At Intrepid Spirit Centers service members may use art therapy as a modality within their individual treatment plan (Photo by: Madigan Army Medical Center, Joint Base Lewis-McChord, Washington).

"What we try to do is to get the patient to a place where they are able to take back control of their personal narrative and defeat the enemy within."

The treatment team reinforces that the service member is not "inadequate, defective, or broken," but rather is at war with the enemy within.

Engel explained that providers can increase their effectiveness by entering into the warrior culture and partnering with the service member.

"We try to frame our program in military language and how to win. It's a different way of understanding," he said. "We enter the culture of the warrior. We need to adapt and adjust to their culture to create a victory."

Four weeks after the program concludes, self-report measure for PTS, depression, and sleep are significantly improved, Engel noted.

Patients also take an objective neuropsychological standardized test called Microcog during the first two days of the program and after four weeks outside the program. Microcog is a computer-based measure of cognitive function that is task based and looks at nine cognitive domains: general cognitive functioning; general cognitive proficiency; information processing speed; information processing accuracy; attention/mental control; reasoning/calculation; memory; spatial processing; and reaction time.

The Department of Defense uses a similar test for all soldiers preparing to deploy called ANAM, or Automated Neuropsychological Assessment Metric.

"We see highly statistical and clinically significant improvements in six of nine neuropsychological domains," Engel said.

One reason for service members' success is that they “have learned to modulate their affect," and as a result, their cognitive functioning seems to have improved, Engel noted.

"Their brain seems to be able to perform and function better on objective measures," he said. "The psychological 'noise' and pain become more manageable because of the simultaneous care provided."

Service members are aware of the model of care before deployment.

U.S. Public Health Service Capt. Alicia Souvignier, director, Warrior Recovery Center/ISC at Fort Carson in Colorado, explained that "service members are briefed pre- and post-deployment on concussions and the services of the ISC. We also have relationships with primary providers and behavioral health teams that refer patients to our clinic."

The outpatient recovery center at Fort Carson offers services in neurology, physical medicine, neuropsychiatry, social work, physical therapy, occupational therapy, speech language pathology, and music therapy to patients who have had more than one concussion in the past year or have symptoms of TBI/PTS.

It offers individual treatment for issues affecting the patient, including memory, attention, emotional well-being, anger management, dizziness/balance, sleep, and vision. There is also a six-week IOP that addresses symptoms of TBI in the interdisciplinary format.

Patients at ISCs have access to a nationwide TBI portal "that allows us to manage each patient's plan of care, track the patient, and regularly check in on progress of the patient toward goals," Souvignier said. “The portal also allows us to produce a comprehensive discharge plan to do a warm hand-off to the patient's primary care manager."

Each ISC uses the others as resources and "we are truly a team," she said; however, "each post has a different population and different resources, so the same solution doesn't always work everywhere."

Intrepid Spirit Centers are located at military bases in seven states, with planned expansions of two more ISCs. The National Intrepid Center of Excellence is located at Walter Reed National Military Medical Center in Bethesda, Maryland (Photo by: Defense Intrepid Network for TBI and Brain Health).

There are 10 state-of-the-art ISCs across the country. In addition to Fort Hood and Fort Carson, there are ISCs at Eglin Air Force Base, Florida; Camp Pendleton, California; Fort Bliss, Texas; Fort Campbell, Kentucky; Fort Bragg, North Carolina; Fort Belvoir, Virginia; Joint Base Lewis-McChord, Washington state; and Camp Lejeune, North Carolina. The overarching NICoE is located at Walter Reed National Military Medical Center in Bethesda, Maryland.

Dr. Thomas DeGraba, chief innovations officer of the NICoE, stressed the importance of the interdisciplinary model of care used across ISCs.

"We created NICoE as a proof of concept that an interdisciplinary, holistic, and patient-centric outpatient program can heal mind, body, and spirit from the invisible wounds of war," he said. "The model of care allows each ISC team to build a care plan for the individual service member."

Prior to the creation of the NICoE in September 2010, one of the biggest problems among the service members was the stigma of TBI and PTSD, DeGraba explained. "The feeling was that patient recovery could only plateau to a certain extent. Our mission was to break down that misconception."

The research done from interactions with the service members who participate in the program helps inform clinical practice guidelines for TBI that are a combined effort, not just for military specialty clinics, but for primary care physicians and neurologists in civilian practice, DeGraba expounded.

"The end goal is to place service members on a path to heal the brain from traumatic injury and psychological health conditions and allow service members to return to full active duty and be in control of those things that were taken from them in combat.