Air Force Maj. Pamela Novy, PhD, is a frequent visitor to Arlington National Cemetery’s Section 60, where many of the more than 5,700 service members killed in Afghanistan and Iraq now rest. As a clinical psychologist with the Deployment Health Clinical Center on the grounds of Walter Reed Army Medical Center in Washington, D.C., Novy goes there with service members she is treating for post-traumatic stress disorder (PTSD). As her patients walk among the white stone markers, they often come across the graves of friends and colleagues. Grief that’s been held in check, sometimes for years, comes flooding out. They stand by a grave and talk, or go back to the van and cry, Novy says.

“When they’re in Afghanistan or Iraq, if a person’s gone, the attitude is, ‘We’ve got missions that have to go on, numb it out and drive on.’ So for many of them, this is the first time they’ve actually faced the loss that they experienced,” Novy says.

Novy is one of the psychologists working for a component center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, or DCoE. In addition to providing direct care for service members struggling with trauma, these psychologists promote resiliency, help service members and veterans monitor their health and well-being, and develop new tracking methods to prevent service member suicides.

The need for those services and expertise is great, and steadily increasing. About 2.4 percent of the nearly 2 million service members who’ve deployed to Afghanistan since late 2001 and Iraq since early 2003 have been diagnosed with PTSD, says Air Force Lt. Col. Christopher Robinson, PhD, DCoE’s senior executive director for psychological health.

In addition, about 15 percent of all service members who’ve deployed report PTSD symptoms, and a similar percentage experience depression, he says. Service members, particularly those who have been deployed more than once, also deal with high rates of divorce and substance abuse, and their children often experience academic and discipline problems at school.

“What we’re trying to prevent is 10 or 15 years from now, having a bunch of people with chronic PTSD that didn’t get the care they needed,” Robinson says. “There is a sense of urgency here.”

Authorized by Congress in 2007, the DCoE is the umbrella organization for the Center for Deployment Psychology, the Center for the Study of Traumatic Stress, Defense and Veterans Brain Injury Center, Deployment Health Clinical Center, National Center for Telehealth and Technology and the National Intrepid Center of Excellence. Here, the Monitor reports on the work of several psychologists who are playing critical roles in promoting resilience and recovery.

Confronting pain

As director of the Specialized Care Program of the Deployment Health Clinical Center, Novy is mainly responsible for running a treatment program for service members with PTSD located at Walter Reed. The program offers three weeks of therapy, eight patients at a time. Patients participate in group therapy, two weekly sessions of individual therapy, educational lectures and sessions of yoga and acupuncture, too.

Patients come from all branches and levels of the military. Most have suffered at least one mild traumatic brain injury from an improvised explosive device. Many are also experiencing trouble with spouses and children due to repeated separations.

“What we hope to accomplish is that they can function better, that they can engage in more pleasurable activities, rather than avoiding things, that there’s more joy in their lives, and better relationships with spouses and family members,” she says.

Since Novy took over the program in March 2010, she’s sharpened the focus of the field trip to boost its therapeutic benefits. At Arlington, the patients also visit the Tomb of the Unknown Soldier. “It’s a hard trip to make for some but what happens is they realize they’re stronger than they thought they were,” Novy says.

Novy’s program is achieving results, says clinical research psychologist Kristie Gore, PhD, who directs research and program evaluation for the Deployment Health Clinical Center. As measured from assessments given the first day of the program, then again near the last day of treatment and one and three months out, patients experience clinically significant decreases in PTSD symptoms and depression. Their general mental functioning also improves and physical health complaints decrease, she says.

“We don’t expect to get rid of someone’s PTSD or heal them, if you will, in three weeks, but we expect to put them on the road to recovery, and give them the tools they can use to solidify those treatment gains,” Gore says.

The fact that Novy has experienced some of the same stresses as her clients while in Iraq from June 2008 to January 2009 helps her build a better rapport, she believes. She says she only wishes she could do more.

“There are lots of people who aren’t getting the services they need,” she says. “Sometimes it’s because they don’t speak up.”

Preventing suicide

As deputy director of the National Center for Telehealth and Technology, psychologist Mark Reger, PhD, helped design a new suicide surveillance system to help improve the military’s suicide prevention efforts. Suicide remains a significant problem in the military, with a 37 percent increase from 2006 to 2009 for the Army alone.

