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Accelerated resolution therapy and a thematic approach to military experiences in US Special Operations Veterans
  1. Diego Hernandez1,2,
  2. K E Kip2,3,
  3. C J Long2 and
  4. J L Redman4
  1. 1 Balanced Living Psychology, Tampa, Florida, USA
  2. 2 College Public Health, University of South Florida, Tampa, Florida, USA
  3. 3 Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  4. 4 Division of Counseling and Family Therapy, Regis University, Denver, Colorado, USA
  1. Correspondence to Dr Diego Hernandez, Balanced Living Psychology, Tampa, FL 33618, USA; docdiego{at}earthlink.net

Abstract

Accelerated Resolution Therapy (ART) is an emerging therapeutic intervention that has demonstrated effectiveness in treating post-traumatic stress, anxiety and depression. The ART protocol aligns with first-line trauma-focused psychotherapies and clinical guides in the USA and UK. This review addresses previous ART research that includes members of US Special Operations Forces. Observations from that research has led to a thematic conceptualisation of trauma through ART interventions. These include three clusters of traumatic memories and several themes relevant to individual distress but not necessarily symptoms that meet diagnostic criteria for PTSD. ART represents a movement in treatment away from the symptoms, to the individuals’ story. Not only the story of an event, but how that experience becomes incorporated into one’s sense of identity. The themes identified (and treated with ART) appear to have broader application to the entirety of one’s military experience, not just PTSD. These themes may be helpful in directing treatment and may help to focus on significant aspects of service not traditionally associated with PTSD. Theoretically, some of these areas may have protective implications in suicide.

  • public health
  • adult psychiatry
  • suicide & self-harm
  • depression & mood disorders

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Key messages

  • Accelerated Resolution Therapy (ART) is an emerging therapeutic intervention that has demonstrated effectiveness with post traumatic stress, anxiety and depression.

  • ART research has included members of US Special Operations Forces.

  • Therapeutic content of past research sessions has led to a thematic conceptualisation of themed clusters of combat memories.

  • ART provides a broader conceptualisation for addressing the whole military experience.

Introduction

Accelerated Resolution Therapy (ART) is a non-invasive emerging psychotherapy that is a highly portable approach to addressing unintegrated or traumatic memories.1 2 It moves treatment away from addressing symptoms to addressing the narrative within the memory reconsolidation window.2 ART is a manualised approach adapted from eye movement desensitisation and reprocessing (EMDR)2 ART satisfies the similar US and UK evidenced-based treatment guidelines for PTSD.1 Although ART was initially developed to address specific memories, it has been applied to complex grief in older adults in hospice supportive care and in a pilot study for cancer diagnosis and treatment.3 4

The initial stage of ART is relaxation and orientation to the use of smooth pursuit eye movements.1 2 This is followed by several structured imaginal exposures until the participant can recall the event without distress. Gestalt interventions are used in what is called the director’s intervention. This is an opportunity for the individual to shift their focus to some other aspect of the memory, address unfinished business like a conversation that never took place or to imagine the event differently. Each intervention is based on the individual’s need, and they can visualise a preferred narrative.1

There are presently over 600 therapists in the US Army trained in ART. Mainly at Army medical facilities like Ft. Belvoir and Walter Reed, as well as deployed and embedded and able to conduct sessions in theatre with Special Operations Forces (SOF). The potential of ART within the military can be seen in a recent publication in Military Medicine. While deployed in Afghanistan, behavioural health responded to a unit members’ traumatic death by administering single 45–60 min ART sessions within 96 hours. Eight US soldiers who received ART reported rapid improvement of both depressive and acute stress systems. Positive results sustained 1 year postincident.2

ART research has shown an average of three to five sessions, with significant reduction in symptoms of anxiety, depression and PTSD, along with improvements in pain and sleep.1 A recent subgroup analysis of previously published ART research examined SOF-identified participants who have shown similar benefits.1 A reduction in anxiety, depression and PTSD will likely reduce impulsivity and lower risk for suicide. Several research participants stated that if they had access to ART prior to beginning the Med Board process, they would have remained in the Army. In addition, ART research focused on symptoms of PTSD among civilians, Veterans, active-duty military, homeless Veterans and active-duty SOF in the process of medically separating from active service. Previously reported themes in combat memories where multiple memories could be addressed in a single ART session based on the related theme.1 Secondarily, themes were observed or common scenarios that appeared integral to the distress measured. This thematic approach is more well developed in the Random controlled trial for complex grief in older adults in postloss hospice care.3 4 The researchers first identified common scenarios to guide the clinician, and then used these themes to target related memories.

