PTSD treatment readiness and the looming Iraq war PTSD bubble
This essay concerns Posttraumatic Stress Disorder (PTSD), but it is not intended as an introduction to PTSD. Instead, it discusses current events having to do with America's readiness to provide PTSD treatment to veterans returning from the war in Iraq and Afghanistan. If you don't already know the symptoms and causes of PTSD, this essay might not be the best place to start your reading. Instead, we recommend starting out reading this essay and this topic center for introductory information.
Concern about how best to treat PTSD cases in the population of veterans returning from service seems to be in the news lately. For example, a few nights ago, I happened upon a short CNN segment where a representative from the Department of Veterans Affairs (or VA for short) was interviewed regarding the state of the VA's readiness to care for the mental health and specifically the PTSD needs of returning veterans. There was a rather alarmist tone to this report, and it seemed to me that though the VA spokesperson addressed the questions asked of her fairly well, what she had to say was not what the interviewer wanted to hear. The interviewer said (more or less), "We hear there is a problem with regard to how ready the VA system is to provide PTSD care"; The VA spokesperson said (more or less), "we've anticipated the need for expanded PTSD care, and we've hired more therapists to help make therapy available". The interviewer never really acknowledged that (to my mind quite reasonable) answer but instead went to another guest who again repeated the mantra, "The VA system isn't prepared to address the problem".
Also last week and more importantly, a report from the National Academies (national academy of sciences, institute of medicine, etc.) was released that reviewed current therapies available for treatment of PTSD (see also the Washington Post article). Though multiple therapies for PTSD were evaluated, only one therapy (Exposure Therapy) was identified as adequately supported by scientific data showing it works to treat PTSD. Anyone who only casually glanced at a story about the report might easily come away thinking that the therapies besides Exposure Therapy are all crap, and by extension, many therapists out there who don't practice Exposure Therapy are also crappy. I've come away from these two experiences thinking that it would be easy for someone to encounter the media coverage and walk away thinking that therapists don't know what they are doing when it comes to treating PTSD, and the VA is an incompetent institution, at least with regard to the treatment of PTSD. Neither of these impressions strike me as being all that correct.
The VA and PTSD have a long history
First, the idea that the VA system doesn't know much about how to treat PTSD or isn't doing their job properly is a wrong perception. The VA system, as a health care system specifically designed to provide for the needs of military veterans, has a long history of treating PTSD and is responsible for funding and supporting a large portion of the current research on PTSD. The modern concept of PTSD evolved out of work that was done largely through the VA system (I believe) addressing the needs of veterans returning from the Vietnam War. The fact that PTSD became an official diagnosis in 1980 (with the publication of DSM-III) is not a coincidence but rather is a reflection of the spike in interest in PTSD which resulted from Vietnam veterans returning home and being treated at the VA for their PTSD. The VA's interest in PTSD has continued steadily since this earlier period. The National Center for PTSD, founded in 1989 and currently a locus of much PTSD research related activity, is a part of the VA system, for example.
If I speak well of the VA's long term commitment to PTSD research and care, it is because I have been exposed to it directly as part of my training. The profession of clinical psychology in America and the VA system have been closely allied since shortly after World War II. It is common practice for a clinical psychologist to do a one year internship (similar to a doctor's residency) at a VA hospital after completing academic coursework, but before completing the Ph.D. degree. I did my clinical internship at a VA hospital (at the San Francisco VA medical center during the mid 90s). Probably about 75% of the cases I worked on were PTSD related. I helped to treat PTSD on inpatient units, and in outpatient group therapy formats. I worked on a specialty unit that treated dual-diagnosis PTSD and substance abuse, and with a long term therapy group for veterans with PTSD. I also helped with PTSD service connection evaluations. The point is, my experience of the VA system was that there was a wide array of quality PTSD care available to veterans, much of it tailored to the needs of individual patient groups, and also a fair amount of PTSD treatment research being conducted.
