Many veterans never dreamed of needing help coping with life following combat deployments. While the impact of surviving in a combat zone has left many veterans seeking help in overcoming posttraumatic stress disorder (PTSD), there have been significant advances in treatment. An overview of available therapy approaches for PTSD can enhance a veteran's treatment options. There are three evidenced-based psychotherapies researched with veterans and recognized to be effective in the treatment of combat-related PTSD. Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), and Eye Movement Desensitization and Reprocessing (EMDR) are all accepted as being effective treatment approaches. Each form of therapy has the potential to make a positive difference in the lives of veterans who are treated. Since each therapy addresses specific treatment issues, veterans should know that if one treatment has not worked well for them, other options are available in your community.

Veterans dealing with PTSD frequently exhibit symptoms of distress when recalling memories, thoughts, feelings, and situations related to the traumatic event. Sights, sounds, odors, and images become triggers for veterans who suffer with hypervigilance, reexperiencing of nightmares and flashbacks, along with avoidance/numbing responses. Veterans learn to manage such anxiety by developing an avoidance response toward anxiety-producing experiences. CPT, PE, and EMDR treat the presenting issues of PTSD in their own unique way.

Prolonged Exposure (PE) exposes the veteran to re-experiencing the traumatic event rather than avoiding it. It usually lasts about nine sessions for each trauma. The veteran is asked to relive the upsetting memories along with the strong emotional and physiological responses as the trauma event is recalled in a controlled setting. The goal is to help relieve the distress by reducing the power of the memory as the veteran is repeatedly exposed to the thoughts, feelings, and situations related to the trauma. The PE treatment begins by educating the veteran regarding his/her symptoms as well as understanding the goals of the treatment. Next, the veteran is taught how to control their breathing as a means of relaxing.

Then the veteran is asked to describe the memory in detail as though it was happening in the present (e.g., "I see blood"). During the 90-minute sessions this is repeated 2-3 times. The sessions are audio taped and the veteran is asked to listen to the tape as homework once a day until the next session. The other form of homework is called In vivo exposure. The veteran is asked to identify locations that cause them anxiety, like going to a mall. They are then asked to go there for about 30 minutes and stay with the anxiety until it begins to decrease. These exposure processes are designed to assist the veteran in gaining more control of their life, their thoughts and feelings, as they confront the trauma response. Over time it is anticipated the anxiety surrounding the trauma event will diminish.

Cognitive Processing Therapy (CPT) was originally developed for the treatment of PTSD resulting from sexual assault but is now used in the treatment of combat PTSD. The psychotherapy typically requires 12 sessions for each trauma. CPT is based on the idea that PTSD symptoms develop from a conflict between pre-trauma beliefs about the self and one's world (such as, "I am safe") and the post-trauma information (such as, "there is no safe place"). Thus, CPT focuses on what is believed to be a veteran's faulty beliefs or thoughts about a traumatic experience. It is believed that individuals who are exposed to a traumatic event in combat develop PTSD due to disruptions to preexisting beliefs which keep them stuck in PTSD and therefore prohibit their recovery to normal functioning. Such cognitive dissonance is known as a "stuck point" in CPT.

CPT integrates the components of both cognitive therapy and exposure treatment. The exposure component requires the person to write about the traumatic event in detail and then read the written account both inside and outside the session. The accounts are used to determine "stuck points" of conflicting beliefs and assumptions. Initially the treatment begins with the person focusing on distorted beliefs. Treatment then moves to the over-generalized beliefs about oneself and the world in which they live. Clients are taught to challenge their assumptions and beliefs through Socratic challenging. Daily worksheets are used in treatment. Once the dysfunctional beliefs are deconstructed, more balanced self-statements are created and practiced. The resolution of the cognitive dissonance is accomplished through the process of cognitive restructuring of the person's view of self and the world.

Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy that simultaneously addresses all aspects of the traumatic memory including visual images, beliefs, emotions, and body sensations. The EMDR treatment approach follows eight distinct phases allowing for the reprocessing of the disturbing memory. Treatment time is generally about 1-3 reprocessing sessions per memory. The veteran is not asked to talk about the event. Rather, an image, thought and physical sensation associated with the event are identified and paired with eye movements, or other forms of stimulation. The brain begins to "digest" the experience as new associations are made. This reprocessing of the disturbing memory results in changes in the veteran's level of disturbance (the negative emotions transform to healthy ones), change of belief occurs (e.g., "I am ok now") and an elimination of the negative physical responses connected to the trauma memory. This form of therapy treats memories of past events, current triggers, as well as enhancing the veteran in preparing to manage future events. Since the veteran does not have to talk about what happened in EMDR therapy, even persons with classified information can be treated without needing to discuss the details of the mission.



Veterans have the right to expect effective, timely care. Continuity of care and effective treatment is deserved by all our veterans. Having treated veterans for the last 31 years, I believe it is important for therapists to stick to forms of therapy that have research support. Each can have positive benefit and it is important for veterans to have choices. Personally, of these three evidence-based psychotherapies, I prefer EMDR in treating soldiers, veterans, and family members due to: (a) the rapid decline in subjective distress during treatment, (b) the spontaneous change in beliefs without Socratic challenging, (c) no narrative is necessary (it is possible to process the memory without knowing the content), (d) no homework is used, (d) there is an increased recall of healthy autobiographical memory, (e) it is amenable for intensive, successive days treatment. This allows veterans to be treated out-patient settings with two reprocessing sessions per day. This means that treatment can be completed within one or two weeks.



In a future post, I'll describe the potential therapy outcomes for veterans in more detail. But if any readers are interested in how specific kinds of problems can change, just ask a question in the comment section below.

References:

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227.

Foa, E., Meadows, E. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449-480.

Resick, P., Nishith, P., Weaver, T. Astin, M., & Feuer, C. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic rape victims, Journal of Consulting and Clinical Psychology, 70, 867- 879.

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd Ed.). New York: Guilford Press.

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