure to a feared stimulus (Solomon et al., 1992). Consequently, the use of complementary therapies for veterans with PTSD may be viable treatment options for individuals still experiencing symptoms despite traditional treatment. Examples of such therapies include music therapy, yoga/meditation therapy, and pet therapy.
During the years of 1914-1918, the term “shell shock” was frequently used and was seen as a major medical issue that affected the frontline troops in World War I. “Shell shock”, more commonly known today as post-traumatic stress disorder (PTSD) was coined by active military personnel and veterans because they were viewed to be reactions of artillery shells (Friedman, 2015a). Shell shock was originally thought to be the result of brain damage due to loud explosions and gun impact. When more active military personnel and veterans who had not been near explosions began exhibiting similar symptoms, that theory quickly changed (Friedman, 2015a). With the attempt to understand and identify this disorder the term “war neuroses” was also used. Initial treatments during World War I for this condition varied. Hydrotherapy, electrotherapy, and hypnosis were used in European hospitals due to the lack of knowledge and expertise about the condition (Friedman, 2015a).
The British army doctors found great difficulty attempting to treat this condition. Active military personnel and veterans coined the term and described the phenomenon as a disorder including symptoms of fatigue, confusion, tremor, vision and sight impairment, as well as nightmares (Jones, 2012). When doctors found no other diagnosis, shell shock was the term used as a diagnosis (Jones, 2012). Charles S. Myers, a psychologist appointed by the British army served as a consulting psychologist to the British Expeditionary Force to offer expertise and gather data for future policy to address war-induced psychiatric issues (Jones, 2012). Myers’s first case was described as exhibiting symptoms such as tremors, loss of balance, loss of hearing and sight, and fatigue. It was described to be a psychological condition with symptoms that were manifestations of repressed trauma (Jones, 2012). Myers along with another psychologist of medical background, William McDougall, strongly suggested that shell shock could be cured with cognitive and affective reintegration. These two psychologists believed active military personnel and veterans repressed traumatic events and with multiple therapy sessions, active military personnel and veterans can learn to revive and integrate these painful memories into consciousness in order to be healed. During this time, those who supported this theory were greatly criticized. Many people stated they believed the active military personnel and veterans who did experience shell shock were cowards or malingering (Jones, 2012). During World War I and in the early years after the war, psychologists such as Myers fought for the increase in treatment for active military personnel and veterans who appeared to be suffering from “shell shock” (Jones, 2012).
Shell shock was replaced with the term Combat Stress Reaction (CSR) during World War II. This was also considered “battle fatigue” by some. Many of the WW II discharges were said to be because of combat exhaustion (Friedman, 2015a). In 1952, the American Psychiatric Association produced a Diagnostic and Statistical Manual of Mental Disorders (DSM-I). The flaw that was found with this diagnosis was that if symptoms were present after six months, another diagnosis was required (Friedman, 2015a). After years of continuous revision, DSM-I added Post Traumatic Stress Disorder to the third edition, DSM III, which stemmed from research during the Holocaust, sexual assault victims, and Vietnam War veterans (Friedman, 2015a). With continuous research and advancements, DSM-5 has been created to accommodate the various mental disorders. The major change made to DSM-5 states that PTSD is no longer considered an anxiety disorder but now associated with mood states such as depression. PTSD is now categorized under the Trauma-and Stressor-Related Disorder category (Friedman, 2015b). PTSD is now only diagnosed if the following four symptoms are present for at least a month and impair daily functioning: reliving the traumatic event, avoiding situations that may cause one to recall the event, negative feelings, and hyperarousal (Friedman, 2015b).
Since the early signs of PTSD, psychologists and medical experts have studied and researched various cases and symptoms to better understand the condition. According to Friedman (2015a), neurobiological research has indicated that PTSD may be associated with stable neurobiological alternations in the autonomic and central nervous systems. Brain imaging has suggested that excessive amygdala activity and reduced prefrontal cortex and hippocampus activity is noticed in PTSD (as cited in Friedman, 2015a).
With continuous research, PTSD has been treated with pharmacotherapy and psychotherapy. However, due to the large and growing number of active military personnel and veterans, more complementary therapies have been sought after to provide active military personnel and veterans with various options to treat PTSD. With over 2 million troops sent to Iraq and Afghanistan since 2001, it is important that these active military personnel and other U.S. war veterans receive appropriate care and treatment (Tuerk, Steenkamp, & Rauch, 2010). In the United States, pet therapy began in 1919 at St. Elizabeth Hospital in Washington, D.C. Secretary of the Interior, F.K. Lane, suggested dogs can serve as companions for those in psychiatric units (The Health Benefits of Pets, 1987). In the early 1940s, in an Army Corps Convalescent Hospital located in New York, patients were encouraged to work with animals at a farm associated with the hospital. After World War II, increasing efforts were made to incorporate animals in outpatient psychotherapy (“The Health Benefits of Pets”, 1987) The use of complementary therapy continued to expand into various intervention during the late 1990s and early 2000s. In 2010, a pilot study was created on the effects of music therapy of veterans with significant PTSD symptoms in which many participants were returning from Iraq and Afghanistan. Positive results from this experiment created a growing area of study on the potential positive effects of music therapy on veterans diagnosed with PTSD (“Music Therapy Program”, 2014). Newer therapies, such as yoga and meditation have become more prevalent in aims to provide active military personnel and veterans suffering from PTSD additional options that better suit their needs. Pilot studies in 2013, focused on the benefits of yoga and relaxation in this specific population (Staples, Hamilton, & Uddo, 2013). With increasing research and empirical evidence, complementary therapies are progressing and being used more widespread in the United States.
Levine’s 1997 Theory of Pendulation is used to describe the complex concept of treatment of PTSD using music as therapy. Levine describes pendulation as a process similar to the movement of a pendulum where a person moves between a moment of solitude, safety, and comfort, to a painful and uncomfortable space (Bensimon, Amir, & Wolf, 2012). These two opposite spectrums can be considered the healing vortex and the trauma vortex (Bensimon et.al., 2012). Pendulation refers to the victim’s experience and the autonomic nervous system’s response to move between sympathetic and parasympathetic modes in optimal balance (Bensimon e.al., 2012). In Levine’s theory, the body is a container for traumatic events. When pendulation occurs in a safe environment that promotes healing, such as therapy, pendulation occurs in an activating and calming sequence. When dealing with an episode properly, the nervous system will eventually remain in the parasympathetic state (Bensimon, et al., 2012). The pendulum process is one that is stated to be a healthy strategy that promotes healing and recovery. The exposure to traumatic thoughts and sensation frequently provides for a type of habitual response, which will eventually not require a sympathetic response from the body (Bensimon et al., 2012).
Another theory related to post traumatic stress disorder is Foa and Rothbaum’s Emotional Processing Theory that discusses the relationship between PTSD and knowledge available prior, during, and after trauma. Foa and Rothbaum proposed the idea that one’s vulnerability to PTSD was impacted by views previous to the trauma. Those with rigid pre-trauma views would be more vulnerable to PTSD (as cited in Brewin & Holmes, 2003). Emotional processing theory states, those with a prior sense of safety faced a distorted view after the trauma, whereas those with negative prior views toward competency and safety will have confirmed views after the traumatic event (as cited in Brewin & Holmes, 2003).
Foa and Rothbaum also discuss seven mechanisms that are involved in the exposure treatment of PTSD. Exposure treatment therapy is a method associated with emotional processing theory and has shown effectiveness (as cited in Brewin & Holmes, 2003). The first mechanism stated that reliving the trauma should promote habituation of fear, which in turn reduces fear and anxiety levels (as cited in Brewin & Holmes, 2003). In exposure treatment, the trauma memory is prevented from being negatively reinforced. The third mechanism involved states that re-experiencing the trauma memory in an environment that supports the patient incorporates safety information into the traumatic experience (as cited in Brewin & Holmes, 2003). The fourth mechanism states that the trauma memory can be better individualized from other events and the patient will be able to recognize and isolate the trauma. Additionally, the treatment provides an opportunity for the patient to experience a sense of courage in being able to face the traumatic experience (as cited in Brewin & Holmes, 2003). The sixth mechanism involved in exposure treatment states that the patient may be able to reject previous negative evaluations as being inconsistent with the evidence of the matter. The last mechanism states that out-of-body experiences may exist and dissociative states may occur due to the traumatic experience (as cited in Brewin & Holmes, 2003). Exposure treatment utilized in emotional processing theory is stated to have varying effects such a reduction in anxiety and alterations in memory structures (as cited in Brewin & Holmes, 2003).
Streeter, Gerbarq, Saper, Ciraulo, and Brown (2012), proposed a theory that explains the relation between the use of complementary therapy, specifically yoga, and its impact on PTSD symptoms. Yoga practices, which are geared toward self-understanding, self-regulation, and healing have been shown to increase an inhibitory neurotransmitter gamma amino butyric acid (GABA) in the body. With the implementation of yogic exercises, the underactivity of the GABA system and the peripheral nervous system are corrected through the stimulation of the vagus nerves. This is relevant to those suffering from PTSD, due to the low activity levels of the GABA system commonly found in those diagnosed with depression, anxiety and PTSD. Through this proposed theory, those with stress related disorders such as PTSD can fully engage themselves in yoga rituals to decrease depression, anxiety, and other related symptoms (Streeter et al., 2012).
Significance to Nursing
Post-traumatic stress disorder is significant to nursing because of the high active military personnel and veteran population that are diagnosed with PTSD in the United States. Approximately 11% of those deployed to Afghanistan and 20% of those deployed to Iraq return from their deployment with posttraumatic stress disorder (USVDA, National Center for Posttraumatic Disorder, 2015). Such high PTSD diagnoses place active military personnel and veterans in vulnerable positions. Vulnerability, or the susceptibility to harm, results from an interaction between resources available to individuals and communities (Mechanic & Tanner, 2007).
