CPT Erik Johnson, OTR/L, MS, was treating a military patient who was involved in a firefight in Iraq when the soldier saw his friend killed. After the incident, the man started showing signs that he was not coping well with the memory. He began avoiding people and when he returned to the U.S., he had no interest in the activities that used to bring him joy. But Johnson was optimistic that he could help him.

Cases of post-traumatic stress disorder among soldiers have jumped in the past decade. According to a study published in the June issue of Archives of General Psychiatry, between 8.5% and 14% of soldiers returning from Iraq report serious functional impairment because of either PTSD or depression.

“We are an important part of the behavioral health team,” says Col. Robinette Amaker, OTR/L, PhD, CHT, FAOTA, occupational therapy consultant to the Army Surgeon General. “We can help the team determine how severe the case is ... and then find ways to help them come out of their shells by discovering what motivates them.”

Catching the Signs
In Iraq and Afghanistan, when soldiers begin to show signs that they cannot function in the field, a “moving unit” comprised of an OT or OTA and a psychologist, social worker or behavioral health technician will come to the site to evaluate the soldier.

“Very frequently, a commander will see that someone in their unit is decompensating,” Amaker says. “The soldier may stare off into space, start having problems with anger, or not be able to start basic tasks like getting dressed or shaving.”

First, the team will give the soldier an opportunity to have a long night of sleep and a robust, healthy meal to see if meeting these basic needs improves functionality. If he or she still appears to have symptoms of post-traumatic stress, then the soldier will be referred to a “combat stress unit,” which includes an OT, a social worker and a psychologist. The soldier will travel to the combat stress unit to have several days of counseling and group therapy, and will be asked to perform tasks that require coordination and concentration, such as constructing a tent or building a sidewalk. If soldiers continue to show signs of post-traumatic stress, then they may be sent back to the U.S. for treatment.

Once in the U.S., these soldiers receive care through the Walter Reed Army Medical Center’s Warrior Transition Brigade, an Army program that supports veterans while they are healing. The mission of the WTB is to promote a timely return to duty or to a productive civilian life. OTs work with soldiers in both inpatient and outpatient settings. For example, OTs may lead classes that teach stress management, anger management or life skills.

Engaging Activities
“A lot of times post-traumatic stress soldiers have difficulty with starting and stopping activities, so we want to engage them in something they enjoy to get them up and involved rather than sitting,” Amaker says.

OTs may work with PTSD patients using activities to help them learn to dissect projects into incremental tasks. If someone becomes easily overwhelmed and unable to start, then the OT in a model-building class may suggest that the patient begin by taking off the plastic wrapping. The OT may then ask the patient to perform the next task while he or she steps away for a minute.

Once soldiers are ready to transition to outpatient care within the WTB, they will work with OTs to set career goals and find internships that will give them practice using cognitive and social skills.

“With PTSD, many times soldiers struggle to be in a social setting and with communication,” says Sara Meisinger, OTR/L, chief of the Occupational Therapy Work and Education Program with the WTB. “They are on edge all the time and anticipating that something will go wrong. If they go into a crowded area, they get overwhelmed easily because there is so much to keep track of.”

Typical internships include working as a dispatcher in a fire department or as a dog trainer in the Paws for Purple Hearts program. The dog training internships have been particularly successful with PTSD patients, Meisinger says. In this program, the patients work with trainers to teach dogs over 90 commands that will be needed when the dogs are matched with veterans who suffer from disabilities. The presence of a dog can be calming, plus the dogs and PTSD patients are often learning similar skills, such as how to be comfortable in a noisy, public setting.

Working With Apathy
Some PTSD patients are so depressed that they have no desire to return to normal routines. “One obstacle I face is the patient that doesn’t want to get better,” says Johnson, who is now stationed in Afghanistan. “That’s why the initial interview is so important, because it gives you a chance to build rapport and find out what makes them tick.”

In the case of the soldier who witnessed his friend’s death, Johnson helped this patient re-engage in social situations. At that time, Johnson was working in the U.S., and when the man was an inpatient, he took him to different hospital units to meet staff or other patients. This gave the patient opportunities to practice talking to people. Once he was comfortable, they went downtown to go out to dinner and visit a bookstore.

“It was initially hard for him to relate to civilians who didn’t understand what he had been through,” Johnson says. “But we talked about the fact that most people will never have the opportunity to see what he saw, and he needed to accept the fact that they probably won’t understand.” After two months, the patient was comfortable ordering food at a restaurant and talking to civilians.

OTs such as Johnson, Amaker and Meisinger say the majority of patients who receive treatment improve and re-engage with the activities of daily life.

“It’s hard to see people come back with PTSD when they were happy, energetic people two or three years ago,” Johnson says. “But I enjoy helping those people come back to life. The reward for me is seeing someone go from light to dark, back to light again.”

Heather Stringer is a freelance writer.