At a time when citizens of the United States are more concerned than ever about military spending and veteran’s benefits, there is no better time to examine one of the most widely diagnosed mental health issues affecting our troops: Post-Traumatic Stress Disorder (PTSD). PTSD is an anxiety disorder that can develop after exposure to a traumatic event such as assault, rape, disaster, or military combat. It can affect both men and women, but is more prevalent in women, and even more so in women who have served in the military.
According to the U.S. Department of Veteran’s Affairs, of those that served in Operations Iraqi Freedom (OIF) or Enduring Freedom (OEF), about 11-20% of Veterans who served in OIF or OEF have PTSD.13 Although PTSD is often associated with combat-related experiences, it can also be caused by Military Sexual Trauma (MST), which may happen in war, military training exercises, or even during peacetime. What’s more, the VA estimates that 23% of women experience sexual assault while serving in the military.
With veterans at increased risk for suicide, homelessness, mental health issues, disability, and even unemployment, our veterans, particularly those with PTSD, need our help. Research suggests that getting these veterans into high-quality treatment programs could reduce the post-deployment costs to society. The key to this, however, lies within correctly identifying and diagnosing PTSD while still in the early symptomatic stages so that soldiers may receive the appropriate treatment.
With this in mind, it is imperative that we determine best practices for screening soldiers for mental health impairments while making provisions for an easier re-entry and transition back into civilian life. More specifically, we need to determine what methods of therapy prove to be the most successful, sustainable, and cost-effective in regards to treating individuals who present with PTSD.
In this paper, I will research what treatments are available for PTSD and attempt to determine if there are any viable alternatives when compared with conventional treatment methods. I will give a brief overview of Complementary and Alternative Medicine (CAM) treatment methods and attempt to determine which methods warrant further exploration. This area of research is of personal interest due to the fact that I have family members that are likely suffering from PTSD and refuse to acknowledge their symptoms or seek treatment. I am curious to discover if having alternative treatment options would increase their likelihood to seek help.
Before we can attempt to treat PTSD, it is vital to understand exactly what it is and how it is commonly diagnosed. By definition, PTSD is a mental health condition that can occur after a patient is part of or witness to some terrifying, horrendous, or violent physical or emotional event. Examples of these types of events are: assault, battery, rape, war, natural disasters, acts of terrorism, and serious accidents during which many people are killed or injured. The person surviving the ordeal often has flashbacks; feelings of panic, fear, or guilt; constant replaying of the event in his/her mind; or deep feelings of emotional numbness.
It is now understood that persons with PTSD not only relive their experience via nightmares and flashbacks, but they also present with increasingly detached or estranged behavior patterns. Their symptoms can be further aggravated by related disorders such as insomnia, depression, and substance abuse. When compounded, the disorder may lead to an inability to function in social or family life, often causing occupational instability, marital problems, and even family discord.
Before a medical diagnosis can be made, a particular group of symptoms must be identified and last for at least a month’s time.12 Although each individual may experience these symptoms in their own way, PTSD is characterized by four main type of symptoms, which include: (1) reliving the event, (2) avoidance of things that remind you of the event, (3) negative thoughts and feelings, and (4) the feeling of always being on edge. It is important to note that diagnosing PTSD can be challenging as it can often have a delayed onset with symptoms appearing six months to many years after exposure to trauma. This, in particular, is one of the reasons clinicians can find it difficult to immediately and accurately diagnose PTSD in those soldiers returning from overseas tours of duty.
Additional obstacles military personnel and veterans might face include: the stigma associated with PTSD and a military culture that emphasizes valor and bravery; military personnel might be concerned that they will be perceived as weak and not fitting in with their peers; others will blame them for their illness or lose confidence in them; seeking help will harm their career; being diagnosed with a mental illness will prevent them from being deployed or continuing with their current mission; and the length of time required to complete therapy.3 Barriers specific to seeking or completing conventional therapies include concerns about the invasiveness of treatment, lack of emotional readiness for treatment, stigma associated with having a mental health condition, and logistical issues.
What may be considered the main barrier to diagnosis lies in the fact that there is no objective medical test that can be used to definitively diagnose PTSD. Instead, a person must receive a diagnosis of PTSD from a qualified mental health care provider based solely on a self-reported survey. To further complicate matters, patients with undiagnosed mental health disorders like PTSD often visit medical clinics or providers that are ill-equipped to provide traumatic stress screening to our veterans. Oftentimes, especially with male soldiers, admitting that they have a problem is a sign of weakness that they are not capable of readily acknowledging. It is important to reiterate the fact that in order to qualify for treatment one must be willing to both seek treatment as well as truthfully self-report via survey.
