This is the last post I’m doing on combat PTSD, at least for a while, and to write it I’ve been searching for answers to this crucial question. What are the treatments that actually work? It’s the same question that I spent years struggling with as I tried one therapy after another to help with depression. The military is experimenting with a great many alternatives to standard medication, including several also used for treating depression. I’m not at all surprised since this condition so commonly adds to the other problems of PTSD.
That leads me to ask your help in thinking about effective treatments. Some of you have PTSD as well as depression, whether through exposure to a single overwhelming event or a more prolonged experience living in a threatening, unsafe environment - and whether or not you’ve had a formal diagnosis. These experiences may not compare to the violence of combat and daily living with lethal threats all around, but the problems of treatment are similar. Imperfect as the parallel may be, I’d like to hear about what’s worked for you.
The whole question of treatment also raises the question of what its goal is - how far can it go in improving life? A recent comment by the blogger at Healing Combat Trauma has given me a new way to think about this. He points out that there’s a big difference between “healing” and “curing”.
As he sees it, curing is all about reversing the course of an illness by treating symptoms. He calls this looking for the “toggle switch” to turn them off. Healing is a process that restores a state of wellbeing, a “flourishing condition” - as the dictionary defines “health” - and takes much longer to achieve in a sustainable way. That distinction makes a lot of sense to me and brings out the fact that new approaches to PTSD in the military definitely look to curing rather than healing.
The military is experimenting with all sorts of alternative treatments. There are programs testing the effectiveness of Reiki or “touch healing,” spiritual ministry, yoga practice and Qi Gong - a form of controlled breathing, meditation and physical movement that is a mainstay of Chinese healthcare. These must sound far out to the conservative military, but, of course, they’re widely used in civilian life.
The one treatment that is well supported by rigorous trials is a form of cognitive therapy known as Prolonged Exposure. It consists of repeated telling of the story of traumatic events - exactly the ones the veteran wants to avoid - in order to defuse their impact and enable relaxed remembrance of the past. The result can be an ability by the veteran to talk calmly about memories that used to bring on terrifying nightmares. This form of exposure, combined with other cognitive therapy to change negative habits of thought, has worked well with such veterans as Warren, who told his story in the PBS series, This Emotional Life.
The military is trying additional ways of achieving this same goal. EMDR is one technique now in use. That stands for Eye Movement Desensitization and Reprocessing. Like the concept of exposure (though EMDR is not “prolonged”), the patient re-imagines and discusses traumatic events while tracking the movement of a rapidly moving finger with his/her eyes. The intent is also to create emotional distance from trauma and to reprocess thinking about the experience.
A third approach - though aimed at a more limited outcome - puts veterans back into combat situations by means of virtual reality. This medium creates a full sensory experience of scenes similar to the ones where traumatic events occurred. This is often done while monitoring stress reactions to measure the moderation of responses, especially the “startle” response to sudden, unexpected sounds and sights - a symptom that turns everyday life into a constant lookout for danger.
A recent article in the Huffington Post by Belleruth Naparstek has a good overview of other experiments - all aimed at curing specific symptoms associated with particular parts of the brain. One uses biofeedback to help a veteran measure his ability to induce changes in heart-rate and other stress indicators through guided imagery, progressive relaxation and breathing exercises.
Prior to introducing those techniques, the therapist explains in basic terms the neurophysiological changes that PTSD produces. This crucial step helps a patient see the condition in more objective, physical terms instead of emotional and moral ones. The emphasis is on empowering veterans with skills that they can use on their own. This approach avoids the terminology of curing illness and presents the treatment as training to master new life skills.
All these experiments emphasize the curing of symptoms during short, intensive treatments. The goal is not only to improve a patient’s condition but also to do so rapidly, at reasonable cost and with techniques that can be put into wide use.
In sharp contrast to these methods is the extensive therapy approach set out by psychiatrist Jonathan Shay in Odysseus in America. The book summarizes his work with Vietnam veterans and describes the major phases in healing that he uses together with his colleagues in their Veterans Improvement Program.
Rather than think in terms of curing symptoms, Shay’s method seeks a healing of the whole person, both on an individual level and as part of family and community.
To address this total condition, the method starts with reducing the intensity of the worst symptoms and restoring the body through sobriety and the ending of wild behavior. Medication may be used to enable veterans to focus on the work of healing. Safety and trust have to be established, and to do that the primary message of the program is “You are not alone.” Veterans work primarily in groups of their peers, with the professionals more in the background. Veterans can readily establish trust and a sense of safety with each other since they all have first-hand knowledge of combat trauma.
In that safe group setting, the veterans support each other in telling their stories. This enables them to mourn their losses and reach a point where their pent-up feelings can be released. In Shay’s program for Vietnam vets, this always includes a visit to the Vietnam Memorial in Washington, DC, that black granite wall inscribed with the names of the more than 58,000 soldiers killed in the war. Often, the act of coming to that shrine and finding the names of their long-dead friends is the moment of emotional breakthrough and release.
The third phase of this program is a reconnection with spouse and children, if they haven’t been permanently alienated. It also involves a reaching out to the larger social community. Veterans may do that by volunteer service, by speaking to civic groups, by sharing their stories at supportive public gatherings or other forms of social engagement. The idea behind reconnection is both to rebuild the closeness of intimate relationships and to restore purpose and structure to their lives.
Dealing with PTSD and depression is a complicated process. While everyone seeks long-term healing, the reality is that most therapies have the more limited goal of improving the worst symptoms. Of course, these go together, but veterans dependent of government-sponsored care often don’t have the option that the rest of us might have to undertake the longer and more demanding treatment that tries to achieve a full reintegration into family, work and social life.
So I’d like to ask what your experience has been with treatments. Do you think the short-term curative approaches can add up to long-term healing? Which therapies have you tried, and which have really helped?