Specifically, having a diagnosis of PTSD puts active military personnel and veterans in vulnerable positions because of the stigma associated with having a mental illness. Often, individuals dealing with mental illness are stigmatized through discrimination and prejudice (Corrigan, Druss, & Perlick, 2014). Therefore, the fear of being stigmatized causes active military personnel and veterans to often avoid empirically supported treatments associated with mental illness. In fact, studies have demonstrated up to 50% dropout rate and non-response rate for empirically supported treatments amongst patients with mental illness (Schottenbauer et al., 2008).
By not being treated appropriately, active military personnel and veterans face debilitating symptoms associated with PTSD and are left susceptible to harm. Therefore, the ANA code of ethics calls for nurses to advocate for patient rights (Rossetti, 2005). In regards to active military personnel and veterans with PTSD, nurses have an obligation as patient advocates to provide the most relevant health and social care (Choi, 2015). Since current treatments create a sense of stigmatization for active military personnel and veterans with PTSD, nurses must therefore be knowledgeable about complementary therapies such as music therapy, meditation/yoga therapy, and pet therapy. Providing active military personnel and veterans with complementary PTSD treatment without stigmatization may support adherence to treatment and therefore lead to positive patient outcomes.
Purpose and Research Questions
The purpose of this paper is to investigate whether the use of complementary therapies can improve outcomes for active military personnel and veterans with PTSD. By reviewing relevant literature on this topic, the following research questions may be answered:
For active military personnel and veterans, does the use of music therapy, yoga, meditation, or pet therapy reduce the symptoms of posttraumatic stress disorder in active military personnel and veterans diagnosed with PTSD?
Due to the increasing number of active military personnel and veterans suffering from PTSD, it is necessary to view how current complementary therapies have an effect on the symptoms of PTSD. PTSD is a debilitating mental illness that interferes with many aspects of an individual’s life. There are various treatments and interventions that an individual with PTSD can undergo. Typically, treatment for PTSD consists of pharmacological interventions and cognitive processing therapy. However, it is essential to look at how non-pharmacological therapies affect the symptoms of PTSD.
In the following chapter, four types of complementary therapies are reviewed to see whether or not they have an effect on the symptoms of PTSD. These interventions include music therapy, pet therapy and yoga/meditation therapies. These therapies provide a complementary option as treatment for individuals with PTSD. An in-depth literature review relevant to the topic will be conducted to explore how these treatments in previous research have an impact on the symptoms of PTSD.
Post-Traumatic Stress Disorder (PTSD) is a disorder that develops after an individual experiences a frightening and disturbing event. This disorder can be life-altering and debilitating without the proper therapeutic interventions (“Post-Traumatic Stress Disorder”, 2016). One population that is extremely vulnerable to PTSD is military personnel. Witnessing death, dealing with injury, living in fear, and living through life-threatening circumstances are all risk factors soldiers may face during deployment (“Post-Traumatic Stress Disorder”, 2016). The prevalence of PTSD in active military personnel and veterans display alarming statistics. The National Vietnam Veterans Readjustment Study (NVVRS), that began in 1986, interviewed 3,016 American veterans who served in the armed forces during the Vietnam war. The results of this study stated 15.2% of males and 8.1% of females were diagnosed with PTSD. The estimated lifetime prevalence of PTSD associated with this specific sample was 30.9% for males and 26.9% for females (Kulka et al., 1990). This exemplifies how prevalent PTSD is amongst U.S. soldiers and veterans.
Living with PTSD can create dysfunction in the life of a soldier and veteran. Seeking treatment from a professional is necessary in order to properly live and cope with this disorder. Medication such as selective serotonin reuptake inhibitors have been prescribed to those battling the disorder in conjunction with psychotherapy interventions (PTSD: National Center for PTSD, 2016). Today, several clinical guidelines regarding psychotherapy are provided for the treatment of PTSD (Hamblen, Schnurr, Rosenberg, & Eftekhari, 2016). Cognitive Processing Therapy has been shown to be effective and serves its purpose by allowing the veteran or soldier to assess their feelings and find different ways to process their traumatic experience with the assistance and guidance of a healthcare professional (Hamblen et al., 2016).
Despite the effectiveness of psychotherapy and pharmacotherapy other complementary therapy options are still being explored in effort to provide soldiers, veterans, and other individuals diagnosed with PTSD, various treatment options that suit their individual needs (Hamblen et al., 2016). This literature review aims to continue to examine and explore the use of non-traditional and newly introduced complementary therapy for veterans and soldiers in the United States who are suffering from PTSD. This literature review will delve into complementary therapies and their effects on PTSD symptoms in United States veterans and soldiers. Examination of these non-pharmacological therapies was limited to music therapy, pet therapy, yoga and meditation therapy because these complementary methods are the most prevalent in the literature. This review intends to research these adjunctive methods and determine the impact or lack thereof on the symptoms of veterans and soldiers who were diagnosed with PTSD.
Search strategy. In order to understand the profound impact of non-pharmacological interventions on the symptoms of PTSD, an integrative review of literature was conducted using various databases. Articles were searched through the following databases: CINAHL, Science Direct, PsycINFO, PubMED, Medline, PsycNET. A diverse net of search terms was used to find literature pertaining to the topic. These included: PTSD, posttraumatic stress disorder, shell shock, combat stress disorder, veteran*, veterans, soldier*, soldiers, military, military personnel, active duty, therapy, complementary alternative therapy, non-pharmacological therapy, non-pharmacological interventions, auditory therapy, music therapy, pet therapy, animal-assisted therapy, animal assisted interventions, canine therapy, meditation, yoga, exercise, relaxation therapy, and mantra. The inclusion criteria for this topic included: participants and subjects who are current soldiers or veterans from any war deployed in the United States Army, participants or subjects ages 18 and over, participants and subjects that are suffering from PTSD due to war-related trauma, articles that discuss effects on symptoms of PTSD, articles that include music therapy, pet therapy, and yoga/meditation therapy, articles that have been published in the last twenty years (1986 to present), and articles that are published in English. The exclusion criteria include participants or subjects that have PTSD unrelated to war, participants or subjects under the age of 18 years, and articles published before the year 1986. After reviewing the articles with the desired inclusion and exclusion criteria, 10 articles were selected to use in the integrative literature review.
Data reduction, analysis, and synthesis. Initial articles which met the standards for inclusion and exclusion criteria were read and reread to understand the stated results of each research study. Information from the articles was then extracted onto data forms for critique and appraisal. Critiques of validity and reliability in studies were based on the research design employed for each study. Depending on the determined research design of an article, either a quantitative, qualitative or systematic review research critique was implemented using appraisal criteria as outlined in the research textbook (Schmidt & Brown, 2015). Based off findings, 10 articles met the criteria for acceptable validity and reliability of results.
Once the final articles were compiled, information from the articles was extracted for synthesis with the aid of charts. A summary chart of these 10 articles was constructed by the authors to better organize and understand presented data. Measurable criteria in the summary chart included: author(s); year, country; study purpose; type of research methodology; level of evidence; sample size and demographics; independent and dependent variables; key study findings; and the study strengths and limitations. A thematic chart was also created by identifying measurable patterns of PTSD symptoms studied throughout the 10 articles. Both the summary chart and thematic chart were then compared and contrasted to identify common relationships in data relating to the effects of nonpharmacological therapies on PTSD symptomology. Results accrued after constructively analyzing the data from the 10 articles will be discussed in this research paper.
Description of studies. This integrative review is based on information gathered from ten research articles. Seven quantitative studies were used (Oman & Bormann, 2015; Johnston, Minami, Greenwald, Reinhardt, & Khalsa, 2015; Rosenthal, Grosswald, Ross, & Rosenthal, 2011; Bormann, Thorp, Wetherell, Golshan, & Lang, 2013; Staples, Hamilton, & Uddo, 2013; Bormann, Liu, Thorp, & Lang, 2012; Stern et al., 2013) Two qualitative reviews were used (Bensimon, Amir, & Wolf, 2012; Bensimon, Amir, & Wolf, 2008) . Lastly, there was one systematic review used with a quantitative research method (O’Haire, Guérin, & Kirkham, 2015).
Two of the quantitative articles had randomized controlled trial experimental designs (Oman & Bormann, 2015; Bormann et al., 2013). Three of the quantitative articles had quasi-experimental designs (Johnston et al., 2015; Rosenthal et al., 2011; Staples et al., 2013). One of the quantitative articles had a retrospective design (Stern et al., 2013) Finally, the remaining quantitative article used a prospective intervention study design (Bormann et al.,2013). The two qualitative articles consisted of a general qualitative research study design (Bensimon et al., 2012) and a phenomenological approach (Bensimon et al., 2008). The systematic review used a total of 10 articles (O’Haire et al., 2016) ranging from 2004-2014 that met the inclusion criteria of experiencing trauma and receiving animal assisted therapy.
The sample sizes for the seven quantitative studies ranged from 5-140 soldiers/veterans. The sample sizes for the two qualitative studies both included 6 soldiers/veterans. Eight of the studies were from the United States while two of the studies were from Israel. Sample characteristics were similar throughout the majority of the studies and met the inclusion criteria as previously mentioned for this integrative review. Approximately 90% or more of the participants were males who had undergone combat related trauma. The ages of participants ranged from 22-64 years old.
