Healing the Invisible Wounds

May 16, 2016

Photography by Juliane Backmann

For nearly 10 years, UCLA’s Operation Mend has been helping to repair the physical injuries suffered in combat in Iraq and Afghanistan. Now, it has launched a program, under the direction of Jo Sornborger, PsyD, that is focused on the psychological traumas of war and the repercussions of mild traumatic brain injury.

In March 2016, UCLA’s Operation Mend, which since 2007 has provided free specialty medical and surgical care to post-9/11-era service members wounded in combat or training, launched a new program to address the psychological damage of war. With a three-year, $15.7-million grant from the Wounded Warrior Project, the Operation Mend Intensive Treatment Program joins Emory Healthcare in Atlanta, Massachusetts General Hospital in Boston and Rush University Medical Center in Chicago to form the Warrior Care Network. The Intensive Treatment Program at UCLA, directed by Jo Sornborger, PsyD, is based on multiple cohorts of 10 veterans, each accompanied by a family member or caregiver. The participants spend three weeks at UCLA, followed by three weeks at home connected via video teleconferencing. Dr. Sornborger spoke with U Magazine contributor Lyndon Stambler about Operation Mend’s new mental-health program.

How does the Intensive Treatment Program differ from the services you have been delivering through Operation Mend?

Dr. Sornborger: Operation Mend has, since 2007, been providing medical and surgical care to wounded warriors. In 2009, we embedded a psychological-health program that focuses on how families are functioning under the stress of war-related injuries and provides psychological-health screening and sessions focused on the patients’ pre- and post-surgical care, with follow-ups after their return home to see how they are managing their recovery. Our new Intensive Treatment Program is dedicated to the mental health of wounded warriors and is focused on providing treatment to these men and women struggling with post-traumatic stress, traumatic brain injury and depression. The program takes a holistic approach and includes four main components: evidence-based treatment for psychological health, healing arts, wellness and community engagement.

Why is this program needed?

Dr. Sornborger: There is a serious gap in care for those returning from post-9/11 military conflicts. Operation Mend patients are chronically or catastrophically injured. Many have traumatic brain injury and/or post-traumatic stress. When they return home, they often have limited access to care and isolate themselves from family, friends and community. We have learned a great deal from Operation Mend patients and family members. We learned that for patients to feel empowered to take on their own healthcare, they need to refocus and rebalance, as a family. They need support to do that. Operation Mend fills that gap in care.

Let’s talk about the psychological-care services that will be provided.

Dr. Sornborger: The overarching framework for our Intensive Treatment Program is really expanding and nurturing our participants’ social networks, beginning with their core social network: their families. Beyond the family, the program expands the participants’ social networks by providing attendees with a cohort that includes 10 patients and their family members, which helps reduce isolation and increase opportunities for support. We then link attendees to national veterans-service organizations and resources within their own communities, providing opportunities for them to feel empowered to access care and support. Operation Mend originated from the Maddie and Ronald Katz family’s vision of a family-focused program. Our goal is to infuse the same focus into our Intensive Treatment Program. Family members are as much a part of the program as our patients. We take time to have conversations with family members. Sometimes it’s challenging. Sometimes it’s eye-opening for them.

What are some of the specific treatments that are provided?

Dr. Sornborger: Two anchor treatments in the new program are cognitive-processing therapy (CPT) for post-traumatic stress and cognitive training. For each, there are 12 sessions over the 21 days our patients and their family members are at UCLA. Since there isn’t a universally applied treatment model for cognitive training, our traumatic-brain-injury team — spearheaded by Delany Thrasher, PhD, director of neuropsychology for Operation Mend; Robert Asarnow, PhD, in psychiatry and biobehavioral sciences; and Christopher Giza, MD (RES ’94, FEL ’96, ’00), medical director for traumatic brain injury for Operation Mend — has developed an integrated model so our patients will receive cognitive training for challenges related to symptoms of mild traumatic brain injury. Patients also receive cognitive-processing therapy for post-traumatic stress. CPT-intervention developer Patricia Resick, PhD, of Duke University, and Carie Rodgers, PhD, of the San Diego VA, are providing case consultation with our clinicians to provide patients with the highest quality treatment for post-traumatic stress. Sessions will address war-related psychological trauma and symptoms related to cognitive challenges such as memory and concentration. CPT and cognitive training focus on developing skills to manage these challenges. We use a variety of mobile apps to support face-to-face treatment sessions. In the sessions and activities at UCLA, our patients learn how to enhance daily life and improve psychological-health skills. After returning home, the three-week video telehealth portion helps to identify whether or not what they have learned is working.

