There was a time when Sean Brack would encounter a sticky floor and be transported back to war. He would peel his foot up from the floor of a movie theater, and it would remind him of standing in a pool of blood, and walking through that blood to get to a wounded friend.

The flashbacks happened in 2010, when Brack thought of killing himself. After three tours to Iraq, Brack, a sergeant first class, had problems sleeping, isolated himself, and was on his way to becoming an alcoholic, he recalled. He was due to deploy to Afghanistan with the 504th Battlefield Surveillance Brigade from Fort Hood.

Then, Brack, 47, entered part of what would become a series of studies at Fort Hood on a type of therapy for post-traumatic stress disorder, called cognitive processing therapy.

Studies have been done on CPT’s effectiveness on civilians and veterans, but a paper published Wednesday in JAMA Psychiatry included results of the largest study on the treatment’s effectiveness on active duty soldiers to date.

Over the course of 12 sessions at Fort Hood, nearly half of active duty soldiers in one-on-one therapy and 40 percent in group therapy recovered from PTSD, the study found.

More Information Demographics of CPT study Total: 268 service members Average age: 33. Time in service: 10.9 years No. of deployments: 2.3 Suicide ideation: 17.5 percent Married or cohabiting: 67.9 percent Ethnicity or race: Black: 28 percent Hispanic: 23 percent White: 40 percent Other: 8 percent Source: JAMA Psychiatry

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The results, however, show CPT’s effectiveness among military members lags behind its effectiveness among civilians, according to one of the study’s authors.

CPT examines how someone thinks about a traumatic event and how that affects their emotions, said Patricia Resick, a professor of psychiatry and behavioral sciences at Duke University who developed CPT in 1988. CPT, along with prolonged exposure therapy, are the two primary “talk” therapy methods used to treat PTSD.

In a small room with 10 people, some in uniform and some not, Brack attended group sessions of CPT over 12 afternoons, twice a week for six weeks. “What you focus on is what you're feeling now, and trying to find out what are the triggers for those things,” Brack said.

According to the Department of Veterans Affairs, about 11 to 20 out of every 100 veterans who served in Iraq and Afghanistan have PTSD in a given year.

“When a trauma happens later, you revert to old thinking,” Resick said.

When bad things happen, many people believe it’s because they are bad people or did something wrong, she said. Control issues, either going out of control or becoming a control freak, was something Resick observed both in soldiers with PTSD and also in the rape victims for whom the therapy was originally developed.

In Brack’s case, he became a control freak. He was a platoon sergeant, responsible for keeping his soldiers safe. He would plan endlessly for every possible contingency on missions. When he came home, he was unable to turn away from this kind of thinking. Even for small decisions he’d stay up at night, thinking about contingencies.

CPT, Brack said, helped him learn what he could control. “I put down the problem,” he said. “I totally shut myself off from it and tell myself this is not life or death now, this is not something that has to be solved before I sleep tonight.”

He likened his problems to a Gordian knot. "It's never just one problem." he said. "It was like a big ball of tangled string, and there was no telling where the ends were or how to get through it."

The problem of how to treat PTSD may be another Gordian knot.

CPT’s effectiveness on active duty soldiers with PTSD is not as strong as among civilians, which researchers said is a point of ongoing research.

The study included 268 soldiers, with 135 in individual therapy and 133 in group therapy. It began in 2012 and finished in 2014 as part of the mufti-institutional STRONG STAR Consortium, which is funded by the U.S. Department of Defense and based at The University of Texas Health Science Center at San Antonio.

Alan Peterson, director of the consortium and one of the authors of the study, said about 80 percent of civilians can be treated to the point where they don’t have PTSD within 12 sessions of CPT.

“With veterans, the results have not been as good: 40-50 percent,” said Peterson, a professor of psychiatry at the UT Health Science Center San Antonio.

Among active duty soldiers, results from the most recent study found CPT’s effectiveness also to be around 40 to 50 percent.

“Our hope is if we intervene early, we might be able to get more promising results,” Peterson said. “As it turns out, we didn’t get that. We didn’t get the same kinds of results with civilians. It’s closer to the results we get with veterans.”

The study also found that individual CPT sessions had better results than group sessions, such as the one Brack attended.

“Our hypothesis was that it would be equal,” Peterson said.

In an editorial in JAMA Psychiatry to accompany the study, three authors, Charles Hoge, Daniel Lee and Carl Castro, called the CPT study at Fort Hood “one of the most important clinical trials to emerge from the Department of Defense and Veteran Affairs (DOD/VA) research portfolio.” They noted, however, that much still needs to be done in the field of treating PTSD

“Unfortunately, this state-of-the-art clinical trial demonstrated group CPT to be only half as effective as individual CPT two weeks after treatment,” the authors wrote.

The editorial also noted the high number of soldiers who did not complete 12 CPT sessions. Only 155 of the 268 soldiers completed nine of 12 sessions.

Resick said the dropout rate in most of her other CPT studies was very low. Many of those who failed to finish CPT at Fort Hood left due to the unique transitory nature of the Army, either to being discharged or moving to another duty location or deploying, she said.

“When you're dealing with active military they're moving around,” Resick said. “Our intentional dropouts is a low percentage.”

Peterson said there are five current studies to dive deeper into the results of the most current study. Future studies may measure whether military PTSD could require additional sessions of CPT, which is normally 12 sessions.

“There’s nothing magic about 12,” Resick said, adding that some patients will be allowed to have up to 24 sessions.

These questions, and others on treating PTSD, are to be explored in future research, Peterson said.

Brack said he got better after completing CPT, and that on his next deployment to Afghanistan he had better strategies for handling his emotions. The father of two retired in 2014 and now lives in Lampasas.

He said he realizes his symptoms will never be completely gone. Memories still “ooze out.” Still, he said he’s learned how to think about what he thinks about when he encounters triggers like sticky floors.

“It's not a closed box that you're afraid to open, you already know what it is that you're trying to do, that you're trying to look at it,” Brack said. “It's easier to take it out and talk about what you've discovered.”

jlawrence@express-news.net