Critical critique analysis. When appraising evidence, the American Association of Critical Care Nurses (ACCN) has developed a hierarchy system to grade the levels of evidence (Peterson et al., 2014). The purpose of this is to determine the quality of the evidence to ensure credibility of the evidence. The levels of evidence are rated in alphabetical order, with A being the highest level of evidence to M being the lowest level of evidence. Using this grading system, three articles used in this integrative review are rated B (Bormann et al., 2012; Bormann et al., 2013; Oman & Bormann, 2015), and seven articles were rated C (Bensimon et al., 2008; Bensimon et al., 2012; Johnston et al., 2015; O’Haire et al., 2015; Staples et al., 2013; Rosenthal et al., 2011; Stern, et al., 2013). With the majority of the articles rated at level C, probable threats to internal validity to these studies are present.
To measure the symptoms of PTSD, six of the studies used a version of the PTSD Checklist (PCL), either the military version (PCL-M) (Rosenthal et al., 2011; Stern, et al., 2013; Staples et al., 2013) or the civilian version (PCL-C) (Bormann et al., 2012; Bormann et al., 2013; Oman & Bormann, 2015), This checklist is a brief self-report screening tool that measures the level of PTSD symptom severity using 17 items that are scored from 1 (not at all) to 5 (extremely) (Ruggiero, Del Ben, Scotti & Rabalais, 2003). The PCL had Cronbach alpha scores of .94, .85, .85, and .87 for the PCL total, re-experiencing, avoidance and hyperarousal scores, respectively, indicating high reliability and internal consistency (Ruggiero et al., & 2003).
Three studies used the Clinician Administered PTSD Scale (CAPS), a different yet analogous instrument to the PCL, to assess PTSD symptoms (Johnston et al., 2015; Bormann et al., 2013; Oman & Bormann, 2015). It is administered by a clinician who rates 17 items from the instrument that is represented by the PTSD diagnosis criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (Weathers, Keane & Davidson, 2001). It examines PTSD symptoms as a whole, as well as, three subscales of PTSD symptoms, which include re-experiencing, avoidance and hyperarousal. Evidence from various studies show the CAPS to have high internal consistency as supported by Cronbach alpha scores that range from .80 to .90 for PTSD symptoms as a whole and for the three subscales (Weathers et al., 2001).
Three articles have assessed depression in participants using the Beck Depression Inventory II (O’Haire et al., 2015; Rosenthal et al., 2011; Stern, et al., 2013). This instrument was developed in 1972 by psychiatrist Aaron T. Beck in order to measure the presence and severity of depression in clients (Beck, Steer & Brown, 2015). It is a self-rating scale that contains twenty-one items corresponding to a symptom of depression. A score of 20-28 indicated moderate depression and a score of 29-63 indicates severe depression (Beck et al., 2015). High internal consistency of this instrument was demonstrated by a meta-analyses conducted by Huang and Chen (2015), with 52 studies using the BDI-II with Cronbach alpha scores ranging from .83 to .95.
When looking at the sampling method in these ten articles, three articles used purposive sampling (Bensimon et al., 2008; Bensimon et al., 2012; Stern et al., 2013). These articles were qualitative studies that recruited military personnel and veterans suffering from PTSD through clinician referrals. Six of studies used convenience sampling to recruit participants (Bormann et al., 2012; Bormann et al., 2013; Oman & Bormann, 2015; Johnston et al., 2015; Staples et al., 2013; Rosenthal et al., 2011). Johnston et al. (2015) and Staples et al. (2013) recruited veterans and military personnel through referral by a clinician. Bormann et al. (2012), Bormann et al. (2013), Oman & Bormann (2015) and Rosenthal et al. (2011) recruited participants via the media, flyers, brochures and presentations. The systemic review (O’Haire et al., 2015) obtained ten articles by searching databases, which included ERIC, HABRI Central, Medline, PILOTS, Proquest, PsycARTICLES, PsycINFO, and Scopus. However, out of these ten articles, only two studies used war veterans with PTSD.
The articles used in this integrative literature review have similar strengths and limitations. A small sample size was the most prevalent limitation amongst these studies (Bensimon et al., 2008; Bensimon et al., 2012; Stern et al., 2013; Johnston et al., 2015; Staples et al., 2013; Rosenthal et al., 2011). The sample sizes ranged from 5 to 30 participants, which can lead to a type II error and threats to internal validity. All of the articles had a high percentage of male participants in the sample, ranging from 83% to 100%, making the studies difficult to generalize the results to females. In terms of racial diversity, majority of the articles had equivalent numbers of Caucasian and African American participants. Many of the studies contained high attrition rates of 29% and over, causing threats to validity. It is unknown whether or not these participants that left the study had different characteristics then those who stayed in the study. These studies also did not conduct a follow up measure after the intervention was completed to evaluate the long term effects of these complementary therapies on PTSD.
When looking at the strengths, many of these studies used well-known instruments to measure PTSD, such as the PCL and the CAPS. These instruments demonstrate high internal consistency, validity, and reliability, as mentioned previously. Another strength to be noted is that these complementary therapies produced no adverse effects. The findings in many of the studies also suggest that these therapies had a positive effect on PTSD symptoms.
Meditation. Meditation is a calming activity, which requires a quiet mind and intense focus; it has been used as a complementary therapy for veterans with PTSD. In four articles, meditation therapy is used for researchers to measure if meditation can lower PTSD and increase quality of life.
The first article by Bormann et al. (2011) evaluated if increasing existential spiritual well-being (ESWB) and meditative prayer could reduce self-reported PTSD symptoms. Researchers used a randomized control design, with a control group of veterans receiving consistent therapy and an intervention group receiving meditation classes. The experimental group consisted of a total of 146 subjects who were recruited and then randomly assigned to the treatment and control group. The treatment group consisted of sixty-six male veterans who participated in six weeks of 90-minute meditation classes in addition to standard care. The control group received only standard care. Both the control and intervention groups were pretested and post-tested on posttraumatic stress symptoms as measured by a PTSD Checklist (PCL) and Functional Assessment of Chronic Illness Therapy–Spiritual Wellbeing (Bormann et al., 2011). Post-test findings indicated that one contributing mechanism that partially explains how the meditation intervention reduces PTSD symptom severity in veterans is by increasing levels of spiritual well-being (Bormann et al., 2011).
Over the 6-week group-based intervention period, there were significant improvements in the meditation group for self-reported PTSD symptoms. The posttest PCL showed an average decrease in self-reported PTSD symptoms, 6.3 (SD = 11.20) in the meditation group compared with 2.6 (SD = 7.16) in the control group (Bormann et al., 2011). Overall, the meditation was shown to increase experience of spiritual well-being increasing feelings of meaning, purpose in life, faith, and assurance (Bormann et al., 2011). This was statistically significant on the Functional Assessment of Chronic Illness Therapy–Spiritual Wellbeing test results because the meditation intervention to spirituality change was significant and positive (B=4.89, p<0.0001) showing increased feelings of spirituality (Bormann et al., 2011). It was established that spirituality was increased with meditation and PTSD symptoms were decreased with meditation. Then researchers examined if spirituality also had a significant effect on PCL symptoms (b=-0.46, p=. 001). However, once the effect of spirituality was controlled on the posttest scores on the PCL, the meditation intervention effect was no longer found to be significant (b= -1.57, p=. 344) indicating that spirituality mediates the effect of meditation on PCL symptoms (Bormann et al., 2011). These results indicate that spirituality is a catalyst for meditation; both are needed to reduce the symptoms. Meditation can be used in all areas of life, after being practiced frequently during stress-free or peaceful times; the repetition of a meditation may become a way to elicit the relaxation response rapidly (Bormann et al., 2011). A calming mechanism for the body interrupting the stress response upon encountering stressful events can reduce PSTD symptoms by having control over feelings.
This sense of control over feelings was also recognized in the second study when Rosenthal et al. (2011) researched if meditation could counteract the body’s response to PTSD through improved relaxation. Researchers knew that PTSD is associated with persistent symptoms of increased arousal and an exaggerated sympathetic response to stimuli (Rosenthal et al., 2011). Researchers used the uncontrolled pilot study to measure meditation’s effect on five veterans. The veterans meditated twice a day, for twenty minutes, for 12 weeks. The meditation training was followed up with a teacher who monitored experiences and ease of practice by way of a standard procedure for verification of correct practice. Bormann et al. (2011) study also encouraged at home practice, however, the sessions were not monitored. The effects of PTSD were measured with a baseline, eight week and twelve week assessment. These tests focused on efficacy of treatment, which was assessed using the Clinician Administered PTSD Scale (CAPS) for PTSD assessment and diagnosis for both military veteran and civilian trauma survivors. Secondary outcome measures were assessed using the PTSD Checklist—Military Version (PCL-M) (Rosenthal et al., 2011). Then to see if this meditation intervention improved veterans’ lives, The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), the Beck Depression Inventory (BDI), and the Clinical Global Impression-Severity (CGI-S), and Clinical Global Impression—Improvement (CGI-I) scale exams were used.
The assessments used in Rosenthal et al. (2011) study were self-rated, which allowed an honest reflection of the veterans’ feelings during the meditation. Positive results were obtained. All subjects improved on the primary outcome measure, as determined by the CAPS (mean change score, 31.4; p = 0.02). Significant improvements were also observed for 3 secondary outcome measures: CGI-S (mean change score, 1.60; p < 0.04;), Q-LES-Q (mean change score, -13.00; p < 0.01), and the (PCL-M) (mean change score, 24.00; p < 0.02; (Rosenthal et al., 2011). There were no follow-up measurements taken to assess if interventions had long-term effects. The study reported that meditation may bring veterans a sense of peace and increased spirituality to those who had a prior belief in a higher being. This association can help veterans focus on a positive concept, which can decrease hyperarousal, and other symptoms related to PTSD (Rosenthal et al., 2011).