Themes related to combat appear to cluster into three groupings: (1) strong physiologically and fear-based experiences where sensory aspects were dominant (2) involves moral appraisal or failure of moral integration (also known and studied as ‘moral injury’) and (3) grief and loss, which is the most prominent and is likely due to the bonds built though service and combat. Something best captured in the expression to ‘lay down one’s life for the one on my left and the one on my right’.

Many of the non-combat service-related themes observed in the first three studies would not meet formal diagnostic criteria for PTSD. These themes were related to military service, identity, ability, injury and family relationships. The significance of these themes in the life of these individuals and near absence in the literature is likely due to the heavy focus on guideline-defined symptoms and disorders, such as PTSD. Several of these themes may consequently be factors in suicide and suicide prevention.

Reconceptualising themes into stress points of military experience

These non-combat themes integral to sustain one’s distress are transitional and family/relational stresses. When one solely focuses on combat and traumatic experiences, it is done to the neglect of the entirety of the military experience, the individual and their family. When the focus is on symptoms, the narrative is missed. With ART, the focus is on the images and sensations that are part of the narrative. It is often the strong sensory aspects of a memory that keep the narrative stuck. Working with these themes, they can be broadly grouped into the following categories: service and deployment stress, combat stress, family/relational stress and transitional stress.

Each stress point represents an aspect of identity, relationships and experience. While identity continues to be shaped by skill acquisition, experience, achievement and loss, family and relational stress is present from deployment to transition to civilian life. These themes correspond to individual session content in previous research; however, this content was only loosely categorised and is yet to be more robustly explored.

Service and deployment related stress

Experiences during induction and basic training start conditioning the service member. For a SOF team member, it begins with the arduous qualification. A key issue appears to be the formation of identity and corresponding skills that reinforce or challenge that identity. This is both an area of loss when leaving the service and is particularly significant when the loss is a premature separation from the military due to injury and reduced capacity to perform at previous levels. Themes from service and deployment related stress overlap the categories to follow.

Combat/operational stress

SOF, like all service members, are trained to perform specific functions. A team undergoing combat operations gains increased camaraderie, which continues to become enhanced though subsequent trainings and deployment and is believed to be a protective factor for operations.5 This physical conditioning creates over-relied on response sets. One of the challenges of transitioning to civilian life is the reliance of those response sets in non-combat environments. For example, among SOF members, a common area of difficulty and distress is driving. With ART, we address the physiology of driving and well-learnt driving-related behaviour acquired in combat zones as it emerges stateside, as well as the corresponding frustration, shame and guilt.

SOF members are subject to multiple deployments and combat operations that may last from hours to days.6 One of the benefits to ART is to address multiple events by a common theme or sensation.1 For example, one Special Forces Medic had a disturbing image of a facially injured solider who tried to speak. In session, the entire event was addressed along with similar events and not revisited in as much detail as the target memory. The individual was able to recall the initial event without distress as well as the other matched images.

ART interventions for combat are broken down into clusters. The first is physiologically and fear-based experiences. The second involves moral appraisal or failure of moral integration (moral injury). The third cluster is grief and loss. Physiological and fear-based experiences seem to correspond to fear-based memory. Individuals are more likely in session to re-experience strong aspects of the event and abreactions, as described in the 2014 case report in Military Medicine.7 Related themes are ‘hot spots’ in the narrative, such as: moment of fear, moment of freeze, moment accepted one’s own death and moment of injury. Each of these can all be addressed with the basic ART protocol (Figure 1).

Figure 1

Overview of theme-based ART interventions for combat memories. ART, accelerated resolution therapy.

