DePuY 2017 Honorable Mention

Cognitive Therapy for Soldiers Suffering From Posttraumatic Stress Disorder and Traumatic Brain Injury

2nd Lt. Noelle Walker, Illinois Army National Guard

Download the PDF

(Photo taken 8 September 2016 by Erin Bolling, USAMMDA PAO)

A young man named Daniel Somers, in love with his high school sweetheart, Angeline Roth, married at the early age of eighteen. Two short years later he was off to the races, enlisting into the National Guard and deploying to Afghanistan shortly thereafter for thirteen months. Between 2001 and 2007, he served in over four hundred combat missions in Iraq and Afghanistan, returning home for the last time in 2007. According to a document repository from the U.S. House of Representatives, Daniel Somers killed himself on 10 June 2013 at only thirty-one years of age. He left a letter of explanation to his wife before committing the act that was later brought to public light: “My mind is a wasteland, filled with visions of incredible horror, unceasing depression, and crippling anxiety, even with all of the medications the doctors dare give.”1

His story is like many others. In 2015, the Department of Defense reported that 266 active-duty soldiers and 209 reserve-component soldiers killed themselves. This data presents an enormous deficit in soldier resilience with respect to handling posttraumatic stress disorder (PTSD) and depression.2 In 2010 a study published in Military Medicine titled “Spiritual Fitness” found that, “spiritual fitness is key to ensuring optimal force readiness and protection and enhancing resilience and recovery following combat-related trauma. The early identification of spiritual risk factors in individuals can minimize future dysfunction and negative impact on the unit.”3 Thus, spiritual fitness, observed as a pillar in the Army’s Comprehensive Soldier and Family Fitness standard, is imperative to soldier resilience.

In 2014, the New York Times described the results of a study that compared two groups, one of which received therapy for suicidal thoughts and one that did not. The article reported that “therapy prevented 145 suicide attempts and 30 deaths by suicide in the group studied,” a reduction of 26 percent.4 For this reason, the Army must implement mandatory, preventative, cognitive therapy for all soldiers in order to increase spiritual fitness, strengthen resilience, and prevent soldier suicide.

Soldier Resilience: The Problem

CNN reported in March 2014 that “almost 25 percent of 5,500 active-duty, nondeployed Army soldiers tested positive for a mental disorder of some kind.”5 According to USA Today, U.S. military suicide rates are roughly 20 percent higher than civilian suicide rates.6 The number of suicides has risen each year since 2001, and the steady increase has been rumored by experts to be “the new normal.” The executive director of the National Center for Veterans Studies, Craig Bryan, stated, “I do think there is a sort of creeping mind-set of, ‘well, this is just how it is now.’ The sense of urgency about this problem has started to fade away.”7

The overall purpose for a soldier to maintain a healthy spiritual state is to increase his or her resiliency. Resiliency, as defined by Julio Peres et al. in their article “Spirituality and Resilience in Trauma Victims,” is “the ability to go through difficulties and regain satisfactory quality of life.”8 Arguably, one of the largest problems in the military is the number of soldiers with PTSD. Treatment for soldiers with PTSD is very limited in terms of physical solutions such as medications. Peres et al. state that the best way for individuals to maintain (or regain) resilience is through spiritual coping: “Several studies have shown that many people cope with traumatic or stressor events on the basis of their religious beliefs … Positive religious coping has been associated not only with better physical and mental outcomes in medically ill patients but also among trauma patients.”9 Spiritual health is imperative to the well-being of all soldiers, argued in this paper to be the cornerstone of resilience.

Edmund S. Higgins, a writer for Scientific American Mind, reported in January 2017 that “recent data suggests mental disorders are not improving and that diagnoses are on the rise.”10 There was a large boom in prescription medications for mental health in the 1990s and 2000s, and as the stigma for mental illness began to dissipate slightly, more people turned to medication.11 Over the past twenty years, mental health-related issues have increased. Suicide rates in the United States have risen to a thirty-year high, with roughly forty-four thousand Americans dying by suicide each year, according to the American Foundation of Suicide Prevention.12 A study referenced by Higgins conducted in 2010 calculated the number of diseases and injuries between 1990 and 2010. They found that while other serious conditions became more manageable, mental diseases had only grown over the past two decades, and more medications were being used to treat these mental diseases than ever before.13 According to Higgins, “New antidepressants lift mood no better than the tricyclic antidepressants discovered in the 1950s. Lithium, first used in 1949, remains the gold standard for bipolar disorder.”14 Higgins argues that our primary solution to the problem is preventing or counteracting mental illness by teaching cognitive therapy skills.