In the third study, researchers Oman and Bormann (2015) studied how repetition, self-efficacy, and meditation are intertwined. This randomized control trial, with a pre and post-test, focused on meditating throughout daily life to interrupt unwanted thoughts and behaviors (Oman & Bormann, 2015). Researchers compared a 75 veteran control group that received consistent management counseling and a 71 veteran-meditation intervention group, which also received case management. The meditation intervention group chose a spiritual word to repeat throughout the day, during moments of stress and insomnia, for a period of six weeks. Oman and Bormann (2015) had both the control and meditation intervention veterans fill out pretest surveys week one and post intervention surveys week six, after receiving either the meditation intervention or management. Researchers stated that self-efficacy was tested by having veterans “Rate their ability to manage PTSD symptoms on a scale of 1–10”. One, showed symptoms very difficult to manage, 10, indicated symptoms easy to manage (Oman & Bormann, 2015). Multiple facets make up quality of life, so researchers used several tests to observe how meditation changed well-being in veterans. These tests included CAPS for diagnosing PTSD symptoms, PCL-C to assess PTSD symptoms, Brief Symptom Inventory (BSI-18) to test depression, mental health component summary SF-12 version 2 to test mental health, and spiritual well-being FACIT-SP to test spiritual well-being (Oman & Bormann, 2015).
Using hierarchical linear regression modeling, the authors found that self-efficacy to control PTSD symptoms increased significantly (p= .003) over the six-week treatment period compared to the TAU group. Meditation alone was found to significantly decrease CAPS score (p= .04), PTSD symptoms (PCL, p= .01), depression (BSI-18, p= .003) and increase mental health (SF-12 version 2, p= .009). Self-efficacy was found to significantly (p= .01- .009) mediate the relationship between the MRP intervention and the five well-being outcomes. Oman and Bormann’s (2015) results were significant and similar to Bormann et al.’s (2011) study, because meditated self-efficacy together with meditation lowered PTSD symptoms. All three studies showed that meditation and spirituality help with reduction in depression and PTSD symptoms. Results also reflected an improvement in overall mental health while the meditation intervention was used (Oman & Bormann, 2015). None of these studies followed up with veterans to conclude if these improvements were directly correlated to daily meditation or if some meditation could lead to an all-around improvement in physical health overtime (Oman & Bormann, 2015).
Consistently, in all four studies, medication was used in conjunction with the meditation intervention. In the fourth meditation article Bormann et al. (2013) studied the effects of veterans beginning medication and meditation simultaneously. In this prospective single blind randomized control study, researchers had a control group called TAU, which consisted of 70 veterans who received medication only. The meditation intervention group was called MRP TAU, and entailed 66 veterans who received both medication and meditation (Bormann et al., 2013). The meditation intervention consisted of six weekly 90-minute group meditation classes, which included writing portions and discussions of meditation and personal feelings regarding PTSD symptoms. Effectiveness of the meditation was measured using pre and post-tests. These examinations include CAPS, the BSI- 18 score to examine depression, SF-12 version 2 to test mental health and spiritual well-being was tested using FACIT-Sp. Additionally, the PCL was used, which is a brief self- report-screening instrument for the level of PTSD symptoms (Bormann et al., 2013).
The post-test showed, 24% of the MRP TAU meditation intervention subjects had reduced CAPS PTSD scores (p=. 05) (Bormann et al., 2013). Compared with the control group, only 12% of TAU post-test scores had reduced PTSD symptoms (Bormann et al., 2013). Researchers found that MRP TAU meditation intervention veterans also reported significant improvements in depression (BSI- 18, p= .0001), mental health status (SF-12 version 2, p= .04), existential spiritual well-being (FACIT-SP, p= .0001) and in symptoms of PTSD (PCL, p= .05) compared with TAU subjects. This study emphasized that the down time and quietness associated with meditation may facilitate veterans to learn to manage hyperarousal, thereby building self-efficacy for tolerating anxiety produced by confronting unwanted memories and feared situations and taking control over them (Bormann et al., 2013, p. 265). Once again, meditation was found to increase control over mental well-being by relaxing the body as a whole.
Overall, when adding meditation therapy into veterans’ treatment plans PTSD symptoms decreased and quality of life increase. The consistency in testing showed comparable results that made it easy to compare results and would make tests repeatable in the future. In no way is meditation a cure for PTSD; nevertheless, it is found to be helpful in controlling and lessening the symptoms.
Yoga therapy. The use of yoga therapy as a complementary therapy was evaluated for its impact on the symptoms of PTSD in active military personnel and veterans. Two articles used yoga as an intervention to evaluate its effects on PTSD symptoms, along with other psychosocial factors.
Johnston, Minami, Greenwald, Li and Khalsa (2015) evaluated the effects of yoga on posttraumatic stress disorder (PTSD) symptoms, resilience, and mindfulness in military personnel. The researchers used a single arm study with pre and post-tests, a form of quasi-experimental study. With this research design, they recruited twelve participants, 11 being male, that met their inclusion and exclusion criteria, and had them participate in the yoga intervention. The intervention included 90-minute group classes, two times a week, for 10 weeks (Johnston et al., 2015). Seventy-five percent of the participants attended at least ten classes during the intervention, with a mean attendance of 13.67, ranging from 3 to 18 of 20 classes that each participant attended (Johnston et al., 2015). Before the intervention began, participants had baseline tests on resilience as measured by the Resilience Scale, their PTSD symptoms as measured by the Clinician Administered PTSD Scale (CAPS), and mindfulness as measured by the Five-Facet Mindfulness Questionnaire (FFMQ), as well as posttests to measure the changes in these three variables. There was a clinically significant reduction in PTSD symptoms (t = 2.822, p = .009) with a 25% drop on CAPS score from baseline, along with reductions in the CAPS subscale scores for re-experiencing (t = 2.204, p = .030), avoidance (t = 1.999, p = .038) and hyperarousal (t = 3.086, p = .006) (Johnston et al., 2015). Prior to the yoga, the mean scores on CAPS indicated that the group was experiencing severe PTSD symptoms but by the end, the mean score on CAPS indicated that the group now scored in the moderate range. The Resilience Scale (RS) demonstrated an increase in resilience from baseline to post-intervention, however it was not considered statistically significant (t = - 1.220; p = .124) (Johnston et al., 2015). For mindfulness, the mean score also showed an increase from baseline, however it was not statistically significant (t = - 0.9500; p = .181) (Johnston et al., 2015).
Staples, Hamilton and Uddo (2013) examined the feasibility and effectiveness of a yoga program as an adjunctive therapy for veterans with military-related PTSD. The authors conducted a preliminary pilot study with the use of yoga postures with veterans from an outpatient VA PTSD population. The authors recruited twelve participants by referral from PTSD Clinical Team clinicians, of these ten were male. The yoga intervention was provided by three certified yoga instructors, and was conducted twice a week for one hour, for six weeks long, totaling twelve sessions (Staples et al., 2013). The mean session attendance was 10.5 (SD = 1.6). Baseline and post-intervention data were collected from the PTSD Checklist – military version (PCL-M), which assessed for the severity of PTSD symptoms, the Pittsburgh Sleep Quality Index (PSQI), which measured the quality of sleep, the State-Trait Anger Expression Inventory-2 (STAXI-2), which measured anger and the Outcome Questionnaire 45.2 (OQ-45.2), which measured quality of life (Staples et al., 2013).
The PCL-M yielded results that were not statistically significant, with the exception of the subscale hyperarousal (t = 2.92, p = 0.014). The PSQI only showed statistically significant improvements in its total score (t = 2.78, p = 0.020) and the subscale daytime dysfunction (t = 2.57, p = 0.026). There were no statistically significant improvements in the STAXI-2 or the OQ-45.2 total scores or subscales.
These findings differ from one another as Johnston et al. (2015) has shown greater reductions in PTSD symptoms that were clinically significant as opposed to only the hyperarousal subscale showing statistical significance in Staples et al. (2013).
Pet therapy. The use of pet therapy has been researched as a form of complementary therapy for veterans suffering from post-traumatic stress disorder. In the systematic literature review by O’Haire, Guerin, and Kirkham (2015), the use of animal assisted interventions was examined for those who experienced trauma including, those diagnosed with post-traumatic stress. Animal-assisted interventions are broadly defined in the review as any intervention that includes an animal during a therapeutic treatment (O’Haire et al., 2015). Ten studies qualified for inclusion and two studies focused specifically on war veterans with a prior diagnosis of PTSD. Participants were surveyed with standardized instruments or interviewed. The review found that veterans self-reported positive outcomes after experiencing an animal-assisted intervention (O’Haire et al., 2015). One study used in the systematic review written by Nevins et al., (2013) reported a war veteran found lasting changes at 12 weeks post AAI (-44% change). The veteran also reported increase in sleep duration that continued three months after the intervention was provided. When addressing quality of life, the case study reported increase in satisfaction with quality of life (+180% change) and increased resilience focused behaviors after the animal assisted intervention (35%) (as cited by O’Haire et al., 2015).
