The United States military is one of the largest consumers of clinical psychology in the world and given that we are emerging from a period of sustained military conflict in Iraq and Afghanistan, the need for PTSD therapy and trauma therapy among combat veterans is high. The military is, if nothing else, a master of efficiency and, unsurprisingly, has brought a so-called empirically-based practice approach to the provision of counseling for PTSD and trauma in the manner you might imagine they bring to their procurement and distribution of socks. Sadly it’s a demand psychology is all-too-well constructed to accommodate.
The “gold standard” of PTSD therapy
Prolonged exposure therapy is what David J. Morris, a Slate correspondent and Marine veteran who received the treatment, calls the military’s “gold standard” treatment for PTSD. Typically an 8-week course of treatment, a PTSD therapist or trauma counselor works with the veteran to identify the most troubling traumatic memory from combat and guides him or her through a series of exercises wherein he or she tells and retells the experience repeatedly until he or she is able to do so without experiencing PTSD symptoms. The idea is that through re-experiencing the event in the safety of a therapist’s office, the habit of reliving the trauma–what is presumed to be behind the symptoms–will cease, resulting in freedom from the symptoms.
Morris’s thoughtful article in Slate this week, “Trauma Post Trauma,” suggests the insistence on prolonged exposure therapy as the dominant treatment for PTSD is based on suspect research. I believe the problem is part of a larger matter in psychotherapy, namely the limits of method.
Innovation becomes method for trauma therapy
Like any approach that becomes clarified into a method and then tapped by the establishment as a preferred course of treatment, prolonged exposure therapy works as a treatment for PTSD. Much of the time, in many circumstances. As with so many innovations, prolonged exposure therapy developed in response to the first-hand trauma experience of it’s creator, Edna Foa, a clinical psychologist and researcher who experienced trauma first-hand witnessing the Second Intifada in Israel. The approach and Dr. Foa deserve credit as a genuine offering in the lexicon of therapeutic approaches to the treatment of trauma. Unfortunately, as is also so often the case, on the journey from innovation to method the very ingenuity of the therapist who developed the method (Foa) is absent in its application in the treatment room. Just as the army doesn’t want Privates to innovate with the orders given to them by Sergeants, method seeks only replication and application. Innovation is discouraged. The good sense of the trauma therapist and the particular complexities of the veteran seeking help are suspended.
Morris points out that some researchers cite a dropout rate of this type of trauma counseling at 50 percent and quotes leading psychologists and psychiatrists in the field of PTSD as critical of the validity of the research designed to support it’s approach.
All relevant. But here’s what has me more concerned: Morris describes his own experience as a patient of prolonged exposure therapy, comparing it to the “reconditioning” scene in A Clockwork Orange where Alex’s eyes are held open mechanically so he is exposed to material against his will. Morris goes on to report that his PTSD therapist insisted he only talk about the identified incident even when he felt the need to talk about other traumas. The method insisted that the most traumatic experience be the sole focus of treatment. He describes a worsening of symptoms including difficulty sleeping and not leaving the house, culminating in his attack a remote control with a knife.
Morris portrays this as a failure of this method, exposure therapy, as a PTSD treatment but I see it rather more so as a failure of method, period. We can presume his trauma therapist was licensed, leaving us with the story of a clinical encounter where the patient (Morris) is experiencing the treatment as akin to torture, producing a decline in functioning and an increase in distressing symptoms. To suggest that Morris’s trauma therapist was simply unskilled seems unlikely (Morris is not alone in having a troubling response to this method of treatment). We must examine the question of what is happening in a therapy encounter wherein a patient is having such an intense, terrifying response to the treatment and yet the therapist is either unaware or unwilling to adapt the plan based on the nature of that response. The order (the directive to follow the treatment method) desperately needed to be challenged.
The problem of method is that it presumes that the curative power lies in the method itself–it locates the cure in technique. The practitioner is effectively a reproducer of method, like a slightly fancier auto-plant worker cranking out fenders based on the design and process of a set of innovators far removed from the production plant. The researchers say what works, the therapists execute it.
Nowhere is there room for live, adult human beings to examine together the question of whether or how, in the particular case of that particular treatment, a given approach is working. We become slaves to the data–some distant research study published in some journal rather than being curious and responsive about what is happening right there in he room.
Might there be multiple traumas? Or trauma from childhood or outside of the combat experience (as is very often the case with PTSD) that may complicate that treatment? What other mental health issues may be present? What about the current context of that soldier returning to the States to reconnect with friends and family, to find civilian employment? What if it’s simply the case that a particular patient, with a particular set of circumstances isn’t getting better? Or, as was the case with Morris, what if the treatment makes things worse? If the method doesn’t allow for it, these matters can’t be attended to. And no method can allow for every possibility.
Patient and therapist as innovators
For both the person seeking treatment for trauma and the trauma therapist, therapy is terribly hard work. We may wish that the “right help” can be packaged and reproduced. It’s more efficient that way. We could have more confidence that it would work and be able to rely on less skilled practitioners. In reality, for therapy to be truly successful both therapist and the patient must be innovators themselves–borrowing wisely from past discoveries (including those outlined in research studies) as all innovators do, but also creating new a method of their own: The method that is going to help that patient. People are messy. Trauma is pretty messy, too.