B0038M1ADS EBOK (37 page)

The foundation for therapy is built through empathy and normalizing
the warrior's experience. This means helping the warrior to understand
that they're not crazy; that their reactions make sense in the context of
their experiences; that their reactions are part of the body's normal protective responses; that it's very hard for anyone to imagine what it would be
like to go through what they went through; that no one is in any position to
judge or second-guess what happened, except perhaps their own buddies
who were actually there (and even then, that might not be correct); that reactions to current stresses make sense in the context of everything that
has happened in their life; and that you'll help them to the best of your
ability to successfully navigate their difficulties and serve as their ally and
advocate. It's helpful to point out to the warrior any of their strengths you
observe that will help them be successful and to provide them with a summary of what to expect in future sessions.

The other component of an empathetic response, in addition to normalizing the warrior's experience, is the ability to be aware of your own
feelings and reactions, whether there's sadness, horror, disgust, appreciation, laughter, etc. That doesn't mean that you have to express all of these
emotions openly (although that can be good, depending on the situation),
but you have to at least be aware of them as they're occurring and not filter
them. The warrior needs to feel that you're "online." Since warriors often
do a very good job of compartmentalizing their wide range of experiences,
thoughts, and feelings, as well as dissociating each from the other, modeling the opposite can be most beneficial.

Minimize the use of psychological concepts and jargon; provide clear
and straightforward handouts. For example, warriors don't need a detailed
education on the topics of "assimilation" or "accommodation," given that
the psychological definitions of these terms don't have much to do with
the English-language definitions, and the fact that "accommodation" in the
English language doesn't mean the same thing as "integration," which is
the preferred concept to talk about with warriors.

They also don't need handouts with extensive "if' statements. (For
example, "If you had prior positive experiences in your relationships with
others and in relation to powerful others, you may have come to believe
that you could influence others" or "If you previously believed that 'I can
control what happens to me and can protect myself from any harm,' you
will need to resolve the conflict between prior beliefs and the victimization
experience," two actual quotes from commonly used patient handouts on
control and safety from the 2007 Veteran and Military version of Cognitive
Processing Therapy.)

Avoid starting sentences with the words, "You need to " or
"You will need to " or "It is necessary to (consider this or that, do this or that) or "It is important to understand (or realize) that
", because these types of statements presume that you know
what's best for them, and that you're there to deliver answers to them
rather than to help them to learn or discover the answers for themselves.

Be very careful with the diagnostic labels that you apply. Avoid personality disorder (Axis II) labels, even "traits," as this often conveys more about
what the health-care professional thinks of the client than what is beneficial for the client's treatment. If you have to write something in the Axis
II diagnosis section, write "No Axis II Diagnosis" rather than "Deferred."
All medical labels, particularly those in the Axis II category, can affect how
the warrior views him- or herself, as well as how all health-care professionals view and treat the warrior. Axis II labels undoubtedly cause much more
harm than good in overall health care.

It's important to appreciate that many behaviors considered "negative" or "maladaptive" are beneficial. They may not be beneficial to others
or society, but serve a useful purpose for the individual. For instance, probably the surest way to reinforce survivor's guilt is by labeling it a "cognitive
distortion" or "negative affect."

In contrast, encouraging the behavior in the right way resolves it by
helping the warrior to discover exactly why they "punish" themselves, why
they believe they deserve punishment, what they're punishing themselves
for, and what they get out of it (they do get something positive). See chapter 9 for more on this topic.

TYPES OF TREATMENT OFFERED: THE COLD, HARD FACTS

This section will cover the range of commonly used treatment options and
their effectiveness and limitations, including psychotherapy, medications,
and other emerging therapies. The treatment of PTSD, depression, and
anxiety often utilize very similar or identical techniques and medications.
Consequently, this section will stay focused on PTSD, but bear in mind
that these same treatments are applied to the other conditions as well.
(The treatment of symptoms related to concussion/mTBI was discussed
in chapter 2.)

Treatment Effectiveness

Often just going to see a mental health professional can be of benefit even
if the professional doesn't prescribe a specific "evidence-based" treatment
(a treatment that has been shown in scientific studies to be effective). This
is because there are effects just from making the effort to talk to someone
about your problems. Because of this, any scientific study of treatment
effectiveness has to include a comparison (control) group of people who
receive no treatment or another type of treatment. A treatment is only
considered to be "evidence-based" when it has been proven to be effective
through such a comparison, preferably repeated in several studies.

So how effective are PTSD treatments for combat veterans?

The answer is not so effective-at least, not what we would like to
see. Often the difference in improvement between people who receive
treatment and people in comparison groups is small. Because of this, it's
necessary to try different strategies, combine them, and modify treatment
to find the right approach that will work for each individual.