The second study written by Newton et al. (2014), as cited in the literature review, reported on six veterans who had service dogs. The review stated there were drops in the frequency of nightmares when living with a service dog as well as reduced fear of public spaces and less use of psychotropic medications (as cited in O’Haire et al., 2015). The review found that war veterans reported decreased PTSD symptoms and depression as well as an increase in outreach and social support (O’Haire et al., 2015). The research article by Stern et al. (2013) supports the findings that there is potential benefit in having a pet. Military veterans with PTSD were surveyed using various instruments and findings displayed that when using the Lexington Attachment to Pets Scale, the mean total score of the 30 participants was 81.8 with a mean score for each of the 23 individual items of 3.56 with 4 being the highest degree of attachment (Stern et al., 2013). Although no intervention was used, the participants’ response on the Dog Relationship Questionnaire survey reported that upon the arrival of their pet, they have experienced overall improvement (Stern et al., 2013). The scoring of the respondents was based on a Likert scale with 1 being strongly disagree and 5 being strongly agree. When assessing the results, the veterans reported feeling calmer and decreased feelings of irritability and anger. Participants reported feeling less worried about issues of safety for themselves and loved ones and also stated their feelings of self-worth also increased (Stern et al., 2013). Veterans also reported being less bothered by bad dreams or nightmares since having a dog, with a mean score of 3.03(1.07) (Stern et al., 2013). Participants did not, however, report being less bothered by memories or flashbacks of traumatic experiences, with a mean score of 2.87(1.07). (Stern et al., 2013). Stern et al. (2013) also assessed the PCL-M scores. The scores ranged from 35-85 with a mean score of 63.6 (SD=11.2). Results from the BD-II revealed moderate to a severe range of depression (M= 29.0, SD= 13.3). The were no pre and posttest to assess if there was a change in levels of depression. The BD-I II administered only assessed the current levels of depression in veterans with canines (Stern et al., 2013).
Although both the systematic review and research article reveal there is a lack of literature that supports the idea of animal assisted interventions as a complementary method of treating PTSD, both works suggest there is potential in the use of animal-assisted interventions for those dealing with traumatic stress. Canines may allow veterans to freely express emotions without the fear of judgment during human interaction (Stern et al., 2013). Short-term improvements in depression, PTSD symptoms, and anxiety were noted in participants after the animal- assisted interventions. Given the preliminary nature of the information, animal therapy is advised to be a complementary method and should not replace standard care (O’Haire et al., 2013).
Music therapy. Music therapy, in conjunction with traditional therapies, can be used as a safe bridge to examine and reduce the effects of traumatic events. To better understand the effects of music therapy, Bensimon, Amir, and Wolf (2012) explored the therapeutic process of group music therapy (GMT) and how it impacts young soldiers that suffer from post-traumatic stress disorder. Using a mixed method analysis, the authors asked six soldiers diagnosed with PTSD to participate in a 90-minute weekly session of music therapy over a 4-month period. Data were gathered though open-ended, in-depth interviews and recording with digital cameras (Bensimon et al., 2012). Originally there were nine men, 20-23 years old, who were diagnosed with PTSD who were involved in the study. These men, who shared their traumatic experiences during the study, also received psychotherapy in addition to music therapy (citation).
The music therapy sessions offered the soldiers opportunities to play wind, harmonic, percussion, and melodic instruments as a way to re-enact the trauma through sound. The music therapist, and the participants, sat in a circle where they were free to communicate and improvise music on instruments of their liking. The music therapist introduced relaxing music as an intervention about half way through the sessions (citation).
Qualitative analysis of the interviews and recordings revealed that over the length of the sessions, the participants talked less and less about their traumatic events and more about every day events. (Bensimon et al., 2012) During therapy, the participants provided positive feedback about GMT and its influence on their lives. The soldiers reported diminished feelings of shame, loneliness, depression, and enhanced feelings of belonging, togetherness, acceptance, intimacy, connectedness, optimism, hope, and general improvement in their well-being (Bensimon et al., 2012). Members of the group reported increased concentration, reduction in hallucinations, and a reduction in the consumption of antidepressants. Participants reported better organization in life and the ability to quit smoking (Bensimon et al., 2012).
Similar patterns regarding the influence of music therapy on traumatic events were further observed in a mixed method study by Bensimon, Amir, and Wolf (2008). Specifically, the researchers examined the therapeutic process of group drumming therapy and how it affects young soldiers that suffer from post-traumatic stress disorder. Subjects included six soldiers who experienced traumatic events and were diagnosed as suffering from PTSD. They were asked to participate in a 90-minute weekly session of music therapy over a 4-month period. Data were gathered though open-ended, in-depth interviews and recording with digital cameras (Bensimon et al., 2008). Nine soldiers with PTSD, ages 20-23 years old, were initially enrolled; however, six soldiers were only able to complete the trial. In addition to music therapy, subjects also received psychotherapy.
The music therapy sessions provided soldiers the opportunity for group drumming through the use of a Darbuka, Tabla, Indian drum, floor drum and two djembes in order to re-enact trauma through sound. The music therapist and the participants, sat in a circle where they were free to communicate and improvise music on instruments of their liking. Drumming and talking were spontaneously enacted during the first 75 minutes of each session, but the last 15 minutes of each session were spent listening to relaxing music.
Qualitative analysis of the interviews and recordings from subjects demonstrated positive feedback about group drumming and its uplifting effects. Soldiers reported new feelings of openness, togetherness, sharing closeness, connectedness and intimacy (Bensimon et al., 2015, p. 38). Participants noted how loud drumming provided an outlet for rage because it was an acceptable form of expression. Consequently, soldiers reported feelings of relief, satisfaction, and empowerment after drumming loudly (Bensimon et al., 2015, p. 44).
Overall, both studies on music therapy reported positive outcomes for soldiers who suffered from traumatic experiences and diagnosed with PTSD. Subjective reports from both studies concluded that soldiers had improved feelings of togetherness, connectedness/belonging, and intimacy after finishing sixteen 90-minute weekly music therapy sessions in a matter of 4 months.
This integrative review of the literature confirms that complementary therapies have the potential to positively impact war veterans and active military personnel diagnosed with PTSD. Complementary therapies, specifically, meditation, yoga, pet, and music therapy were researched and this integrative review supports the effectiveness of these interventions. Stress is believed to induce a decrease in the parasympathetic nervous system while increasing the activity of the sympathetic nervous system. This overall imbalance in the autonomic nervous system can impact the well-being of an individual (Streeter et al., 2012). Due to the decrease in the activity of the parasympathetic system, the neurotransmitter, Gamma-Amino Butyric acid (GABA) becomes underactive and results in reduced beneficial effects of inhibiting nerve transmission in the brain, creating a natural tranquilizing effect (Streeter et al., 2012).
Those diagnosed with the debilitating disorder of post-traumatic stress, have consistently displayed low levels of GABA activity (Streeter et al., 2012). The findings from this integrative review suggest that those suffering with the disorder, specifically the active military and veteran population, can increase GABA levels by introducing and incorporating complementary therapies into daily life activities. Yoga therapy, includes practices that aim to reduce stress, arousal, and avoidance symptoms of PTSD by promoting relaxation, conversely increasing GABA activity (Johnston et al., 2015). The studies used in this integrative review support the idea of decreased PTSD symptoms through adjunctive therapy and this is evidenced by self-reports and standardized instruments utilized to display the decrease of depression, anxiety, fearfulness, and irritability due to the diagnosis of PTSD.
The results of this review support the importance of prolonged complementary therapy for veterans and active military personnel in order to produce a sustaining impact. Studies in this integrative review varied in duration, with the longest study being 12 weeks long, allowing only the short-term impact to be evaluated. Complementary sessions should be incorporated into daily life in order to have continuous long-term effects. By incorporating these complementary interventions, those dealing with PTSD have a consistent outlet in addition to the medications and traditional therapies they may be receiving. The findings of this review recommend military personnel suffering from PTSD use these interventions in addition to their standard plan of care, as the interventions do not substitute standardized medical care nor is there enough empirical research that supports the replacement of traditional treatment (O’Haire et al., 2015). The studies supported the evidence that adjunctive therapy may alleviate symptoms of PTSD and allow active military soldiers and veterans to improve their quality of life.
The various complementary therapies provide active military personnel and veterans different avenues in which treatment may be sought. Active military solders and veterans suffering from PTSD should assess which adjunctive therapeutic interventions fit their individual needs. Finding an intervention that is most enjoyable, practical, and feasible may increase adherence while simultaneously improving symptoms. A complementary therapy such as meditation therapy found that participants who had prior beliefs that were aligned with meditation allowed the participants to have improved symptoms such as less hyperarousal and an improvement in focus (Bormann et al., 2011). Stern et al. (2013) surveyed veterans who believed their canine companion helped them with their symptoms. Being that this survey was only done on veterans who supported the idea of canine companionship, this information supports the idea that these complementary interventions should be tailored to the individual’s needs and are more effective when the individual has prior beliefs that support the efficacy of the adjunctive therapy (Stern et al., 2013). Soldiers and war veterans may also choose to participate in multiple complementary therapy sessions of personal interest in order to provide varying positive effects and different emotional outlets. Due to the positive effects witnessed in these therapies, a combination of adjunctive therapies may potentially improve the overall quality of life in a soldier or veteran.
Complementary therapies discussed in this review have found that there may be other benefits in the style of the intervention. Findings suggest that group settings may foster a sense of belonging, unity, understanding, and healing. Participants in music therapy found that there was benefit in group therapy sessions. Group therapy sessions allowed active military and veterans to communicate, empathize, and find healing in a communal experience (Bensimon et al., 2012). Group complementary therapy sessions can decrease feelings of loneliness often associated with active military and veterans who are diagnosed with PTSD. Group style interventions promote intimacy and connectedness which in turn can enhance therapeutic effects (Bensimon, et al., 2012). Findings during the meditation therapy also support that group sessions may have an additional positive effect on the complementary therapeutic interventions as social support appeared to be an important factor in therapy (Omann & Bormann, 2014).
The findings in this integrative review reinforce what is known about complementary therapy for active military and veterans with PTSD and further show that although these therapies should in no way replace traditional medicine and interventions, the addition of them may be beneficial. PTSD symptoms may be minimally to moderately decreased with these interventions and can allow active military and veterans positive coping strategies. Additional rigorous studies on complementary therapy and PTSD symptoms will allow a better understanding of what can be done for those who suffer from traumatic experiences after serving their country.