The ART protocol will identify and target each aspect of experience. Often there is a shift in narrative following the structured recall (imaginal exposure), like cognitive processing therapy.8 This shift is initiated by the individual once their relationship to those events have changed. For example, a SOF medic started his session by saying ‘I am a failure because I couldn’t save my friend’. During imaginal exposure, he muttered, ‘Check, check, check, check’. At completion, he stated, ‘I did everything I could. I went by the book and did everything I could’. In this case, the participant initiated rescripting following imaginal exposure.

The second cluster involving moral appraisal or failure of moral integration (moral injury) encompasses the following themes: an action taken and/or an action not taken. Either can be by will, lack of will or orders; this includes a range of appraisals such as actions that occur while participating in war or operations, actions or inactions by the government, justification for war or operation, perceived personal failure, failure of leadership, larger existential questions and questions of right and wrong. These themes are described in the literature as: transgressions by others, transgressions by self and betrayal.9

Gestalt interventions as part of the director’s intervention have the following goals: opportunity to view the event in a manner that is consistent with one’s sense of self or moral values, redo a situation, and view what may have happened differently. The aim is to integrate the moral appraisal of the event or acts into one’s sense of self and moral self. Some of these interventions are to imagine that a child was not killed, one was able to save someone, a deceased child lived and grew up and lived a better life that one helped fight for and leadership had listened or made a different call. These themes are common scenarios from combat with moral implications. Their use is dependent on the distress and needs expressed by the participant (Figure 2).

Figure 2

Gestalt intervention freezing time.

The third cluster: grief and loss may be a critical theme in combat-related PTSD as individuals identified with complicated grief show lower response rate to treatment as well as lower remission rates compared with those without complicated grief.10 These themes have significant overlap with complex grief as seen in the application of ART with survivors in hospice supportive care.3 4 The themes reflect loss of life, loss of a friend, loss of someone who had similarities, conflicted feelings, injury and loss of ability. Grief and loss tend to be embedded in earlier losses in life.11 Often the work involves addressing earlier loss(es) in what ART calls a scene match, or in EMDR, a float back.8 These interventions create the opportunity to resolve unfinished business, provide a conversation with that person, express self towards that individual, hear from that individual and carry a memento or some aspect like trait, leadership style, etc, forward into one’s present life. The focus shifts from loss of the relationship to the impact of that relationship in the present. Three ART interventions used include freezing time, last conversation and waiting room (Figures 3 and 4).

Figure 3

Gestalt intervention last conversation.

Figure 4

Gestalt intervention freezing waiting room.

Family or relational stress

An important aspect of a service members’ career is also the establishment of an intimate relationship, marriage and children.12 Memories may be related to separation from loved ones while deployed and any resulting conflict or loss. Operators are high performers much like professional athletes. One characteristic of SOF is their high level of performance in multiple domains.13 This level of high performance creates an over-reliance on problem-solving strategies, communication and other abilities that makes one successful in combat. These same skills, mission critical in life and death situations, do not adequately correspond to marital, family and work relationships. In fact, use of these over-relied on tools are often points of stress in a relationship or a family. It is a transitional factor because how the body learns to operate in Fallujah does not help one at Walmart or in the shops.

For example, on a team, trust is earned though reliance on other team members in training and combat. Often, teams will be quick to carry one another’s burden for those with established trust. Consequently, absence of trust may be a potential liability. In our experience, attempts to run the family like an Operational Detachment Alpha often results in family conflict. The parent may become frustrated because his or her ‘little solders’ do not listen.

Family relationships may be both predictors in suicide as well as protective factors. Distressing interpersonal relationships with a partner at home has been consistently identified as a factor in 56%–68% of suicides.14 According to the 2017 Psychological Autopsies of SOF Suicides by the American Association of Suicidology, they reported ‘no discernable pattern related to deployments or combat’.12 They did however report instances of suicide tended to relate to interpersonal issues, substance abuse and financial problems. Several interventionists in the ART research reported distress around these ‘non-combat memories’ and were given the approval to address them in relationship to the participants’ current distress. These memories are related to themes of divorce, infidelity, betrayal and ideas of family.

