Some psychologists are gung ho about using prolonged exposure therapy to treat PTSD, but others are more skeptical.<\/p>\n
\u201cIt\u2019s a terrible therapy, just terrible,\u201d Dr. Bessel van der Kolk, medical director of the Trauma Center at the Justice Resource Center, exclaimed as we walked to a PTSD conference at Penn Law\u2019s Center for Ethics and the Rule of Law. \u201cIt merely re-traumatizes vets who have previously been traumatized. You can quote me on that \u2013 and you should.\u201d<\/p>\n
Other vets and counselors were less outspoken, but equally troubled by this therapy.<\/p>\n
\u201cIt\u2019s very intense,\u201d observed Cathy Coppolillo, a staff psychologist for nearly a decade at the Clement J. Zablocki VA Medical Center in Milwaukee. \u201cI\u2019d guess that half the people we try to treat with PE get a few sessions into the protocol and disappear. Not only do they go away untreated, but they think all therapy looks like that.<\/p>\n
\u201cIn those cases, we\u2019ve probably lost the person for good, which feels like the worst way possible to fail a patient,\u201d Coppolillo added. \u201cSo if I\u2019m unsure at all about their ability to tolerate PE, we do something else.\u201d<\/p>\n
Coppolillo said other VA hospitals around the country have also been reporting a 50 percent dropout rate for PT patients. But Dr. Edna Foa, who invented the therapy, insisted that the attrition rate is no more than 20 percent, which she said was about average for all therapies.<\/p>\n
Coppolillo screens her patients for the ones that might benefit from PE because it can reduce the intensity and frequency of nightmares and flashbacks, she said. But not all qualify. Some can\u2019t deal with intense emotions involved in reliving traumas.<\/p>\n
\u201cThe combat vets I see have learned (via combat experiences and military training before that) that emotions are potentially life threatening, given their ability to destabilize and distract from the tasks at hand,\u201d she told me. \u201cSo emotions are more than just unpleasant and unfamiliar \u2013 they feel life threatening. And that\u2019s one of the reasons so many vets drop out of treatment.\u201d<\/p>\n
Many vets show up at the VA medical center suffering from PTSD as a result of the roadside bombs that blew up their buddies and forced them to begin filling body bags with pieces of their comrades, Coppolillo said. And PE can work for those vets.<\/p>\n
But PE is not very effective in treating the wounded soul syndrome, Coppolillo said.<\/p>\n
\u201cSo many of these vets are suffering with a moral injury because they were forced to do things that violated their moral code,\u201d she explained. \u201cRevisiting these horrible memories can habituate vets to traditional PTSD, but it can\u2019t touch that sense of guilt.<\/p>\n
\u201cI think about one vet who had some pretty rough stuff done to him during his year in Iraq, but he\u2019d also done some pretty rough stuff to others,\u201d she said. \u201c\u201dWe tried PE, but habituation doesn\u2019t do much for moral wounds. Finally he said to me, \u2018I\u2019m just a monster, and I\u2019m going to have to live with that fact for the rest of my life.\u2019\u201d<\/p>\n
Without atoning for their actions and forgiving themselves, many vets become stuck \u2013 kind of like the \u201cdry drunk\u201d who throws away the bottle, but never finds anything to replace it.<\/p>\n
\u201cSo many veterans feel they don\u2019t deserve to move forward and live happier, more fulfilling lives, given the \u2018monster\u2019 they feel is lurking within them,\u201d said Coppolillo. \u201cThis limits the effectiveness of any kind of treatment (including PE) if someone feels they deserve their suffering and that to fix it would be morally wrong. In my experience, this is unbelievably common.\u201d<\/p>\n
At the PTSD conference, Foa said she didn\u2019t believe the concept of moral injury was a particularly helpful one.<\/p>\n
About a quarter of her patient load at the VA medical center in Milwaukee involves military sexual trauma, Coppolillo said, and they are a little easier to treat than moral injuries.<\/p>\n
\u201cMy experience has been that PTSD symptoms that arise from sexual trauma seem to resolve a bit more quickly than do symptoms related to moral injury,\u201d said Coppolillo. \u201cMy gut sense is that that\u2019s probably because there isn\u2019t the same sense of moral injury holding the symptoms in place.<\/p>\n