Implications for nursing practice. The integrative review of literature illustrates the positive effects of adjunctive therapies and how meditation, yoga, pet therapy and music therapy reduce common PTSD symptoms. Nurses should not only attempt to implement adjunctive therapies into their practice, but administrators should incorporate teaching about complementary treatments into schooling. When nurses are educated in pharmacological treatments, there should be content dedicated to complementary therapies. If nurses are educated about complementary therapies, they will be more comfortable recommending these adjunctive treatments for patients. Understanding the ins and outs of a therapy can support a nurse’s recommendation if it would enhance a veteran’s life. Nurse educators should also integrate the biological effects of complementary therapy so nurses can understand how these treatments can lower the sympathetic nervous system and hyperactive arousal state (Rosenthal et al., 2011). Complementary therapy should be incorporated into nursing practice by nurses who understand how meditation, yoga, pet and music therapy can help veterans. If nurses understand the effects of complementary therapy they will advocate for administrative support to incorporate these treatments into their care. Nurses should coordinate complementary therapy with established veteran treatment programs; such actions would allow interested veterans to start treatment as soon as possible to promote positive outcomes. If more studies can demonstrate that PTSD symptoms are decreased with these additional therapies, insurance companies could start covering the expenses of beginning such therapies. More knowledge will be obtained regarding complementary therapy if more nurses are versed in the matter and are proactive when trying to incorporate it into veteran’s treatment plans.
Future research. Further research can enhance the understanding of the benefits to using complementary therapies. Current literature focuses on studies that incorporate one specific intervention. Examining the use of simultaneous complementary therapies can enhance future research. Another suggestion for future research would be to conduct a follow up analysis on participants after the study. A longitudinal follow up study can help conclude if specific complementary therapies are helpful for an extended period. Additionally, future research on complementary therapies for veterans and active soldiers should be longer than the ones observed in the literature review. Another issue noticed in the literature is that existing therapy does not define a concrete optimal dose for an intervention. Therefore, future research needs to identify an optimal dose needed for the therapy to be effective. Overall, future research would better support the need to incorporate the use of complementary therapies with traditional treatments.
Gaps in the literature. Gaps in the literature surfaced after conducting an in-depth analysis. One gap in the literature was a lack of consistent measurement tools for what was being measured in each study. The measuring tools that assessed the quality of life and PTSD were not consistent in the literature review. An additional gap in the literature is that the articles found were only in English and the majority of the studies were conducted in America. There was also a limited number of randomized control studies on this topic. A lack of rigor in the available literature creates biased results. Overall, more studies need to be conducted to enhance the findings of complementary therapies used on veterans.
Limitations to integrative literature. There are various limitations noted for the current integrative literature review. Small sample sizes are a limitation in the research. It is challenging to generalize results if the sample does not realistically represent the desired population. The small sample size can also cause risk of having a type 2 error in the studies. An additional limitation in the studies was a lack of equivalency in genders. The majority of the articles had male participants. Another limitation was that the samples for the articles on music therapy used the same sample. Such limitations can increase bias within the findings of the research.
PTSD is an invisible scar that veterans and active military personnel drastically suffer from. Medication and current non-pharmacological treatment options can be enhanced with the use of complementary therapies. Meditation, yoga, music therapy and pet therapy are supplementary methods used to decrease the heightened arousal of the autonomic nervous system and the continuous stress veterans and active military personnel feel. These therapies can be individualized to the veteran or military personnel’s interest in order to promote adherence. Adjunctive therapies have the opportunity to lower PTSD symptoms and promote a higher quality of life for veterans and military personnel.
This chapter will express the significance of the use of complementary alternative therapies for the treatment of PTSD in active military personnel and veterans. A review of literature will be used to discuss the importance and implications of complementary therapies, specifically looking at meditation, yoga therapy, music therapy and pet therapy. The literature review has shown that yoga therapy has the most potential in reducing PTSD symptoms, and thus this therapy will be the basis of the current authors’ project. The project, which consists of implementing yoga therapy to active military personnel and veterans, will be analyzed for its costs versus benefits and for the resources needed to conduct this project. The details of the project will be reviewed, as well as, the steps to put the project in action. Using Lewin’s Change Theory and the Iowa Model, the authors will discuss how this project will be conducted through the use of selected interventions in order to reduce PTSD symptoms. Afterwards, the evaluation of the effectiveness of this project will be assessed and discussed.
With the increasing number of active military personnel and veterans suffering from PTSD, the use of complementary therapies, such as yoga therapy, meditation, pet therapy and music therapy, can provide an alternative treatment option for those suffering with this disease. Research shows that the typical treatment for PTSD consists of pharmacological interventions and cognitive processing therapy. However, many war veterans have not found sufficient relief from these traditional therapies (Solomon et al., 1992).
The 10 studies used in the integrative literature review portray the impact of the four complementary therapies and its effectiveness in reducing PTSD symptoms. The review of literature has found that yoga therapy had the most impact on reducing PTSD symptoms in active military personnel and veterans. Johnston et al. (2015) found a clinically significant reduction in PTSD symptoms (t = 2.822, p = .009) with a 25% drop on Clinician Administered PTSD Scale (CAPS) score from baseline after the administration of yoga therapy. There were also reductions in the CAPS subscale scores for re-experiencing symptoms (t = 2.204, p = .030), avoidance behavior (t = 1.999, p = .038) and hyperarousal symptoms (t = 3.086, p = .006) (Johnston et al., 2015). Staples et al. (2013) also found a reduction in the hyperarousal symptoms (t = 2.92, p = 0.014) after the administration of yoga therapy. The Pittsburgh Sleep Quality Index (PSQI) showed statistically significant improvements in its total score (t = 2.78, p = 0.020) and the subscale daytime dysfunction (t = 2.57, p = 0.026). These findings highlight the positive effects yoga therapy has on PTSD symptoms.
There are numerous practice implications that arise from the literature. In regards to treatment for active military personal and veterans with PTSD, healthcare professionals must advocate for culturally appropriate and congruent care (Choi, 2015). Advocacy is specifically required to incorporate a suitable complementary therapy when traditional therapies ineffectively reduce PTSD symptomology.
A review of the literature suggests complementary yoga therapy provides the broadest range of PTSD symptomology relief in comparison to other complementary therapies (Johnston et al. 2015; Staples, Hamilton, & Uddo, 2013). Although research supports the benefits of complementary yoga therapy, there remains a lack of structuralized roles of healthcare professionals involved with yoga therapy implementation. Therefore, interdisciplinary collaboration amongst nurses, yoga therapists, and psychiatrists is necessary to define the roles for effective integration of complementary yoga therapy as treatment for PTSD.
Ideas generated from the research focus on training nurses to become an integral member of the yoga implementation team of psychiatrists and yoga therapists. In order for nurses to positively contribute to the team, they must expand their skill base to effectively assess the effects of yoga therapy on PTSD symptomology. Based on the Nursing and Midwifery Council (NMC) Code of Professional Conduct, nurses who plan to incorporate complementary therapies to practice must undergo validated training with proof of completing a course (NMC, 2015).
Currently, psychiatrists use a tool with a pretest and posttest to measure changes in PTSD symptomology, this tool is known as the Clinician Administered PTSD scale (CAPS) (See Appendix A). Therefore, nurses must be trained by psychiatrists to utilize the CAPS and must receive proof of training completion.
Nurses can also contribute to the yoga implementation team by identifying and addressing patients in need of complementary therapy. Patients who exhibit minimal improvement after undergoing traditional PTSD therapies must be acknowledged by nurses. Once such patients are identified, nurses can provide psychiatrist approved referrals to yoga therapist to conduct yoga therapy sessions.
Feasibility of the Alternatives
The main intervention identified is to create a team of nurses, yoga therapists, and psychiatrists to effectively implement complementary yoga therapy into practice. To create such a team, resources such as money and time must be utilized; each team member requires specific resources to fulfill their role. However, effective implementation of complementary yoga therapy can provide benefits to both patients and organizations utilizing complementary yoga therapy (USDVA, 2015).
Cost and Benefits
The expenditure of resources varies between nurses, yoga therapists, and psychiatrists involved with yoga therapy implementation. When training nurses to utilize the CAPS tool in practice, organizations planning to implement complementary yoga therapy must reimburse nurses for their training. Psychiatrists will be training the nurses, therefore, organizations must pay for the psychiatrist led training sessions. Yoga therapists will already be hired at the organization, but the therapists’ wages must be accommodated to manage additional yoga therapy sessions. A review of the literature on yoga therapy underlines the use of 90-minute yoga sessions biweekly for 10 weeks (Johnston et al. 2015; Staples, Hamilton, & Uddo, 2013). Hence, yoga therapists’ wages must be accommodated to provide biweekly yoga sessions for 10 weeks. Once yoga therapists begin to run sessions of therapy, the institution providing the service must consider the cost of each therapy session. Material expenditure on a yoga therapy session may involve the cost of providing mats for yoga.
Successful implementation of complementary therapies can provide numerous benefits to an organization. In regards to patients, completion of complementary yoga therapy may provide a reduction of PTSD symptoms, increase patient satisfaction outcomes, and improve patient quality of life (O’Haire et al., 2015). As patient outcomes improve, cost associated with prolonged PTSD symptomology will decrease (Tanielian & Jaycox, 2008). Consequently, organizations will drastically reduce their expenditure on lives lost to suicide and cost related to referrals for co-occurring conditions such as depression, anxiety, dysthymia, and alcohol or substance abuse disorders (USDVA, 2015). Improved patient satisfaction will also improve retention rates of participants in an organization’s complementary therapy program. Therefore, organizations will have long term financial stability due to a constant influx of revenue from successful therapy sessions.