It may sound like I'm a VA fan boy. I'm not. It's an extremely large institution, very political in nature, and it certainly has its share of problems. There may well be problems with how priorities for care are set, or how precious funds are allocated. There are certainly built in conflicts of interest in the system. For instance, the same institution that handles healthcare for veterans disabled by PTSD is also responsible for evaluating and paying service connection payments (which are monthly payments intended to compensate veterans wounded during service for their wounds, including emotional wounds like PTSD). This unfortunate linkage motivates some veterans to present themselves as more wounded than they are (so that they can get paid), and also I think encourages unnecessary cynicism among clinicians who start to see veterans as potentially exaggerating their problems. That sort of gamesmanship should not ideally be injected into the healthcare relationship, but there it is.
I'm not connected to the VA system anymore and don't have first hand knowledge of how it is functioning today other than what I read. Despite the bad press I mention above, what I'm basically saying here, is that I continue to trust the practitioners who work at the VA to do everything they can to provide quality care for PTSD and other mental and physical problems that veterans will present to them. If the VA says they are (have been) ramping up to provide more PTSD care, in anticipation of returning veterans from Iraq, I see no reason to doubt that statement. In spite of that best effort, it is also obvious that there will be constraints and not everyone will get everything they might want with regard to treatment. This is a federal government sponsored program in the era of the Bush administration, remember. After Katrina, anyone who places too much confidence in any federal program is probably being idealistic.
The best psychotherapy treatment for PTSD
The secondary concern I noted above has to do with which treatments are useful for treating people with PTSD. The recent National Academies report reviewed the scientific support for a variety of therapies used to treat PTSD and has concluded that only one therapy (Exposure Therapy) has adequate scientific support at present suggesting that it is effective specifically as a treatment for PTSD. Other therapies, including cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing therapy (EMDR) may work or may not work, but there aren't enough well designed scientific studies of these therapies offered specifically as treatments for PTSD to support their use at present. Note carefully that the report in no way is suggesting that these therapies are bad or useless as treatments for PTSD. It is only saying that the data is not in yet to conclusively judge their utility and effectiveness.
In order to understand why this report is important and how it could be (but should not be) misinterpreted, it is important to understand how therapy has been evolving in the last decades. Psychotherapy is a very diverse and broad field that is actually composed of completing subfields (See my essay "Philosophers, Engineers, Ecologists and Gnostics: Four Approaches to Psychotherapy). In the 1980s when PTSD was a new diagnosis, with one exception, it was very rare for psychotherapies to be subject to scientific studies designed to measure their effectiveness. Psychotherapy was simply not generally an evidence-based field in those days. The exception to the anti-science mindset that governed therapy was behaviorism, which was an approach to psychotherapy that literally grew up within academic psychology departments and which was very scientific in its approach from the start. During the years between 1980 and 2007, the old health insurance system melted down and managed care came into being, which created a minimum reimbursement mentality that wanted to pay for as little care as possible. The only variety of care that such managed care organizations could not justify rejecting was care that had been scientifically proven to be effective and thus could not be easily dismissed (as they could be held liable for withholding it). Behavioral approaches to psychotherapy thrived in the new environment, and other forms of therapy either died out or adapted. Today, it is starting to be the case that any therapy that is not "empirically validated" (e.g., scientifically proven) is considered suspect.
It would be easy to read the National Academies report and conclude that only Exposure Therapy should be offered to returning veterans with PTSD because it is the only therapy which has specifically been validated for the treatment of PTSD. This conclusion would be overly conservative, however, because it fails to put the problem of treating PTSD into proper perspective.
PTSD is a variety of anxiety disorder. This classification is not an accident, but rather a considered decision based on the characteristic symptoms associated with PTSD, which include hyper-reactivity and startle response, intrusive nightmares and waking dreams, and avoidance of situations that trigger trauma memories. The primary thing that keeps anxiety disorders of any variety going strong is that last symptom cluster known as avoidance. In essence, people experience something that makes them fearful, and then they avoid that thing in the future. By avoiding that thing that has triggered the fear, people minimize the amount of fear they experience, but also minimize the possibility of their learning that their fear response is exaggerated or no longer appropriate to the situation in which they find themselves. In avoiding having to feel their fear, anxiety patients also avoid the opportunity to unlearn their fear and so remain trapped inside their fear. Exposure therapy, an application of behavioral therapy, works by asking anxious people to expose themselves to what they fear and to hold themselves in that fear without escaping it until they can habituate to the fear (learn at a body level that the fear is not merited so that the fear level decreases). Usually, exposure therapy is done in stages. A fear hierarchy is constructed, where approximations of the feared thing are ranked in order and then progressively offered to the patient in sequence. The patient experiences fear to each level of the fear hierarchy and then learns that there is nothing to fear really and calms down some. As each level of fear is mastered, the next level of fear stimulation from the hierarchy is offered until the top level is reached and mastered. The type of feared stimulation offered to each anxiety patient is different, and tailored to their diagnosis and unique fear circumstances. Old school Vietnam veterans often reported an avoidance response to the sound of helicopters, so that might have become something that they'd want to habituate to in the context of exposure therapy.