\u201cCertainly, sexual assault survivors feel a deep sense of guilt\/responsibility because of any number of choices they might have made at the time, but that seems to be a really different animal from the deep soul injury many combat vets face,\u201d she added. \u201c\u2018I made a bad choice and that resulted in my assault\u2019 is very different from \u2018The choices I made prove to me I\u2019m a monster.\u2019\u201d<\/p>\n
Another observation is that traumas from the distant past are about as treatable as more recent ones, but they may take longer to treat.<\/p>\n
\u201cI think about our Vietnam vets and how lengthy their treatment tends to be,\u201d said Coppolillo. \u201c\u201dThey\u2019ve spent years suffering and generally not doing well in jobs and relationships that they end up building their identity around their brokenness. Like moral injury, that identity creates a scaffolding that holds the PTSD symptoms firmly in place, and disassembling that scaffolding tends to be quite a bit of work.<\/p>\n
\u201cSo is therapy less effective with stuff that\u2019s 40-plus years old?\u201d she asked. \u201cI wouldn\u2019t say that, as much as I would say it\u2019s more effortful and takes longer because there\u2019s more you have to drill through before they\u2019re really ready for help.\u201d<\/p>\n
One VA counselor, who\u2019s been working with vets since 1970, said he actually tries to steer vets away from dwelling on past traumas.<\/p>\n
\u201cPeople come to me with their slop buckets and try to dump them on me all the time,\u201d he said. \u201cBut I don\u2019t see the need for them to sit and tell me their problems for an hour a day every week for 10 years \u2013 that just builds mental memory and reinforces the slop.<\/p>\n
\u201cThey don\u2019t have to tell me, and I don\u2019t have to listen\u201d said the counselor, who asked that his name not be used because he hadn\u2019t cleared the interview with the VA public information office. \u201cI ask them what their specific problems are and what resources they need to overcome those problems. Then we stack the resources together and allow the vet to process his problems with new resources to collapse the threat.\u201d<\/p>\n
Another Vietnam vet told me of his experience with exposure therapy while undergoing PTSD treatment at the Tomah (Wis.) VA Medical Center.<\/p>\n
\u201cIt was very intense,\u201d he said. \u201cGuys were literally on their knees in tears.\u201d This vet said he told the class how he mistakenly killed two South Vietnamese men that he encountered in the jungle where no one should have been, then checked their bodies and found they were civilians with no weapons.<\/p>\n
\u201cIt was very relieving (to get that story out),\u201d he said, \u2018but I wouldn\u2019t want to do it again.\u201d<\/p>\n
One of the major limitations of most therapies, including prolonged exposure therapy, is that they fail to provide vets with a sense of purpose similar to the mission they experienced in the armed services, said Coppolillo.<\/p>\n
\u201cIf we\u2019re talking about recovery writ broadly for these veterans \u2013 not just from PTSD as a narrowly defined diagnosis, but from ways that their military experience has wounded them \u2013 this question of meaning and purpose is huge,\u201d she explained. \u201cI spend hours each week discussing it in both group and individual sessions.<\/p>\n
\u201cThe loss of belonging to something bigger than the self, and of a defined mission, is so painful, and it\u2019s one of the biggest barriers I see for folks trying to recapture\/create a life that makes sense,\u201d Coppolillo said.<\/p>\n","protected":false},"excerpt":{"rendered":"
Some psychologists are gung ho about using prolonged exposure therapy to treat PTSD, but others are more skeptical. \u201cIt\u2019s a terrible therapy, just terrible,\u201d Dr. Bessel van der Kolk, medical director of the Trauma Center at the Justice Resource Center, exclaimed as we walked to a PTSD conference at Penn Law\u2019s Center for Ethics and […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-396","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/posts\/396","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/comments?post=396"}],"version-history":[{"count":0,"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/posts\/396\/revisions"}],"wp:attachment":[{"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/media?parent=396"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/categories?post=396"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/ericnewhouse.com\/blog\/wp-json\/wp\/v2\/tags?post=396"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}