How do healing arts and wellness components fit in?

Dr. Sornborger: This is to connect mind-body-spirit and includes art therapy and equine-assisted psychotherapy. We also offer Qi-Gong (an ancient Chinese health practice), plus acupuncture, acupressure and meditation. We have partnered with UCLA’s John Wooden Center to provide programs such as movement therapy and rock climbing. The Wooden Center has provided an activity menu for patients and families to choose from as part of this wellness component — things like aquatic joint therapy to help with movement. As for healing arts, we incorporated the National Center for the Intrepid’s art-therapy component in which our patients create a mask that is a metaphor for the psychological challenges they have faced in war or while transitioning home. There’s a lot of research on art therapy as a medium to process trauma and psychological issues. A marriage-and-family therapist who also is a licensed art therapist is facilitating our healing-arts program. We also have partnered with Valerie Coleman, PsyD, PhD, and her team at Stand In-Balance for equine-assisted psychotherapy. Her team includes four-legged animals, most often horses, and a mental-healthcare professional who is also a horseman. Many of our patients have service animals, so this is an extension of the human-animal connection, where the horse provides calming and empathic responses to the patient. Our attendees consider this one of the most healing treatment components.

What specific expertise does an academic medical center offer for the treatment of combat veterans with severe psychological wounds?

Dr. Sornborger: UCLA is a tier-one research facility, exemplifying leading-edge research and innovative technology in areas such as traumatic brain injury. Likewise, our academic partners in the Warrior Care Network have well-established research programs on post-traumatic stress and anxiety disorders. This collaboration allows us to share knowledge and spawn research programs to improve the lives of returning warriors and their families.

How do you determine who will be accepted into the program?

Dr. Sornborger: Post-9/11 warriors injured in the line of duty who are struggling with post-traumatic stress and/or traumatic brain injury are eligible. Since not all wounded warriors are in need of intensive treatment, the four academic medical centers in the Warrior Care Network spent a year-and-a-half developing the inclusion criteria and outcomes assessments we believe will demonstrate best practices for our wounded warriors. For our program, our participants must be working with a healthcare team in their communities and be able to travel to UCLA, accompanied by a supportive companion who can participate. At UCLA, before being accepted into the program, our patients will receive advanced psychological and traumatic-brain-injury diagnostics to ensure they receive appropriate treatment.

Substance abuse where the impairment would impede treatment and active psychosis would exclude participation. The benefit of the Warrior Care Network is that each medical center has specialty areas. This enables the participating centers to easily refer patients whose needs warrant a specific site specialty. For example, UCLA may receive an inquiry for a warrior struggling with military sexual trauma or transgender issues. We know this is one of Rush University’s specialties, so even if a warrior is living in San Diego, we would refer him or her to Rush in Chicago. Under the Warrior Care Network, this would continue to be at no financial cost to the participant.

What characteristics would make a patient best suited for UCLA?

Dr. Sornborger: Because we have a wonderfully developed surgical and medical-specialty program, UCLA will receive more physically injured patients and those in need of advanced traumatic-brain-injury diagnostics. We will continue to refine our cognitive training, and I expect programs that focus more on post-traumatic stress will consider sending traumatic-brain-injury patients to us.

How will this network and UCLA help with the societal difficulties faced by these veterans?

Dr. Sornborger: Transitioning back to civilian life is among the greatest challenges faced by post-9/11 veterans. Operation Mend helps to provide a needed, but sometimes elusive, support system. When you add in post-traumatic stress and/or traumatic brain injury, it makes it extremely difficult for the individual to reach out to get the care he or she needs. The VA can be difficult to navigate. Through Operation Mend, and now our Intensive Treatment Program, we have an intermediate and collaborative step that offers hope to patients and their families and provides them with family-focused care that is rarely available. I know from having done this work since 2009 that our service members and their families are very resilient. They have so many talents and are so capable. We remind them of how capable they are and how invested we are in helping them to successfully participate in daily life again.

For more information about UCLA Operation Mend, visit: operationmend.ucla.edu To learn more about the Warrior Care Network, visit: warriorcarenetwork.org