One size does not fit all
Exposure therapy is not an easy therapy to get people to want to participate in. As you might imagine, if you are terrified of something and the best treatment available requires you to expose yourself to that thing again and again, you might want to avoid therapy. It is consequently important to have alternative therapies to offer patients who cannot tolerate the preferred therapy. If an alternative empirically validated therapy is not available (which is the case in this instance), then the next best thing to offer someone is a therapy which is empirically validated for treating related problems, and which theoretical models predict should be helpful. This would describe the status of cognitive behavioral therapy as it is used in the treatment of PTSD. Cognitive behavioral therapy is empirically validated for the treatment of agoraphobia, for instance, which is a paralyzing anxiety disorder in which people experience panic attacks (usually) and then start avoiding the places where those attacks have occurred, ultimately forcing them to become prisoners in their own homes. Agoraphobia and PTSD are not the same thing by any means, but they are closely related nevertheless.
Secondary or alternative treatment approaches are also nice to have around to be able to offer to people who do not respond to the primary recommended treatment for one reason or another. Sometimes there are subsets of people with a particular disorder who end up responding better to one treatment approach than to another. Also, people have different needs and different personalities and different treatment approaches appeal more to some than to others. A particularly verbal patient might prefer a course of cognitive behavioral therapy for anxiety to a pure exposure therapy (because CBT will emphasize her verbal strengths), and that would be okay if it worked. The important thing is that people's suffering is relieved without causing them further harm.
Here is a final reason why a diversity of treatment approaches are important, even if all are not optimal. New treatment approaches come about when clever therapists who are familiar with a variety of approaches to helping people (not all of which are scientifically validated) recombine those various approaches so as to create something new. Dialectical behavior therapy for borderline personality disorder and related conditions, which is one of the major therapy advances of the last 20 years, is a case in point. DBT represents a clever recombination of monk style meditation techniques and cognitive behavioral therapy. Monk meditation was never designed or scientifically evaluated as a treatment for borderline personality disorder issues, and yet it works well in combination with CBT style elements. If the alternative therapy approaches that are going to represent the next breakthrough in PTSD treatment are not represented or if experimentation is not encouraged, then few therapists will ever learn about such alternative approaches and any wisdom encoded in those approaches won't become available. This is not to say that all approaches should be allowed because any might contain something helpful. That would clearly be bad practice. What I am suggesting is that a certain amount of openness to new and alternative approaches needs to be retained even in an era of empirically validated therapy or therapies will become static and will cease to be improved upon.
The conclusion of the National Academies report, and also of this essay, is not that therapies other than exposure therapy for the treatment of PTSD should be banned, but rather that more research is needed, and this time in a hurry so that alternative therapies for PTSD can intelligently deployed when the real PTSD crisis time hits. The real crisis time is not right now (although we are in the ramp-up period). The real crisis time will begin when the war is over (or when a significant number of troops come home), and it will last for years afterwards. PTSD is a delayed stress response. It can occur quickly but it can also (and commonly does) occur months and years after exposure to trauma. We might have a year or so before the poop hits the fan, maybe we'll continue to be at war and the crisis will be put off for a while longer. In any event, a PTSD crisis is coming, no doubt about it. There is not a lot of time to do the work necessary to optimize therapies at this point, so let's hope that the powers that be at the National Center for Posttraumatic Stress Disorder go Manhattan project on it.