Based on the cost/benefit analysis, it is reasonable to implement complementary yoga therapy programs. Resources are initially utilized to accommodate nurses, psychiatrists, and yoga therapists involved with implementing the therapy. However, initial expenditure of resources may result in decreased PTSD symptomology and a consequential decrease in cost associated to adverse patient outcomes (Tanielian & Jaycox, 2008). Therefore, combat related PTSD can be managed with complementary yoga therapies in conjunction with traditional therapies. Yoga therapist will conduct 90 minute biweekly sessions for a span of 10 weeks. Participants will include 15 veterans and/or active military personnel per session. The effectiveness of yoga sessions will be measured by psychiatrist-trained nurses through the use of the CAPS pre-test and post-test. Improvements in CAPS post-test scores in comparison to pre-test scores will indicate successful therapy.
The facility where the intervention would be implemented is a VA community based outpatient clinic in the rural area of upstate New York. Founded in 1997, this facility is approximately 9,500 square feet. This facility currently provides care to approximately 4,200 veterans. There are, however, about 17,000 veterans in the surrounding area. Many of these veterans do not require the services provided at this specific clinic and may not be eligible for the VA health care under current eligibility guidelines, but efforts are being made to expand the clinic in order to better serve the area.
Behavioral healthcare services are offered by a team consisting of social workers and psychiatrists who provide services such as psychotherapy, group therapy, medication therapy, and emotional issues related to alcoholism and PTSD. Smoking cessation programs and specialty services such as optometry are also provided at this location. Board certified physicians and nurse practitioners provide the necessary care for these veterans in need. Home-based primary care services and services at the clinic are provided by the registered nurses, licensed practical nurses, nurse practitioners, and social workers that provide collaborative care with primary care providers. Various mental health counseling and complementary therapies are provided by those who specialize in specific therapies such as psychiatry, substance use, yoga and mindfulness therapy as well. Complementary services are provided by yoga therapists with training in psychotherapeutic treatment of trauma-related disorders and PTSD in veterans. The setting for the complementary therapy, specifically yoga therapy, will be in a room explicitly designed for yoga, in order to properly conduct the intervention. Appropriate lighting and equipment are provided in order to complete the yoga session.
Lewin’s (1947) theory encourages the process of planned change (Scott, 2015). Lewin’s change theory occurs in three stages. The first stage of the change theory acknowledges that an organization is in need of a change. In the first stage, the unfreezing stage, an organization notices the faults in their system and begins to make preparations in order to properly change (Scott, 2015). The second stage of Lewin’s change theory is known as the moving or changing stage. In this time period, planned interventions are executed (Scott,2015). During the moving stage, the organization is educated on the need for change and encouraged to envision and conceptualize the change. The strategies that were discussed in the unfreezing stage are implemented after the need is understood and the new vision is accepted (Scott, 2015).
The final stage of the change theory is the refreezing stage (Scott, 2015). This stage focuses on maintaining the change. After implementing a change, it is in human nature to revert to old protocols. In the refreezing stage, change agents must continue to reinforce and encourage the new interventions of change (Scott, 2015). In order to reinforce and sustain the change, desired behaviors should be encouraged by praising and rewarding those who implement the change. The change should be monitored and the impact of the change should also be measured (Scott, 2015). Evidence of the successfulness of the change should be shared with all those involved in the process in order to inspire and maintain cooperation (Scott, 2015).
Iowa Model of Evidence-Based Practice
The Iowa Model for EBP encourages quality care in a systematic method. This model aims to improve the care that is provided and starts at the organizational level (Young, 2015). The first step of the model consists of finding an issue. This issue can stem from problem-focused triggers that exist in the organization such as a clinical problem or it may be a knowledge-focused trigger, which is derived from research or new literature (White & Spruce, 2015). The second step of the Iowa Model is to form a team that evaluates the change. This team should be invested in the current issue and should consists of different disciplines (White & Spruce, 2015) An interdisciplinary approach is the most effective way of implementing change (White & Spruce, 2015).
After creating a team, the team should use clinical practice guidelines in order to find the best clinical practices available. The team should discuss the best clinical practices found in the literature and decide which will be used to pilot change (White & Spruce, 2015). The pilot in change in practice will consist of setting goals, collecting baseline data, creating EBP guidelines, implementing evidence-based practice, and then modifying the change if necessary (White & Spruce, 2015). After the pilot change is completed, it is necessary to evaluate the change and decide if it is appropriate for the organization. If the organization decides the change is appropriate, it is officially put into practice (White & Spruce, 2015). The Iowa Model also states the importance of continuously monitoring the new practice and gathering outcome data. If continuous success is evident, the results will be disseminated (White & Spruce, 2015).
The first step in the change project is the unfreezing stage. During this stage, the VA clinic will recognize the need to change their yoga program. The change will consist of implementing a yoga program that is evidence-based and can be found in new literature. This new program will be implemented in order to decrease the levels of PTSD in the veterans and sustain better health outcomes. The unfreezing stage also requires the clinic to evaluate the benefits and the costs to generate the change (Scott, 2015). When analyzing the costs and benefits, there will be facilitators of the change, which are the forces that support change, and there will be barriers, which are against the change (Scott, 2015). The need for the change is supported by evidence previously stated in chapter 1 and 2.
In Lewin’s second stage of the change, the moving stage, the VA clinic will implement the new yoga program once the need for it is realized. During this phase, education and vision building are incorporated to bring the change into practice (Scott, 2015). A staff meeting with two psychiatrists, two nurses, and two yoga therapists will be conducted to encourage collaborative care for the patient. During this staff meeting there will be a formal educational lecture by the nurses where the need for the new evidence-based yoga program will be introduced. The meeting will restate the evidence found about PTSD, the yoga intervention that is desired, and the goals of the new yoga intervention. This meeting will allow the health care members involved in the care of the veteran to understand the PTSD symptoms that will be monitored and evaluated with a pre-test and post-test using the CAPS.
After the staff is educated on the new yoga program, it will be implemented in the moving stage as well. During the outpatient visit, the nurses will provide holistic care, and assess the patient physically, emotionally, and psychologically. The nurses will assess the veteran and discuss the severity of the PTSD symptoms. The nurses would make a referral to yoga therapy if deemed necessary. The psychiatrists would evaluate the nurse’s suggestion and approve the referral. A brief education session will be provided to both registered nurses, by the psychiatrists involved in the care, on how to administer the pre-test and post-test CAPS. This will allow the nurses to be better involved in the care of the veteran and understand the change in PTSD symptoms. Before the new yoga session is implemented the nurse will give the veterans a CAPS pre-test. The yoga therapists will then conduct the new yoga program that follows the strict clinical guidelines, in an attempt to provide a more effective session. The yoga session will be modeled after the evidence found in chapter 1 and 2. During the 10 weeks where the new program is being implemented, the nurses will continue to monitor vital signs and ask the veteran to verbalize stress symptoms. After the completion of the 20 yoga sessions, the nurses will administer the CAPS post-test to all the veterans who participated. The effectiveness of the change will be assessed by comparing the pre-test and post-test results. If there is a significant improvement in the post-test, the new yoga program will be made official in the outpatient clinic.
In the last stage, the refreezing stage, the new yoga program must be continuously implemented and the new yoga guidelines should be strictly followed. To prevent reverting to old protocols, the results of the post-test should be shared in a staff meeting with the nurses, psychiatrists, and yoga therapists. Sharing the improved results of the post-test may inspire the staff to follow the new protocols in order to sustain better patient outcomes. In order to support the change and the staff effort, incentives can be given. Incentives may range from positive encouragement to a reward. The yoga therapists and nurses may receive small rewards for properly implementing the program. With continual positive results from the yoga program, the results can be disseminated. This program can then be implemented to the other VA outpatient clinics nearby to better serve the veteran population.
This program will be implemented by two CAPS trained nurses and two yoga therapists, with the approval of two psychiatrists. The yoga therapists have a 500-hour certification from a nearby Yoga Association. After the pre-test screening is completed, veterans will be able to participate in the therapy. The setting for the therapy will be in a large room in the facility that is catered to promote relaxation, through appropriate lighting and music that the yoga therapists provide. The sessions will be conducted twice weekly, for 90 minutes. The therapy will include breathing exercises, poses, meditative practices, and relaxation techniques. The yoga therapists and nurses will continuously support the veterans during the session and encourage them to relax and practice yoga safely. The sessions begin with a check-in to account for the patients participating in the session. There will be a warm-up period in which veterans will practice breathing exercises for 10 minutes. The next 40 minutes will consist of practicing different positions of yoga. The next 30 minutes will be dedicated to meditation and finding inner peace, and the session will be concluded with a deep breathing exercise for the last 10 minutes. The goals for this therapy is centered around relaxation, reducing stress, increasing strength and flexibility, and awareness of the environment, others and oneself. The nurses will also conduct health assessments on the patients after each yoga session, such as monitoring vital signs and assessing for any adverse reactions.
In order to assess the effectiveness of the yoga therapy on PTSD symptoms, the two nurses at the VA clinic will measure post-intervention CAPS scores. These post scores will be compared by the two nurses to pre-intervention scores in order to measure statistically significant differences in scores. These scores will be measured after the 10th week of the yoga therapy. This will give sufficient time to assess the effectiveness of the therapy. After the scores are compared, the psychiatrists will confirm the results of the program. If the therapy shows a significant decrease in PTSD symptoms, then appropriate change can be made to permanently offer this service at the VA clinic. The psychiatrists can prescribe this therapy to the veterans as a complementary part of their treatment. This program can bring positive health outcomes for veterans in need.
