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A Systematic Review of Biopsychosocial Training Programs for the Self-Management of Emotional Stress: Potential Applications for the Military

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A Systematic Review of Biopsychosocial Training Programs for the Self-Management of Emotional Stress: Potential Applications for the Military Hindawi Publishing Corporation Evidence-Based Complementary and Alternative Medicine Volume 2013, Article ID 747694, 23 pages http://dx.doi.org/10.1155/2013/747694 Review Article A Systematic Review of Biopsychosocial Training Programs for the Self-Management of Emotional Stress: Potential Applications for the Military Cindy Crawford,1 Dawn B. Wallerstedt,1 Raheleh Khorsan,2 Shawn S. Clausen,3 Wayne B. Jonas,1 and Joan A. G. Walter1 1 Samueli Institute, 1737 King Street, Suite 600, Alexandria, VA 22314, USA 2 Samueli Institute, 2101 East Coast Highway, Suite 300, Corona Del Mar, CA 92625, USA 3 Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 8, Room 5106, Bethesda, MD 20889, USA Correspondence should be addressed to Cindy Crawford; [email protected] Received 10 May 2013; Revised 26 June 2013; Accepted 22 July 2013 Academic Editor: Tobias Esch Copyright © 2013 Cindy Crawford et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Combat-exposed troops and their family members are at risk for stress reactions and related disorders. Multimodal biopsychosocial training programs incorporating complementary and alternative self-management techniques have the potential to reduce stress- related symptoms and dysfunction. Such training can preempt or attenuate the posttraumatic stress response and may be effectively incorporated into the training cycle for deploying and redeploying troops and their families. A large systematic review was conducted to survey the literature on multimodal training programs for the self-management of emotional stress. This report is an overview of the randomized controlled trials (RCTs) identified in this systematic review. Select programs such as mindfulness- Based Stress Reduction, Cognitive Behavioral Stress Management, Autogenic Training, Relaxation Response Training, and other meditation and mind-body skills practices are highlighted, and the feasibility of their implementation within military settings is addressed. 1. Introduction Multimodal treatment programs, as compared to single modality treatments, have emerged as an important option Combat-exposed troops and their family members are at in the management of stress disorders [8, 9]. Compared to risk for stress reactions and related disorders [1]. Strategies treatment with a single modality, multimodal programs have to enhance psychological resilience among service members the potential to simultaneously address a range of stress reac- are needed. Providing this training prior to deployment tions, both physical and mental, as well as the dynamic nature might preempt or attenuate the posttraumatic stress response, of the disease process over time. Applied at the population depression, anxiety, and other consequences of overwhelm- ing stress. level, the increased variety of modalities potentially has a greaterchanceofprovidingviablealternativesforagiven Complementary and alternative medicine (CAM) and individual. integrative medicine (IM) approaches to self-management of emotional stress are increasingly utilized within comprehen- The military is already a culture in which self-care is rec- sive care models [2]. Surveys have affirmed the widespread ognized as a vital tool in warfare: adequate nutrition, hydra- use of integrative modalities in military populations and set- tion, and sleep are part of a warrior’s battle kit. Therefore, self- tings, including Department of Defense (DoD) beneficiaries management skills that are delivered as multimodal programs [3], active duty military [4], and patients using Veterans involving CAM/IM may be an ideal option for the military Health Administration (VHA) hospitals [5–7]. community to help build resilience, reset the autonomic 2 Evidence-Based Complementary and Alternative Medicine nervous system, and ease emotional stress. Consequently, 2.1.2. Complementary and Alternative Medicine (CAM) in tandem with the mainstreaming of many CAM practices Modality. CAM is defined at the National Center for intheciviliansector,militarypersonnelmayseekCAM Complementary and Alternative Medicine as: any of a therapies to improve their health and well-being, especially number of “diverse medical and health care systems, those CAM therapies that are self-manageable and drugless. practices, and products that are not generally considered A number of model biopsychosocial training programs part of conventional medicine” (http://nccam.nih.gov/). exist in the civilian sector [10–13]. Several have adapted For the purposes of this review, the authors