Medications

A prominent review of the effectiveness of medications for PTSD concluded
that overall, 59 percent of people with PTSD who received medications
recovered, compared with 39 percent of people with PTSD who were given
pills that looked exactly the same but didn't contain any medicine (placebo
pills). This means that just going to see the doctor and receiving a placebo
pill resulted in a benefit for nearly 40 percent of individuals with PTSD; the
medicine was effective in increasing the number of people who recovered by
only 20 percent, and there were still 40 percent of people who did not recover
among the treated group. The review was based on studies in which both
the patients and the doctors evaluating them did not know which pill the
patients received (a "double-blind" scientific design). This ensured that the
conclusions were free of biases, such as the expectations of patients or doctors that the medicines would be beneficial. The results of this review didn't
take into account that some people may have experienced partial improvement in PTSD symptoms or improvement in depression symptoms, which
often coexist, so there may have been some benefits that weren't measured. On the other hand, the review's conclusions were based almost entirely on
studies in civilians, and there is good evidence that combat-related PTSD is
more difficult to treat and less amenable to cure with medications. One of
the only studies involving combat veterans was published more than ten years
after it was conducted, and showed no benefit of treatment using one of the
medications most commonly prescribed for PTSD, sertraline (Zoloft).

Psychotherapy

Studies of various psychotherapy treatments have also shown less than optimal results. It's generally believed by experts in the field that certain types of
psychotherapy, particularly therapies involving cognitive or exposure techniques, are more effective for PTSD than medications. However, there have
been very few head-to-head comparisons, especially in combat veterans.
Studies of the effectiveness of psychotherapy are often influenced by biases
because there isn't a way to keep the patient and doctor "blind" to the group
the patient is assigned to. For example, imagine that you agree to participate in a research study of a promising new psychotherapy, but are told that
you have to wait ten weeks to get treatment; this indicates that you've been
assigned to the no-treatment control group (conveniently termed the "waitlist" group). You (and the other members of this group) may get pissed off,
and probably won't get any better in the next ten weeks (and in fact, may get
worse), while those assigned to the treatment group get to experience the
benefits of treatment immediately. The vast majority of research studies on
psychotherapy have been done this way, and this obviously stacks the deck in
favor of demonstrating that the treatment (whatever it is) is effective. In one
widely cited study of veterans with PTSD conducted by the U.S. National
Center for PTSD, 40 percent who received a therapy called "Cognitive Processing Therapy" recovered, compared with 3 percent of those from the
wait-list control group. Notice that despite the large difference in recovery
between the two groups, the 40 percent recovery rate of the treated group
was similar to the overall rate of recovery in medication studies.

The best psychotherapy-effectiveness studies provide a sham "treatment"
to the control group that includes regular visits with a therapist, who gives
support but doesn't apply any of the specific treatment techniques. These types of studies eliminate biases inherent in the studies that use wait-lists, and
result in smaller differences between groups. For example, in a large 2007
study of women veterans with PTSD, 41 percent recovered from exposure
therapy compared with 29 percent who received the sham "treatment."

Overall, in various psychotherapy studies for PTSD, it's common for
no more than 50 percent of treated individuals to show greater improvements than would be expected naturally (by chance) in the individuals
who did not receive treatment. This is referred to as "effect size," and is a
complicated way of saying that results in treated and non-treated groups
overlap a lot, that many people recover with no treatment, and that the
effectiveness of treatment is not as high as we would like to see.

While the rates of full recovery from PTSD in research studies are
somewhat discouraging, the good news is that most studies show that a
larger percentage of people experience partial recovery. Overall, most
people can expect at least moderate improvement from treatment if they
stick with it. One of the key factors in the effectiveness of psychotherapy
is a willingness and ability to remain in treatment for long enough to benefit; this generally takes at least ten to twelve visits, and sometimes much
longer. Many people drop out of therapy; the reasons are poorly understood, but likely have as much to do with the personality and skills of the
therapist as with the client's own circumstances.

Among psychotherapy techniques, there has been a lot of debate as to
whether exposure therapy or cognitive techniques are more effective. In
2008, the U.S. Institute of Medicine published an extensive review of the
medical literature on treatment of PTSD focused on military and veteran
populations. This respected organization concluded that exposure therapy
(elements of which are described in detail in chapters 6 and 7) had the
highest evidence for effectiveness. One study by National Center for PTSD
investigators showed that simply writing about one's trauma for up to an
hour each week, combined with reading this to the therapist and briefly
discussing it, had nearly the same effectiveness as the complete cognitive
processing therapy program. What the overall data appear to mean is that
we really don't know what works in therapy and that narrating your story is
probably better than any other type of therapy technique or medications.

Harm from Treatment

One thing to consider is that professional treatment has the potential to
cause harm. For example, if you're struggling with issues of grief, loss, or
survivor's guilt that the mental health professional thinks is depression or
PTSD, or you have concentration and memory problems due to PTSD that
the professional believes is caused by an mTBI, or your post-war reactions
are misdiagnosed as a personality disorder, then this could lead to negative
self-perceptions, ineffective treatment, or harmful side effects. Everything
that clinicians do in medicine carries risks, including the diagnostic labels
they apply.

In a 2007 study, we found that soldiers referred for PTSD from the DoD
post-deployment health assessment who failed to show up for their mental
health appointments actually did better than soldiers who attended their
appointments. Although it's likely that soldiers who followed through with
their appointments had more severe PTSD symptoms (and therefore were
in greater need of treatment), the study highlighted that many soldiers
got better on their own, and that referral from the post-deployment health
assessment didn't necessarily result in the desired outcome.