I’ve been a little skeptical about using prolonged exposure therapy to treat post-traumatic stress disorder. Revisiting a trauma over and over again to become habituated to it seems fine in theory, but it has to be agony for vets already traumatized by those events.

So I was pleased to participate in a keynote panel at a conference, Preventing and Treating the Invisible Wounds of War: Combat Trauma and Psychological Injury, at the University of Pennsylvania Law School’s Center for Ethics and the Rule of Law. It featured Dr. Edna Foa, the professor of clinical psychology who invented the therapy.

PE therapy has been embraced by both military psychologists and the Veterans Administration, and Foa insisted that was because it is effective in treating PTSD. So far, about 1,300 mental health professionals have been trained in PE, she said.

She cited statistics showing that 1.8 percent of men in the civilian population have PTSD compared to 5.2 percent of the women, 9 percent of the Vietnam vets and 20 percent of the Iraqi/Afghan vets. There’s no real explanation for the difference between the two vets’ groups except that PTSD didn’t become a diagnosable disorder until 1980, five years after the war in Vietnam had come to an end.

She noted that the military suicide rate, which had traditionally been lower than the civilian rate, has nearly doubled during the Iraqi/Afghan war, exceeding the civilian rate in 2010. One service member kills himself nearly every day, she added, while male veterans are twice as likely to commit suicide as men in the general population

Then Foa addressed treatment, which she said is likely to be either prolonged exposure therapy (PE) or cognitive processing therapy (CPT) in the military and the VA.

PE involves repeated revisiting and recounting traumatic memories that are otherwise avoided because they cause so much pain. After remembering the traumas, there’s a period of processing them, including a recognition of changes of perception that might have occurred as a result. Therapists focus on fear and anxiety, but also on shame, guilt and anger. A second part of the treatment is approaching situations that the vet has been avoiding to show that they are safe in a post-combat world.

CPT involves changing a vet’s thinking in four major ways: learning about PTSD symptoms, becoming aware of thoughts and feelings, learning skills to help question or challenge feelings, and understanding changes of belief that commonly occur after undergoing trauma.

Both therapies may take 10 to 12 sessions – or more, depending on the severity and number of the traumas.

Foa cited one 2007 study of 284 female vets that showed PTSD severity dropped from 80 percent on the PCL scale to 50 percent after PE treatment. PCL is a 20-item, self-report list that measures the 20 symptoms of PTSD that are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

She also cited a 2013 study of 1,931 vets being treated by the VA that showed 62.4 percent exhibited significant improvement of at least 10 points over their baseline PCL scores, with 49 percent dropping below the 50 PCL threshold for diagnosing PTSD.

Her conclusion was that PE and CPT are both more effective than just counseling, although she noted that a few studies have shown military personnel didn’t do as well.

“Some experts suggest that military traumas include more moral injuries than civilian traumas,” said one slide in her powerpoint. “Moral injury is associated with more severe PTSD and with suicide.”

In an aside, Foa told me she didn’t believe the concept of moral injury was a particularly useful one.

She also addressed the issue of inflicting too much emotional distress on patients in a paper published last year in the journal of Cognitive and Behavioral Practice.

“A concern that some clinicians may have with providing PE is patient overengagement, which is excessive emotional distress resulting from imaginal exposure,” she wrote. “Some patients may initially experience significant distress when reviewing their trauma narrative. Should overengagement occur, clinicians can modify exposure procedures to help patients remain grounded while describing their traumas.”

Nonetheless, she said patient dropout was only about 20 percent, about the same as other therapies.

More on this in our next blog.