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Clinician Administered PTSD Scale
Name:________________ ID#:________ Interviewer:________________ Study:___________ Date:_______
A. Traumatic event:
B. Reexperiencing symptoms
(1) intrusive recollections
(2) distressing dreams
(3) acting or feeling as if event were recurring
(4) psychological distress at exposure to cues
(5) physiological reactivity on exposure to cues
Number of Criterion B symptoms (need 1)
C. Avoidance and numbing symptoms
(6) avoidance of thoughts or feelings
(7) avoidance of activities, places, or people
(8) inability to recall important aspect of trauma
(9) diminished interest in activities
(10) detachment or estrangement
(11) restricted range of affect
(12) sense of a foreshortened future
Number of Criterion C symptoms (need 3)
D. Hyperarousal symptoms
(13) difficulty falling or staying asleep
(14) irritability or outbursts of anger
(15) difficulty concentrating
(17) exaggerated startle response
Number of Criterion D symptoms (need 2)
Total Freq, Int, and Severity (F+I)
Sum of subtotals (B+C+D)
E. Duration of disturbance
(19) duration of disturbance at least one month
F. Significant distress or impairment in functioning
(20) subjective distress
(21) impairment in social functioning
(22) impairment in occupational functioning
AT LEAST ONE > 2?
PTSD PRESENT -- ALL CRITERIA (A-F) MET?
(18) with delayed onset (> 6 months delay)
(19) acute (< 3 months) or chronic (> 3 months)
(23) global validity
(24) global severity
(25) global improvement
(26) guilt over acts of commission or omission
(27) survivor guilt
(28) reduction in awareness of surroundings
Author(s), year, country, Purpose
Type of research methodology
Sample and sample size
IV – intervention
Or research variables
Limitations and Strengths
Bormann, Liu, Thorp & Lang (2012).
Does increasing existential spiritual wellbeing (ESWB) and meditative prayer reduce self-reported PTSD symptoms
True Experimental research
66 veterans (97% male) with PTSD. Age 25-84 years old
Control: one 60-min meeting every 1 to 2 months to monitor adherence to medication regimens.
Mantram: six weekly classes (90-min per week) with homework exercises.
PTSD symptoms, spirituality was examined as a catalyst 9mediator to effectiveness of mantram
Findings suggest that spirituality was a catalyst; it was needed to have the meditation become effective.
Mantram used decreased significantly PTSD symptoms,
Majority participants were male (97%)
Reduction of PTSD symptoms and increase of meditation and faith.
Oman & Bormann, 2015.
Purpose: to investigate the effects of the Mantram Repetition Program (MRP) on self-efficacy for managing PTSD symptoms.
Randomized control trial with a pre and posttest design.
N = 146, intervention group n = 71, control group n = 75
Intervention group received the Mantram Repetition Program (MRP) plus Case Management
Control group received case management alone
Self-efficacy and well-being outcomes (which include PTSD symptoms, depression, mental health and spiritual well-being)
When unmediated - CAPS: (p=0.04), but with full self-efficacy meditation: (p=.13)
BDI: unmediated p=.003, mediated with self-efficacy (p=.03)
SF-12: unmediated (p=.03), mediated (p=.03)
Spiritual well-being: (p=.0001)
Limitations: not generalizable to female veterans or younger veterans, only one item to measure self-efficacy
Strengths: RCT, high number of participants, low dropout rate
Bormann, Thorp, Wetherell, Golshan, & Lang (2013).
Purpose: To explore the efficacy of a portable, private meditation-based mantram (sacred word) intervention for veterans with chronic posttraumatic stress disorder.
Single-blind randomized clinical trial
136 outpatient veterans on psychotropic medications diagnosed with military related PTSD. Age- 23-84 years’ old
IV: Six 90-minute weekly group session of Mantram Repetition program (MRP) with treatment as usual (psychotropic medications)
DV: PTSD symptoms, anxiety, depression, mental health related quality of life, spiritual well-being, somatization
PCL: Statistically significant reduction in all outcomes except for
somatization (p=.44), anxiety(p=.31), and re-experiencing (p=.66).
Limitations: TAU group did not meet weekly during the 6-week intervention period, subjects were self-selected, findings can’t be generalized
Strengths: PTSD was measured using both self-report and clinician interviews, measures used have satisfactory evidence of reliability and validity, study assessors were blinded to group assignment, and interrater reliability of the CAPS was good
Rosenthal, Grosswald, Ross, &Rosenthal (2011)
Purpose: to determine whether the Transcendental Meditation (TM) technique can relieve symptoms of PTSD for Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans with the disorder
Uncontrolled pilot quasi-experimental study
Five OEF/OIF veterans. 18-65 years of age with combat related PTSD taking psychotropic medication
IV= Transcendental Meditation (TM), a form of mantra meditation
PTSD symptoms, QOL, depression
All subjects improved on the CAPS, QLES-Q & PCL-M.
On BDI- 3 subjects improved considerably,
1 minimally, and 1 was slightly worse at week 8 relative to
Four subjects rated as much/very much improved at week 8, and 1 was rated
CGI-S: No clinically significant reductions
Limitations: absence of control possibility of placebo effect, unclear who administered the posttest CAPS, unclear if researcher was blinded to subjects receiving TM
Strengths: used reliable instruments for testing (CAPS, PCL-M, BDI)
Johnston et al., 2015.
Purpose: to evaluate the effects of yoga on PTSD symptoms, resilience, and mindfulness in military personnel
Single arm study
12 veterans/active military personal, age 18 and older, diagnosed with PTSD. Some participants on psychotropic medication/ psychotherapy.
Weekly yoga sessions for 90 minutes per session, twice weekly for 10 weeks (20 sessions in total)
PTSD symptoms, resilience and mindfulness
CAPS: clinically significant reduction in PTSD symptoms (t = 2.822, p = .009)
with a 25% drop on CAPS score from baseline, reductions in the CAPS subscale scores for re-experiencing (t = 2.204, p = .030), avoidance (t = 1.999, p = .038) and hyperarousal (t = 3.086, p = .006).
RS: No clinically significant reductions
FFMQ: No clinically significant reductions
Limitations: small sample size (n=12), risk of type 2 error, 92% were male, high attrition rate (61%)
Strengths: Measured prepost effect size of the CAPS measure against meta-analytically for CAPS, Reliable and valid instruments, Significant reduction in CAPS, no adverse effects of intervention
Staples, J. K., Hamilton, M. F., & Uddo, M. (2013).
Purpose: What is the feasibility and effectiveness of a yoga program as an adjunctive therapy for improving post-traumatic stress disorder (PTSD) symptoms in Veterans with military-related PTSD?
12 Veterans (83%male) with combat related PTSD.
1 hour twice a week yoga for 6 weeks 12 sessions total.
PTSD symptoms, quality of sleep, anger, QOL
Significant improvement in PTSD hyperarousal symptoms and overall sleep quality as well as daytime dysfunction related to sleep.
Limitations: Small sample size, lack of a control group
hyperarousal and sleep quality symptoms of PTSD.
Marguerite E. O’Haire, Noemie A. Guerin, and Alison C. Kirkham, 2015,
Purpose: To describe the characteristic of AAI for trauma, evaluate the state of the evidence base and summarize the reported outcomes of AAI for trauma.
Systematic Literature review-qualitative
Initial search result in 453 citations. The final sample included 10 studies. Six studies were published in peer review journals and four were theses.
The use of animal assisted interventions (varied from dogs, horses, or a combination of dogs, horses, and other farm animals)
Trauma related symptoms
Nevins: Decreased PTSD symptoms, depression, dissatisfaction, increase happiness, resilience, satisfaction, sleep, social support
Newton: decreased depression, fear of public spaces, medication use, nightmares and increased outreach
Limitations: AAI procedures were often insufficient to enable replication, lack of literature available
Strengths: Peer-reviewed journal articles and four unpublished theses
PRISMA guidelines consulted.
Stern et al., 2013
Purpose: to further explore the phenomenon of the role of canine companionship in veterans with PTSD
Retrospective quantitative study
30 veterans with PTSD. 90% Men. Ages 34-67
No intervention-use of surveys
Reported feeling calmer, less lonely, less depressed, and less worried about safety issue.
Veterans reported exercising more and taking walks for an average of 49 minutes a day.
Participants noted finding it easier to be around others after having a companion dog.
Limitations: Retrospective study that assessed only veterans who reported their dogs helping them., most veterans in study were older male veterans, limited much literature on the use on nonservice dogs for war veterans with PTSD.
Strengths: Lexington Attachment to Pets Scale had reliability, BDI-II has reliability and validity, other standard instruments used: Veterans SF-36 and PCL-M, dog Relationship Questionnaire indicated a high degree of internal consistency (Cronbach’s alpha= 0.868)
Bensimon, Amir, and Wolf, 2008
Purpose: To explore the meaning of group drumming for young men who suffer from PTSD.
Mixed method analysis
Six male veterans, 20-23 years old
90-min weekly sessions of group drumming for four months
Traumatic and non-traumatic emotions.
Music therapy decreased reflections of traumatic emotions and increased expressions of non-traumatic feelings
Limitations: No control for jeopardizing variables, lack of female active military personal
Strengths: Uniformity of responses, triangulation, peer debriefing, multiple observations
Bensimon, Moshe, Amir, and Wolf, 2012.
Purpose: To explore the therapeutic process of group music therapy (GMT) with young soldiers who suffered from PTSD.
Six male veterans, 20-23 years old
90-min weekly sessions of group music therapy for four months
Limitations: Researcher was also music therapist, playing volume not measured by an objective instrument small sample size limits generalization
Uniformity of responses across participants,
Running head: COMPLEMENTARY THERAPY FOR PTSD 1
COMPLEMENTARY THERAPY FOR PTSD 263).
Strengths: Lexington Attachment to Pets Scale had reliability, BDI-II has reliability and validity, other standard instruments used: Veterans SF-36 and PCL-M, dog Relationship Questionnaire indicated a high degree of internal consi