Thinking Outside the Clinic: Researching Novel Approaches to Improving Psychological Health

By: Cindy Thomsen, Ph.D., Health and Behavioral Sciences Department Head, Naval Health Research Center

When it comes to finding new ways to treat familiar illnesses and injuries, military medicine has always been on the frontline of the fight. This holds true whether the illness or injury is physical or psychological. Navy Medicine researchers are leading the charge to think beyond traditional treatments and explore innovative approaches for improving the mental health, well-being, and readiness of our service members.

At the Naval Health Research Center (NHRC), personnel from our Health and Behavioral Sciences team and their collaborators have been studying novel interventions to improve the mental health of service members.

Two approaches being explored to improve service member psychological health seek to address post-traumatic stress disorder (PTSD) and depression.. One area of research is a study examining the effects of surf therapy for PTSD, depression, and related symptoms; and the other addresses the challenge of treating patients with both PTSD and major depressive disorder (MDD) by evaluating a new treatment approach  combining two different, evidence-based interventions specifically targeting each condition.

Surf Therapy

Surf Therapy (6)

When it comes to surf therapy, staff from the Naval Medical Center San Diego’s (NMCSD’s) Wounded, Ill, and Injured (WII) Wellness Program have a well-established program. They currently offer surf therapy as a six-week program to help our wounded service members recover through physical activity. While surfing has been used to promote recovery for these service members, few studies have examined surfing as a complementary form of therapy for physical and psychological symptoms.

NHRC researchers are partnering with NMCSD’s WII staff to study whether surf therapy also improves the psychological and physical symptoms of injured service members. Researchers want to know: can surfing as therapy improve health outcomes for patients with PTSD, depression, and related symptoms?

According to previous research, physical activity – cardiovascular exercise, resistance training, and yoga – can positively impact mental health outcomes. Physical activity is also associated with improvements in specific conditions and symptoms such as PTSD, depression, and pain. Research indicates physical activity can promote physiological changes that produce effects similar to those of antidepressants.

Additionally, past studies have suggested , beyond simply being physically active, doing so in a natural environment and including social interaction may have an even greater positive effect. Exercising in the presence of water was shown to have the greatest improvements in self-esteem and mood. Based on these findings, surfing would appear to be the perfect activity for a complementary and alternative medicine (CAM) approach to therapy to treat the psychological wounds of our service members.

Surfing is not only a water-based physical activity but also includes social interaction by providing the opportunity for surfers to interact with each other as they wait to catch the next wave. Essentially, in addition to the psychological benefits of the physical actions associated with surfing, it may also act as a form of group therapy.

To further examine these potential benefits, NHRC researchers are working with the NMCSD team to explore both the immediate and longer-term effects of the WII Wellness Surf Therapy Program on the health and readiness of active duty service members by assessing their psychological and physical symptoms over the course of the program. The team will also assess patient satisfaction to fully evaluate the program. Findings from this study will help determine if surf therapy is a beneficial and viable form of treatment for patients with PTSD, depression, and related symptoms.

The study is enrolling active duty service members who receive care in the WII Wellness Surf Therapy Program and having them complete validated, self-report assessments before and after the six-week program, as well as before and after each surf therapy session.

The surf therapy study will not only provide a foundation for future program evaluation studies at other military hospitals and clinics, but also  may contribute to advancements in CAM approaches to treating our service members. Potentially, surf therapy may have long-term benefits for patients and military medicine alike.

For patients, surfing is an activity that many embrace as a life-long pastime, which may serve to help service members who benefit from this therapy a way to maintain their gains over time and reduce their risk for relapse.

For military medicine, leveraging the already well established WII Surf Therapy Program means this intervention does not place additional demands on the military health care system as there is no need to develop new programs or provide additional resources. A win for service members, a win for military medicine, a win for readiness, and a win for innovation.

Cognitive Processing Therapy (CPT) + Behavioral Activation (BA)


In service members and civilians, PTSD is often diagnosed with MDD, a combination associated with greater symptom severity, greater disability, more frequent health care visits, and increased suicide potential. Despite the fact  that these two conditions often occur together, there is currently no psychological treatment  specifically addressing  both.

Patients with both PTSD and MDD often receive evidence-based treatments for PTSD, such as cognitive processing therapy (CPT), a treatment recommended by the Departments of Defense and Veterans Affairs. While this, and other evidence-based PTSD treatments, typically reduces symptoms of both disorders, many individuals still have a diagnosis of MDD after completing treatment.

Researchers at NHRC and collaborators from Naval Medical Center San Diego and Naval Hospital Camp Pendleton are piloting a study that may offer a better way to treat service members with both PTSD and MDD. Researchers developed a novel treatment program combining CPT with behavioral activation (BA), a standard treatment for depression. The goal is to determine if combining these two therapies achieves a significantly greater improvement in depression symptoms than CPT alone.

NHRC researchers selected BA to enhance CPT in their novel treatment design because it is known to effectively reduce depression. Additionally, because it targets behavior, researchers anticipate it will complement the cognitive emphasis of CPT, which encourages patients to examine their trauma-related beliefs.

Researchers randomly assign patients to receive either CPT or the combined CPT and BA intervention. Study participants will complete clinician-administered and self-report PTSD and depression measures before and after treatment, including a three-month follow-up assessment. Additionally, participants will be asked to complete the self-report measures at each session in order to monitor their symptoms throughout the course of their treatment.

To date, there have been no studies that compare an integrated treatment for PTSD and MDD to current evidence-based PTSD treatments. NHRC researchers want to remedy that research gap in an effort to find better ways of treating our wounded warriors and improving their health outcomes.

By looking beyond current and traditional therapy practices and examining novel approaches to treatments that are more effective, our researchers aim to improve the lives, functioning, and readiness of active duty military.

Thinking Outside the Box/Clinic

Surf Therapy (3)

Being able to provide more effective treatments for service members is part of Navy Medicine’s mission. When service members suffer from psychological illnesses and injuries, being able to address their mental health treatment needs requires thinking outside the box and beyond clinic walls. And that’s exactly what NHRC and our collaborators are doing.