included their programs to the military [10, 12–14], and a smaller only CAM modalities that also met our criteria for the number have provided training to military personnel [14]. biopsychosocial model and self-management technique However, to date, there has been no comprehensive sys- (http://www.ncbi.nlm.nih.gov/mesh/?term=complementary tematic review of multimodal biopsychosocial programs for +therapies) and used definitions of CAM techniques of the self-management of stress. The authors posit that these breathing, relaxation, yoga, imagery, hypnosis, and med- interventions could be markedly effective for individuals in itation as described by the National Center for Health high-stress environments such as the military. Statistics on the NCCAM website: http://nccam.nih.gov/ health/providers/camterms.htm. 1.1. Purpose of the Review. A comprehensive systematic review was conducted to (1) survey multimodal biopsy- 2.1.3. Self-Management Technique. Self-management tech- chosocial training programs with at least one CAM/IM niques are techniques in which skills are used independently component for the self-management of emotional stress by an individual without ongoing reliance on a trainer or across all populations; (2) assess the quantity and quality of therapist. The authors excluded interventions where patients the research and programs; and (3) characterize the results solely learn and integrate therapies by themselves (such as by type of program and strength of evidence on stress- through a book or online material) or ones that are trainer related outcome measures. Due to the massive amount of or therapist dependent (i.e., psychotherapy that requires a the literature included, the full report of this review will be therapisttoleadthesessions). detailed in a much larger report, not suitable for detailing in one paper. The purpose of this current report is to (1) 2.1.4. Multimodality Interventions. These interventions are focusonthosestudiesthatwerescoredashighqualityand defined as those ones that have two or more interventions (at demonstrated statistically significant results between groups least one of which is CAM modality) that require an initial (i.e., intervention group versus control or comparison group) training period with a therapist or trainer in which skills are on outcomes of emotional stress for controlled trial study learned, all of which can be transferred into self-management designs; (2) describe the multimodal programs available and techniques. The authors only included programs that have their characteristics; (3) describe the results of outcomes multimodal interventions. An example is a program that related to emotional stress; and (4) discuss what the authors includes relaxation, exercise, and behavioral techniques to believe to be the resource requirements needed to incor- reduce stress. The thought here was that multimodal pro- porate these programs into a military setting for service grams would allow for more of a biopsychosocial approach members and their families. The authors have chosen to to treating the whole person for the complexities of emotional report this subset of data since studies assessed as high stress. qualityaccordingtointernalvaliditycriteriaaretheleast likely to have introduced bias, are more likely replicable, and 2.1.5. Types of Program. Typesofprogramsthattheauthors can be trusted to show a valid effect for the intervention considered were those that include training in at least one and population being studied [15, 16]. If these studies are self-management multimodal training with the intention to generalizabletootherpopulations,thenitisreasonableto reduce psychological or emotional stress. The program did anticipate that an effective program, if implemented in a not necessarily have to be an existing named program per se military environment, could show equivalent benefits for this but had to include interventions that could be developed into highly stressed population. a program (e.g., a potential program). The authors included educational training programs as long as they met these 2. Methods criteria. 2.1. Concepts and Definitions 2.2. Search Strategy. The following electronic databases were searched from database inception through February 2.1.1. Biopsychosocial Model. The biopsychosocial model 2009 across keywords identified: PUBMED, EmBase, (abbreviated “BPS”) is a term introduced in 1977 by the Amer- BIOSIS, CINAHL, the entire Cochrane library as well ican psychiatrist George Engel which describes a health care as the database of abstracts of reviews of effectiveness perspective that acknowledges that biological, psychological (DARE), PILOTS, PsycInfo, AMED, ERIC, and DoD (which entails thoughts, emotions, and behaviors), and social Biomedical Research. Gray literature was also searched factors all play a significant role in
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