The Importance of Spiritual Fitness in Resilience

When someone hears the word “spiritual,” the first thought to enter his or her mind is likely churchgoing or praying before dinner. In reality, spiritual wellness is your state of mind. The National Wellness Institute expounds cogently on what exactly spiritual wellness is: “The spiritual dimension recognizes our search for meaning and purpose in human existence. It includes the development of a deep appreciation for the depth and expanse of life and natural forces that exist in the universe.”15 Bill Hettler, the creator of the wellness model utilized by the National Wellness Institute, argues that spiritual wellness is a growth state, never stagnant and always progressing in one direction or another. The outward sign of spiritual wellness will be demonstrated in one’s value system: “You’ll know you’re becoming spiritually well when your actions become more consistent with your beliefs and values, resulting in a ‘world view.’”16

Our outflow of daily actions are the result of where we are spiritually; our moral decision-making, our behavior toward others, and our motivation and ability to lead. Spirituality is the means by which one is able to grasp the larger picture, and for most individuals, it implies a value system that keeps one’s actions in check. And yet, it is so often overlooked.

According to the Joint Service Psychological Health Program, “the need for spiritual wellness is often downplayed as less important than emotional, physical, or social wellness, but vital to the overall wellness of every Service Member.”17 Downplaying the importance of spiritual health does not have a singular effect; it greatly influences other areas of soldier fitness as well.

Soldiers from Alpha Battery, 2nd Battalion, 32nd Field Artillery Regiment join to say a prayer before a mission 29 October 2007 at Forward Operating Base Liberty, Iraq. (Photo by Spc. Charles W. Gill, U.S. Army)

In a letter quoted in Healthy in Body, Mind and Spirit, Rabbi Menachem M. Schneerson expounds on the connection between physical and spiritual health: “Physical health is so greatly dependent on spiritual health … it is an accepted principle that even a small spiritual defect can cause grievous physical harm. The healthier the spirit and the greater its influence over the physical body—the greater its ability to correct or overcome physical shortcomings.”18 He goes on to say how emotions such as joy, contentedness, or sadness—things having to do with our state of mind—are correlated to physical effects. He states, “Since body and soul are totally connected and united, forming one entity, it follows that every phenomenon in the spiritual realm will also result in a physical phenomenon.”19 Although this perspective may seem extreme, there is an arguable influence that the spirit and body have on each other. The previously cited study, “Spiritual Fitness,” discussed this influence:

Most of the health benefits of spirituality are not limited to specific components, but flow from the combined effect of multiple components across domains … hope and optimism, less depression, fewer suicides, less anxiety, less alcohol and drug abuse, greater marital stability, less risky behavior, and lower mortality from various causes.20


They go hand in hand, the spirit affecting the body, and the physical influencing one’s spiritual state. The importance that spiritual wellness has in creating resilience in soldiers is clear. Where individuals are mentally will determine their effectiveness to fulfill their duties, their ability to support their fellow brothers and sisters, and even their physical well-being.

Reform: Preventative Cognitive Therapy Plants the Garden for Spiritual Health and Resilience

According to the Beck Institute for Cognitive Behavior Therapy, cognitive therapy is defined as “a psychotherapy that is based on the cognitive model: the way that individuals perceive a situation is more closely connected to their reaction than the situation itself. … [It is] a time-sensitive, structured, present-oriented psychotherapy directed toward solving current problems.”21 Rather than a traditional therapy session in which you recover from a traumatic situation, preventative cognitive therapy provides soldiers the tools necessary to properly handle and process a traumatic event, should they encounter one.

The beauty of preventative cognitive therapy is that although it may not reduce the impact of traumatic events on soldiers, it will give them a way to compartmentalize and cope with what they experience.

The Army Leadership Requirements Model requires soldiers to be leaders of presence—composed, confident, and resilient. They require that leaders create a positive environment and are of sound judgment and mental agility.22 The fact that one quarter of our active-duty military suffers from mental illness means that one quarter of our soldiers are not meeting the Army Leadership Requirements Model, something that is cause for alarm. The consistent twenty years of mental health decline despite the military’s efforts to increase resources and resilience training has left us disheartened. Worse, we are nearing complacency. PTSD and the traumatic brain injuries that occur among soldiers are difficult, if not nearly impossible to treat. The Army seems to have lost ground in treating mental health problems of this severity, largely because there are so very few solutions. Daniel Somers poignantly described the dearth of treatment options:

My body has become nothing but a cage, a source of pain and constant problems. The illness I have has caused me pain that not even the strongest medicines could dull, and there is no cure. All day, every day a screaming agony in every nerve ending in my body. It is nothing short of torture.