Once an initial assessment and diagnosis has been made, it is generally recommended that PTSD be managed through the implementation of evidence-based treatment options. Current treatments for PTSD include psychotherapy and pharmacological treatment. Effective evidence-based psychotherapies include cognitive-based therapies and eye-movement desensitization and reprocessing (EMDR) therapy. Pharmacological treatment includes selective serotonin-reuptake inhibitors (SSRIs) and selective serotonin–norepinephrine reuptake inhibitors (SNRI). These treatment options can be used independent of one another or can be combined to create a synergistic effect.
The most popular methods of psychotherapy that are frequently used in the treatment of PTSD are Cognitive Processing Therapy (CPT), Prolonged Exposure Therapy (PET), and Eye Movement Desensitization and Reprocessing (EMDR). Both CPT and PE are recommended as first-line treatments in PTSD practice guidelines around the world, including the guideline jointly issued by the VA and the Department of Defense.11 Once highly controversial, EMDR has been gaining acceptance and is now also recommended as an effective treatment for PTSD.
With CPT, the patient works together with their psychologist to learn skills that will help them to understand how a certain trauma has changed their thoughts and feelings. In this way, they are better able to recognize any thoughts that they have come to associate with the trauma and are thus able to determine how to change their way of thinking. First developed to treat the symptoms of PTSD in sexual assault victims, CPT focuses on the impact of the trauma. In CPT, the therapist helps the patient identify negative thoughts related to the event, understand how they can cause stress, replace those thoughts, and cope with the upsetting feelings.
PE helps patients with PTSD confront what is disturbing them and assists them in learning how to cope effectively through a combination of education, breathing exercises, exposure practice with real-world situations, and talking about the memory of the trauma with the therapist. It requires the patient to repeatedly discuss their trauma until the memories are no longer upsetting. Essentially, PE helps patients to decrease the amount of distress they feel associated with the trauma. They may also be exposed to thoughts, feelings, and situations that are safe but which they may previously have been avoiding. This helps the patient change how he or she reacts to memories of traumatic experiences, as well as learn how to master stress-inducing situations moving forward.
In EMDR, a therapist guides patients to make eye movements or follow hand taps at the same time that they are recounting their specific traumatic event. The general theory behind EMDR is that focusing on other stimuli while revisiting the experience helps the patient reprocess traumatic information until it is no longer psychologically disruptive.
The biggest drawback to psychotherapy is the fact that it does not provide an immediate solution. Rather, a patient must meet with a mental health professional 1-2 times per week for a period of at least 3-6 months. PE and CPT treatments each take approximately 12 weekly sessions to complete. In fact, many patients may find that a single course of therapy is not enough to resolve their symptoms. On a positive note — there are no known side effects associated with continued therapy sessions. In terms of accessibility, these types of treatment can easily be found within the Military Health System.
Pharmacotherapy can also be effective in treating military personnel or veterans with PTSD. According to guidelines developed by the U.S. Department of Veterans Affairs and Department of Defense, SSRIs are recommended for treatment of military personnel and veterans with PTSD.14 Effective pharmacotherapy for PTSD includes the use of SSRIs (e.g. Zoloft, Paxil) and SNRIs (e.g. Effexor XR).16 It is worth noting that medication without therapy is only masking the symptoms of PTSD without actually addressing the root of the problem. In order to be successful and to have the best chance at recovery, it is recommended that this treatment be complemented by some form of psychotherapy.
A review of Veterans Administration data for 20,284 veterans diagnosed with PTSD found that about 64% initiated psychotropic medication and/or counseling, but 36% did not receive or participate in any conventional treatment.18 Conventional treatment options like psychotherapy and prescription medication are those that are found in what is often referred to as ‘modern medicine.’ However, healthcare can be more broadly divided into modern and traditional. In modern medicine, knowledge expansion is achieved through scientific research, which can involve global collaboration and commitment. Such research is well supported financially by industry, governments and/or philanthropic organizations. This is in sharp contrast to the situation with traditional medicine, often referred to as Complementary and Alternative Medicine (CAM), which often does not see the same influx of funds necessary to conduct extensive scientific research for proposed treatment methods.
In recent years, we have witnessed growing interest in CAM. It is important to note that complementary refers to the use of these techniques in combination with conventional approaches; whereas, alternative refers to their use in place of conventional treatments. “Integrative” is another term that is often used to refer to the combination of traditional and non-traditional approaches.