Before Reger led the initiative, the Army, Navy, Air Force and Marine Corps, each maintained separate reporting systems for suicides, and sharing and comparing information was often difficult, Reger says. With the new Department of Defense Suicide Event Report, whenever a suicide or suicide attempt occurs, an investigator collects almost 250 pieces of information on each incident, including information about the service member’s stressors, mental health, family and deployments.

The surveillance system has already drawn out some patterns. For example, the service members who are most likely to die by suicide are young white males of lower enlisted rank who have less education and who recently divorced. People who have had problems with the military’s judicial system may also be at higher risk for suicide, Reger has found.

Reger hopes that this information will help practitioners reach out to those service members most likely to need help, before an attempt occurs.

“One suicide is one too many, and we need to be doing everything we can,” Reger says.

For his next project, Reger will start tracking suicides among combat veterans by comparing the names of some 4.75 million service members who served in the military from 2001 to 2007, many of whom deployed to Afghanistan and Iraq, with the National Death Index maintained by the Centers for Disease Control and Prevention. Trying to understand the suicide rate among former service members, including veterans from National Guard and Reserve units — and not just those who are serving on active duty — could help the Departments of Defense and Veterans Affairs develop more effective suicide prevention programs, he says.

Long-term, the study could also help determine if serving in the military during the years of America’s involvement in Afghanistan and Iraq is associated with a higher suicide rate.

“It’s a very exciting study that we believe will be able to fill some key gaps,” he says.

Training mental health professionals

Psychologist David Riggs, PhD, is tackling military mental health on another level. As executive director of the Center for Deployment Psychology on the campus of the Uniformed Services University of the Health Sciences in Bethesda, Md., he leads a program training military and civilian psychologists, psychology interns, residents and other behavioral health professionals to provide high quality deployment-related behavioral health services to military members and their families.

The center conducts a two-week training program for military behavioral health professionals, primarily psychologists, five times a year as well as shorter sessions for civilian providers located near military and VA hospitals throughout the country. During the two-week military provider training, participants learn about the challenges of providing mental health services in combat situations and deployed environments from psychologists who’ve been there. They learn about the impact of traumatic stress on service members, the stresses families face during long separations, the challenges of reintegration and how to work with physically injured service members. Another vital part of the training is hearing from service members who’ve experienced traumatic stress, Riggs says. “What sticks with me from the various stories I’ve heard is how many times that even as they come seeking help, they’re looking for reasons to turn away again,” he says.

In the coming year, the CDP will expand a new program, a one-day workshop designed for college and university counseling centers. The first half of the daylong program briefs employees who might typically interact with service members and veterans, such as career development staff, on some of the key challenges faced by this population, while the second half orients mental health providers on the effects of combat and deployment stress.

Bringing technology to the front lines

Julia Hoffman, PsyD, is using technology to address two major challenges among service members: the continuing stigma associated with mental health treatment, and geographic distance from treatment facilities, particularly for those who served in National Guard and Reserve units.

As a psychologist with the National Center for Telehealth and Technology, Hoffman develops content for www.afterdeployment.org, the DCoE website where service members, veterans and their families can get information on ways to build resilience and address psychological problems.

The site averages about 4,000 hits a month. Last year, Hoffman helped develop the content for two smart phone apps: a mood tracker and a deep breathing app. The idea is to give veterans and service members convenient access to psychological help.

These tools are “always accessible and they can be used in the natural environment of the user,” Hoffman says.

The mood tracker app is designed to help people monitor their moods, and the deep breathing app is meant to help reduce stress, anger and anxiety with a time-proven relaxation technique. The deep breathing app uses images and auditory commands to guide users through an exercise to slow down and deepen their breathing, Hoffman says.

“The overall goal is to gain control over the physical and psychological responses to stress,” she says.

These days, Hoffman is helping to build a suite of apps called the Virtual Handheld Clinic, which is slated to be released gradually for use over the next two years. The suite may include, for example, an app that would enable patients going through prolonged-exposure therapy to do out-of-session therapeutic exercises. Another app could help a mental health provider assess whether he or she is experiencing compassion fatigue and burnout.

“For those who aren’t in care, it provides an opportunity to have a sort of digital crutch that can actually give you feedback and provide you with things to try that you might not have tried otherwise,” she says.