These themes bear some similarity to themes related to moral integration. For many of these operators, family was something they were sacrificing for and risking in combat; for the most part, the meaning of family plays some part of their fabric for making sense of war. One common and distressing memory is communication with loved ones from theatre, which may be more significant among SOF because ready access to communication technology. One example is an operator calling home after a particularly difficult mission. He stated that the conflict with his now ex-wife was more distressing than the events of that day. Despite a healthier second marriage, he is still awakened by dreams of calling his ex-wife looking for something from the home life he believed he was fighting for. Likewise, the family left behind is often in distress, and in addition to ART, interventions designed for the Army by Gottman et al,12 help couples communicate and build psychological resilience. Preserving family relationships may be a protective factor in preventing suicide.

ART provides a ‘Typical Day’ intervention to address many scenarios such as a typical argument, or typical deployment, or week leading up to deployment.7 There are two ART interventions that can help reframe one’s perception of family and relationships to something more productive. The first is raising your partner’s value. Teams are accustomed to occasions where they provide escort for an observer. The direction is to visualise that event with emphasis on the value of that observer and the need to look out for them and explain when needed. This visualising is followed by visualising their spouse in that same role on the mission. This is followed by visualising the same level of value in previous situations where the operator may have treated their spouse as a liability.

Transitional stress

A much-needed emerging area of military study is transitional stress. While it is estimated that less than 10% of service members develop PTSD, it is suspected that most experience some level of transitional stress.15 Mobbs and Bonanno list grief and bereavement, loss of military self, autobiographical memories, memorialisation of service, service-connected nostalgia, moral injury and the effect of the civilian–military divide, threat of fulfilling Veteran stereotype, and socialised masculinity and stoicism as transition factors.16All of these provide a unique challenge for operators just as when professional athletes retire due to age or injury; there is a loss of identity and the military family or as Sebastian Junger describes it as a loss of one’s ‘Tribe’.17

One of the challenges of SOF in transition is how to bring a high-performing skillset and hard-earned lessons in leadership to the civilian world. For operators, it is far more than becoming gainfully employed. It is finding rewarding and meaningful work that makes use of these high-performing skillsets.

The structure of ART can address each theme when the theme is identified as the focus in a session. In addition to the previous mentioned interventions, one use is to focus on the timeline of one’s complete service as a single narrative, from induction to outprocessing. This may even involve a conversation with a younger self, to saying goodbye to comrades and memories of watching your unit ship out without you. The exercise ends in imagining removing one’s uniform, stowing one’s gear and dressing in civilian clothing.

Conclusion

Evidence from ART research demonstrates the value in moving treatment away from addressing symptoms to addressing the narrative (story) and viewing symptoms as markers of the impact of the narrative and its disruption on living. Themes that have emerged from ART research with active duty and Veterans provide a useful conceptualisation of combat experiences, which can be used to guide how these experiences are addressed in treatment. Likewise, many of these non-combat related themes reflect aspects of the military experience not typically addressed in treatment. The content of sessions, particularly among SOF, extended to non-combat related themes that include family, significant relationships, military identity and other types of loss not traditionally considered under PTSD. It may be more helpful in working with Veterans and active duty to explore significant life events outside of combat experiences through conceptualising the entire military experience.

One proposed organisation of these themes is in the following points of stress: Service and deployment stress, combat stress, family/relation stress and transitional stress. Clinically, they may be more directive in identifying distress and guiding treatment. These clusters and themes spanning the military experience may provide an overall developmental conceptualisation of a service members’ experience and challenges rather than seen through a single lens of mental illness. A significant limitation of this work is lacking a rigorous matrix of themes across studies that would allow one to explore the relationship between themes, symptoms and outcomes. However, these initial observations of the narrative content of this brief intervention may be the beginning of such an exploration.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

References

Footnotes

  • Collaborators Jessika Redman.

  • Contributors DH is the main author of this paper. KEK and CJL have made intellectual contributions. KEK planned and directed each study with input from DH and from CJL. DH was the clinical director for each study. KEK, DH and CJL collaborated on the clinical, theoretical unintellectual aspects of each study and this paper. DH coordinated and organised the reporting in this paper. Collaborator: JLR provided input and editing on this paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DH provides accelerated resolution therapy (ART) training for non-profit ARTinternational. KEK has no financial interest in ART. However, he does advise ISART and organisation that supports ART trained therapists. CJL assists ART training for non-profit ARTinternational. JLR has no financial interest in ART.

  • Provenance and peer review Commissioned; externally peer reviewed.