While evidence-based practice has been the gold standard for treating PTSD, there’s growing recognition that CAM therapies may be useful adjuncts to meet the needs of some veterans who have experienced trauma.9 In fact, a survey conducted in 2011 found that 50% of veterans under the care of the Veterans Administration use at least one form of CAM.10 These additional therapy options may have the potential to both bring relief and/or reduce dependency on prescription medication. They may even motivate reluctant veterans to seek treatment or encourage those already in treatment to become more engaged and compliant. Of the number of CAM therapies currently available, the methods I recommend for further investigation include: acupuncture, service dog training, and yoga/meditation.
According to Traditional Chinese Medicine, disease is caused by a blockage of metaphysical energy known as qi. In order to unblock qi, needles are inserted at particular points or meridians that then allow the energy to flow freely within the body. This practice is commonly known as acupuncture — a therapy that has recently grown in popularity within the United States. Among its many benefits, acupuncture claims to reduce levels of stress, anxiety, and depression. Patients often report improved sleep and less dependence on prescription medication.
The Military Stress Recovery Project, a program of Acupuncturists Without Borders, is unique in that it provides free acupuncture to veterans in more than 25 clinics within the United States. What’s more, because PTSD can sometimes develop into a family problem, the program even extends its services to the partners and children of those affected by PTSD. In this particular program, 5 needles are placed in auricular points within each ear and the patient reclines in a chair for 20-40 minutes, allowing endorphins to flow throughout the body. Unlike conventional psychiatric treatments that are exposure-oriented, requiring patients to reconstruct and re-experience their personal traumatic events, acupuncture for PTSD does not expose the patient to such elements and may therefore be considered a safer and less intrusive method of treatment.
One of the most unique therapies coming to the forefront is that of service dog training. In this scenario, veterans who suffer from PTSD train service dogs for their comrades who return home with combat-related, mobility-limiting injuries. Two great examples of this service can be found in Warrior Canine Connection and Paws for Purple Hearts. Both of these programs help to redirect and re-train the soldier’s trauma-related thought patterns while simultaneously training a service dog. At the simplest level, the dogs provide companionship and touch, which brings about physical changes in the human, including reduced blood pressure.
Rather than focusing on their past trauma, the trainer must direct their attention to teaching the the dog up to 90 different commands, with the ultimate goal of helping another wounded veteran always in mind. What’s more, the dogs offer opportunities for positive interaction with members of the community to their veteran-trainers who, without this ‘forced’ interaction, often isolate themselves from society. Training these animals can result in numerous therapeutic benefits which can include: decreased anxiety/depression, increased patience and impulse control, improved sleep, decreased dependence on prescription medications, and enhanced parenting skills in addition to improved family dynamics. “Dog training, by its nature, draws out affect and helps the veterans retrain themselves as they train the animals. Training dogs requires patience, the ability to use emotionally based praise as a reinforcement, to regulate emotion, and to set boundaries and correct behaviors appropriately.”
The final noteworthy treatment option for PTSD is a blended yoga and meditation practice. In this program, meditation is used to set an intention specifically meant to induce relaxation or alter consciousness. Meanwhile, the physical practice of yoga helps relieve pain, stretches the body, and brings comfort to people.9 In order to be effective, each of these practices must be tailored to the needs of the individual. In particular, creating a sense of a safe space is essential for those that have PTSD. Warrior at Ease is one such newly developed program that trains and deploys mind-body professionals to settings where they can enhance and improve upon the well-being of service-members. Many patients will see a reduction in their anxiety and depression levels, which may lead to a decreased need for prescription medication, especially with continued practice.
To conclude, Post-traumatic Stress Disorder is a mental health condition for which we are still exploring treatment options. While CAM therapies may never replace conventional approaches, there is some evidence that they can help veterans with a range of issues related to PTSD when used in conjunction with other evidence-based therapies. Complementary therapies are not mutually exclusive from conventional treatments. In fact, one could easily adopt a comprehensive approach to treatment by combining therapies from multiple disciplines.
Although many researchers continue to work actively in this area, methodological concerns, such as small sample sizes or lack of non-randomized designs, continue to limit the conclusions that can be drawn. Because few complementary therapies for PTSD have been empirically tested, there is not enough evidence to support the statement that CAM treatment methods are the best option when compared to the conventional treatment methods of psychotherapy and prescription medication. Further study must be conducted in which cost of treatment, number of treatments needed, ease of access, efficacy rates, completion rates, and long-term sustainability can be accurately compared and contrasted.
It is clear that these complementary treatment options will require a large amount of additional investigative research and study before they can officially be recommended for exclusive use. In the meantime, the Department of Defense, along with the Military Health System, should continue to be encouraged to respond more strategically and effectively to the growing populations of servicemen and women who carry the burden of PTSD. We must continue to advocate on their behalf so that they can receive the highest quality of care in return for their service to our country.