… Beyond that, there are the host of physical illnesses that have struck me down again and again, for which they also offer no help. There might be some progress by now if they had not spent nearly twenty years denying the illness that I and so many others were exposed to. Further complicating matters is the repeated and severe brain injuries to which I was subjected, which they also seem to be expending no effort into understanding. What is known is that each of these should have been cause enough for immediate medical attention, which was not rendered.23


The beauty of preventative cognitive therapy is that although it may not reduce the impact of traumatic events on soldiers, it will give them a way to compartmentalize and cope with what they experience. The mental wear and tear that can occur without an understanding of how to channel traumatic events will ultimately lead to the exact same place in which Somers found himself. Studies for preventative therapy are particularly difficult to conduct, as researchers cannot predict if or when a traumatic event will occur that can be used to test the effectiveness of the preventative therapy. However, some studies evinced the success of preventative therapy in preventing relapses of flashbacks or triggered episodes, as did a study conducted in 2003 titled, “Mindfulness-based Cognitive Therapy for Depression: A New Approach to Preventing Relapse,” where data suggested promising results for preventative therapy:

In the only major randomized controlled study reported on preventive interventions after a depressive episode … those rated as receiving more elements of interpersonal therapy did better, often delaying depressive episodes for two years, compared with five months for those receiving a lesser “dose” of therapy. What the authors took from this study was a sense of optimism about cognitive therapy as a preventive measure. The challenge was to develop an intervention that targeted the vulnerabilities to relapse.24


There is tremendous potential for good in arming soldiers with tools to keep their mental fitness intact, and virtually no harm in at least trying.

Objections to the Validity of Spiritual Fitness

Some may dispute the idea that spiritual wellness has anything to do with resilience, as is the case with a Sgt. Griffith, who calls himself a “foxhole atheist.” While taking a required comprehensive soldier and family fitness survey, he grew frustrated with the questions about spirituality. Some of the questions asked about the soldiers daily rituals, if he prayed or meditated. Griffith stated, “I don’t do those things, and I don’t think any of those questions have anything to do with how fit I am as a soldier.”25 At the conclusion of the survey, his results suggested, “You may lack a sense of meaning and purpose in your life. At times, it is hard for you to make sense of what is happening to you and to others around you. You may not feel connected to something larger than yourself. You may question your beliefs, principles, and values.”26 As an atheist, and noncompliant to any sort of spirituality in his life, it is understandable that he does not believe his spiritual state should have any bearing on his ability to perform as a soldier.

Others, such as former Air Force lawyer Mikey Weinstein, believe that the pillar of spiritual fitness should be eliminated entirely because of its appearance as a smokescreen for religion, particularly evangelical Christianity. He claims, “This is a one-inch putt if you’re playing golf. This is clearly, blatantly unconstitutional—and it has to stop.”27

It is clear that spiritual fitness affects soldiers’ resilience, but how the military is able to properly gauge its soldiers’ spiritual readiness is a much stickier subject. Brig. Gen. Rhonda Cornum alluded to the fact that the spiritual fitness test designed by the Army was developed because there seemed to be a connection between resilience and spiritually inclined individuals: “Researchers have found that spiritual people have decreased odds of attempting suicide and that spiritual fitness has a positive impact on quality of life, on coping, and on mental health.”28

Drawing Conclusions

There is clearly much dissension among soldiers about the value of spiritual fitness, but repeatedly, spiritual wellness has been shown to greatly increase soldier resilience by providing a structured worldview and strong moral values, and it has been irrefutably intertwined with physical health as well. Most soldiers are familiar with the questions on the current spiritual fitness assessment. There is no “pass” or “fail”—the questions consist of choices A, B, or C—and the assessment is only taken once every two years. Although it provides the soldier with some private feedback, there are no real ramifications involved with the test. Because of the nature of being spiritually fit, it is not something that can be easily tested, and merely changing the form of testing will not likely yield better results or provide solutions to the mentally ill.

For this reason, reform must take place through means of mandatory, preventative cognitive therapy. It is ignorant to think that those with no mental illness will be able to cope with mental illness in the future. A physical disease, perhaps not even as debilitating as a mental one, would never be treated in that manner. The key word in this discussion is “preventative.” It is much easier to be prevent a disease than to cure a disease. The military is in the unique position of being able to lead society down a new path, as this is a problem for both the soldier and the civilian. Unlike civilians, however, soldiers are trained to go to war and are likely to encounter traumatic episodes that leave them with or worsen a mental disease. By happenstance, this is a perfect pool of individuals to study. This unique position requires action of the military but also provides an opportunity to lead the nation in a new way of thinking, a new strategy. There must be professional, preventative cognitive therapy for soldiers to provide them the coping skills necessary to become and remain spiritually resilient. Perhaps above all, the Army cannot become complacent when a quarter of its soldiers are mentally ill. Now is when the Army should be should be hunting down solutions with a ferocious desire to protect its children.


