Benjamin Keizer, PhD, said therapy for trauma recovery in group settings has a synergistic effect, providing support, motivation, and encouragement during rehabilitation.

AAOS Now

Published 12/31/2019
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Terry Stanton

Psychologist Discusses Psychosocial Factors and Recovery after Military or Civilian Trauma

To further delve into the issues raised by the clinical practice guideline (CPG) on the Evaluation of Psychosocial Factors Influencing Recovery from Adult Orthopaedic Trauma, AAOS Now conducted an interview with Benjamin Keizer, PhD, psychologist and the military cochair of the development workgroup (the nonmilitary cochair is Steve Wegener, PhD, MA). Dr. Keizer is a licensed psychologist at the Center for the Intrepid, San Antonio Military Medical Center, Fort Sam Houston, Texas.

AAOS Now: The CPG document states: “Although military personnel operate in the broader context of society, military service members exhibit a unique psychosocial profile that should be considered following orthopaedic injury,” and it refers to the “concept of the military as a subculture.” How do those observations relate to the CPG’s recommendations?

Dr. Keizer: The military landscape is well known for being one of continuous and often unpredictable change. Observing and responding to the environment can mean the difference between life and death, especially during deployment, where a seemingly innocuous cardboard box by the side of the road in Afghanistan could be trash or an improvised explosive device.

The bulk of cultural competence literature tends to highlight ethnic, religious, and/or racial differences. However, during the past decade, the concept of the military as a subculture has also emerged. Although military personnel operate in the broader context of society, the military contains a unique set of spoken and unspoken norms, beliefs, and shared language/vocabulary. The Army, and the military as a whole, is a diverse organization. A huge gap exists in the lived experience between an Army Special Forces Green Beret, an Army medical laboratory specialist, and an Army culinary specialist (i.e., cook). Due to constant combat deployments, Special Forces operators experience an inordinate number of orthopaedic injuries and subsequently often receive treatment at the Center for the Intrepid.

The frequency of worldwide military operations has created conditions where many military personnel have been deployed to combat, with some having repeated combat deployments. Anecdotally, this has resulted in a growing sense of disconnectedness between combat-deployed military and the civilian population, especially for amputees who receive a frequent barrage of questions from the public about amputation and military service. People who approach amputee patients frequently assume that they must have been injured in combat, an often-inaccurate assumption. Although many of my amputee patients are combat-deployed, very few we are currently treating were actually injured in combat. For example, many were injured on deployment but later elected amputation after a failed limb-salvage process or were injured in a motorcycle accident after returning from deployment. The constant, and often unwanted, conversations about the patient’s amputation and service create awkward moments, which can frequently be a focus of clinical attention and intervention.

The disparity between civilians and active-duty members has been highlighted in the literature as well. Information contained in a 2011 Pew Research poll revealed that less than 0.5 percent of the general population has served on active duty in the previous 10 years of sustained combat. Additionally, both military veterans (84 percent) and civilians (71 percent) agree that the public does not fully understand the problems facing military service members. This disconnect most cogently emerges when my patients are involved in public higher education. Helping patients bridge the valley between their expectations of others and the behavior they observe has been an area of repeated intervention.

Benjamin Keizer, PhD, said therapy for trauma recovery in group settings has a synergistic effect, providing support, motivation, and encouragement during rehabilitation.
Benjamin Keizer, PhD

What are some noteworthy differences between military and civilian culture in regard to recovery from orthopaedic trauma, and what are the overlaps?

The foundational lessons learned from the healthcare needs of service members in World War II and the Vietnam War have guided the rehabilitation treatment process in military treatment facilities (MTFs), which has materialized into three main focuses: patient peer support, interdisciplinary treatment, and colocated practitioners with subspecialty skills. One of the primary methods of engaging in the focus of peer support has been centered on delivering physical therapy, occupational therapy, and recreational therapy treatments via group intervention. As a consequence of group dynamic, professionals and patients are able to capitalize on the synergistic role of immediate peer information, support, motivation, and encouragement during rehabilitation following a life-changing amputation or other severe orthopaedic injuries.

The focus of offering colocated subspecialized interdisciplinary teams in MTFs is accomplished through frequent engagement with staff and professionals in case management, psychiatry, dietetics, physical therapy, clinical health psychology, recreational therapy, occupational therapy, research, orthotics/prosthetics, and unit ministry (religious services). Increased health profession specialization, coupled with a movement toward more highly educated rehabilitation professionals (e.g., fellowship-trained clinical health psychologists and clinical doctorates in physical and occupational therapy), has created the condition for fragmented yet overlapping disciplinary knowledge where no single profession can provide comprehensive patient care. An example of specialized rehabilitation professionals can be found with physical therapists in clinical doctorate programs who are now being trained in psychologically informed physical therapy, which includes a large component of “motivational interviewing.”

The “average” civilian orthopaedic trauma patient simply does not have the same resources available to them as the military member does due to myriad reasons, including cost, time-limited access, insurance, and lack of access or availability of true interdisciplinary teams.

In both military and civilian practice, how do you perceive the outlook for incorporating a greater appreciation for psychosocial factors? The guideline notes, “There appears to be low risk of harm in evaluating the presence or absence of psychosocial factors.” What are ways to overcome the “barriers to psychosocial evaluation” mentioned in the CPG?

I would like to see this CPG influence a focus shift toward conceptualization and treatment of the “whole patient” and not simply just the “hole in the patient.” In other words, interdisciplinary care—a dynamic, interdependent, and collaborative process involving multiple disciplines with complementary backgrounds, expertise, knowledge, and skills engaged in decision-making that provides value-added patient treatments and organizational and staff outcomes. Indeed, the hope is that this CPG will encourage and help set the conditions for a holistic, interdisciplinary biopsychosocial approach to rehabilitation and holistic health, nested within an integrative medicine model.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.

Reference

  1. Taylor P, Morin R, Parker K, et al: The military-civilian gap: war and sacrifice in the post-9/11 era. Washington, DC: Pew Research Center. 2011.