Treating PTSD

Patient undergoing Virtual Reality Exposure Therapy -- photo by John J Kruzel

Patient undergoing Virtual Reality Exposure Therapy — photo by John J Kruzel

Slightly fewer than 200,000 veterans of the wars in Iraq and Afghanistan were found to have service-connected PTSD in 2003. By last year, that number had surpassed 650,000. That means, though, that not everyone who experiences trauma in combat will suffer from PTSD. In fact, when given adequate support, most people recover without needing specific psychotherapy. It is when the person’s natural recovery is disrupted that specialized trauma therapies are needed. Indeed, you may need professional help if the intensity of your symptoms do not subside over weeks or months, when your symptoms cause severe distress, or when your ability to live your daily life is compromised.

According to Barbara Van Daglen of Give an Hour, a non-profit that provides free mental health services to veterans who served in Iraq and Afghanistan, the “D” in “PTSD” should be dropped from our lexicon: “In most cases, especially those without a significant brain injury, they’re going through a reasonable reaction to the terrifying experience of combat,” she says. “If it’s treated well, the effects should be transitory.”

What Works?

In the past decade or so, we have learned a great deal about post-traumatic stress. And even though we do not yet have all the answers, we know enough to take steps to ensure a brighter future for our veterans.

Here is more information on the treatments that have proven to be most effective in reducing symptoms of post-traumatic stress.

Cognitive Behavioral Therapy (CBT) has been shown to be the most effective treatment for post-traumatic stress. Considered the “Gold Standard,” CBT involves working with your cognitions (thoughts) to change your emotions and behaviors. There are several types of CBT currently available:

  • Exposure Therapy: Sometimes called “prolonged exposure”, Exposure Therapy is one of only a few therapies determined in a 2007 Institute of Medicine report to have demonstrated clear effectiveness in reducing the symptoms of post-traumatic stress. Exposure Therapy uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled environment. The goal is to help you face and gain control of the overwhelming fear and distress that are triggered by traumatic memories. Ultimately, Exposure Therapy has been shown to help your body and mind to habituate and relax by disconnecting the traumatic memory from the intolerable sense of fear and distress with which it has been associated. Study after study show that Exposure Therapy helps reduce symptoms and anxiety for those that stay with the therapy long enough for it to be effective.

It sounds simple, but this type of therapy can be very difficult. Reliving the trauma is hard at first, but over time, most patients find it gets easier to talk about it and to engage in activities or situations they had been avoiding. As a result, symptoms tend to lessen and the patient starts to cope with rather than avoid the traumatic experience.

  • Cognitive Processing Therapy (CPT): In CPT, which focuses on trauma-related thought-patterns, as well as the intense emotions that occur following a traumatic event, the therapist will ask you to produce a written narrative about your trauma. The therapist will then teach you to (1) identify and examine upsetting (and often inaccurate) trauma-related thoughts, (2) challenge those erroneous thoughts, and (3) replace them with more balanced and accurate ones. By telling the therapist the details of your trauma, the memories will become organized in a more coherent narrative way, which coincides with a decrease in distressing symptoms.
  • Eye Movement and Desensitization Therapy (EMDR): Eye Movement Desensitization and Reprocessing includes elements from both Exposure Therapy and CPT. It involves you thinking about your trauma while simultaneously moving your eyes back and forth. It’s based on the theory that these rapid eye movements reprogram the brain so that traumatic memories will no longer be upsetting.
  • Virtual Reality Exposure Therapy: Patients undergoing this type of therapy are equipped with a head-mounted visual display that places them in a virtual world in which they experience the sights, sounds, and even smells of combat in order to confront their trauma in a safe and controlled environment. With gradual exposure to memories of the traumatic event, the patient is able to deal with emotions the memories bring up.

Some other therapies you might hear about are Brief Psychodynamic Therapy and Stress Inoculation Training:

  • Brief Psychodynamic Therapy focuses on unconscious processes believed to be expressed as symptoms of post-traumatic stress. According to those who practice this form of therapy, traumatic thoughts and feelings are understood to be so intolerable that they’re forced out of conscious thought. The therapist, in turn, attempts to explore and confront this unconscious material in hopes of making you more aware of it. Ultimately, the hope is that after doing so, you’ll be better able to control how you react to the thoughts, thereby reducing your symptoms.
  • Stress Inoculation Training is an approach that teaches techniques for reducing anxiety, developing better coping skills, and correcting inaccurate thoughts related to a trauma.

Group therapy is another popular approach to treating post-traumatic stress.

So Why Don’t More Veterans Seek Help?

A number of recent studies have shown that less than half of service members and veterans with serious mental health issues actually seek help. For example, one study shows that only 38 to 45 percent of veterans of the wars in Iraq and Afghanistan with symptoms of PTSD, depression, or generalized anxiety disorder showed any interest in obtaining help and that only 23 to 40 percent of those afflicted with one of these disorders had actually done so.

There are several reasons for this.

In addition to fearing that they may be viewed as weak for seeking help, many veterans are afraid that if they start to talk about their trauma, they may lose control and be unable to keep it together at work or at home. According to Dr. Charles Hoge, this fear may not be completely unjustified: “Wartime memories are connected with very strong emotions, some of the strongest that humans can endure.”

Many also don’t feel comfortable speaking with therapists who have not experienced combat themselves. They fear that the therapist won’t be able to understand or relate to what they experienced—or that they will be judged for the things that happen in combat. This fear may also justified: “Many mental health professionals don’t have sufficient understanding of the military experience,” says Hoge, “and have been trained to view problems within a psychological or medical framework, which labels war-related reactions as ‘disorders’ or ‘illnesses’, without differentiating the range of what is normal under these circumstances.”

Lastly, many veterans hesitate to seek treatment for reasons other than those associated with “stigma”, including (1) not being able to get an appointment soon enough after asking for help, (2) navigating complex insurance and reimbursement processes in the private sector, and (3) repeatedly having to miss work to receive a sufficient number of appointments for treatment to be effective.

Above all else, early detection and intervention are essential in slowing the progression of post-traumatic stress. We must, in turn, find ways to make it easier for veterans to ask for help and then tailor treatment to meet their needs.