Notes

  1. Service Should Not Lead to Suicide: Access to VA’s Mental Health Care, Before the Comm. on Veteran Affairs, 113th Cong. (2014) (statements of Jean Somers and Howard Somers), accessed 15 March 2018, http://docs.house.gov/meetings/vr/vr00/20140710/102444/hhrg-113-vr00-wstate-somersmdh-20140710-sd004.pdf.
  2. Keita Franklin, Department of Defense Quarterly Suicide Report Calendar Year 2015 4th Quarter (report, Washington, DC: Defense Suicide Prevention Office, 18 March 2016), 4, accessed 15 March 2018, http://www.dspo.mil/Portals/113/Documents/DoD_Quarterly_Suicide_Report_CY2015_Q4.pdf.
  3. David J. Hufford et al., “Spiritual Fitness,” Military Medicine 175, no. 8S (2010): 73–87, doi:10.7205/milmed-d-10-00075.
  4. Nicholas Bakalar, “Therapy Prevents Repeat Suicide Attempts,” New York Times (website), 1 December 2014, accessed 4 December 2017, https://well.blogs.nytimes.com/2014/12/01/therapy-prevents-repeat-suicide-attempts/.
  5. Val Willingham, “Study: Rates of Many Mental Disorders Much Higher in Soldiers Than Civilians,” CNN (website), 4 March 2014, accessed 4 December 2017, http://www.cnn.com/2014/03/03/health/jama-military-mental-health/index.html.
  6. Gregg Zoroya, “Experts Worry High Military Suicide Rates are ‘New Normal,’” USA Today (website), updated 18 June 2016, accessed 4 December 2017, https://www.usatoday.com/story/news/nation/2016/06/12/military-suicide-rates/85287518/.
  7. Ibid.
  8. Julio F. P. Peres et al., “Spirituality and Resilience in Trauma Victims,” Journal of Religion and Health 46, no. 3 (September 2007): 345.
  9. Ibid., 344.
  10. Edmund S. Higgins, “Is Mental Health Declining in the U.S.?,” Scientific American Mind (website), 1 January 2017, accessed 4 December 2017, https://www.scientificamerican.com/article/is-mental-health-declining-in-the-u-s/.
  11. Ibid.
  12. “Suicide Statistics,” American Foundation for Suicide Prevention (website), accessed 15 March 2018, http://afsp.org/about-suicide/suicide-statistics/.
  13. Higgins, “Is Mental Health Declining in the U.S.?”
  14. Ibid.
  15. “The Six Dimensions of Wellness Model,” National Wellness Institute (website), 2, accessed 4 December 2017, http://www.nationalwellness.org/resource/resmgr/docs/sixdimensionsfactsheet.pdf.
  16. Ibid.
  17. “Spiritual Wellness,” Psychological Health Program National Guard Bureau, Joint Services Support (website), accessed 15 March 2018, http://www.jointservicessupport.org/PHP/Spiritual.aspx.
  18. Sholom B. Wineberg, comp., “The Relationship between Spiritual and Physical Wellness,” in Healthy in Body, Mind and Spirit, Based on the Teachings of the Lubavitcher Rebbe Rabbi Menachem M. Schneerson, Volume 1: A Guide to Good Health (Brooklyn, NY: Sichos in English, 2006), accessed 4 December 2017, http://www.chabad.org/therebbe/letters/default_cdo/aid/2306901/jewish/Chapter-7-The-Relationship-Between-Spiritual-and-Physical-Wellness.htm.
  19. Ibid.
  20. Hufford et al., “Spiritual Fitness.”
  21. “What Is Cognitive Behavior Therapy (CBT?),” Beck Institute for Cognitive Behavior Therapy (website), accessed 15 March 2018, http://beckinstitute.org/get-informed/what-is-cognitive-therapy/.
  22. Army Doctrine Publication 6-22, Army Leadership (Washington, DC: U.S. Government Publishing Office, August 2012), 5.
  23. Daniel Somers, “‘I Am Sorry That It Has Come to This’: A Soldier’s Last Words,” Gawker, 22 June 2013, accessed 15 March 2018, http://gawker.com/i-am-sorry-that-it-has-come-to-this-a-soldiers-last-534538357.
  24. Donald A. Morgan, “Mindfulness-based Cognitive Therapy for Depression: A New Approach to Preventing Relapse,” Journal of the Society for Psychotherapy Research 13 (2003): 123–25.
  25. Barbara Bradley Hagerty, “Army’s ‘Spiritual Fitness’ Test Angers Some Soldiers,” NPR (website), 13 January 2011, accessed 4 December 2017, https://www.npr.org/2011/01/13/132904866/armys-spiritual-fitness-test-angers-some-soldiers.
  26. Ibid.
  27. Ibid.
  28. Ibid.

2nd Lt. Noelle Walker is a treatment platoon leader in the 710th Area Medical Support Company, Illinois Army National Guard. She was commissioned and earned a BS in biology from Loyola University in Chicago. She works full-time as an emergency room technician at Bronson Methodist Hospital, the only Level 1 Trauma Center in Southwest Michigan.

May-June 2018