In his January 17 N. Y. Times article, After PTSD, More Trauma, David J Morris speaks candidly about his need to recover from PTSD and his bad initial treatment experience. This offers a chance to clarify and expand on points made in The Wounds Within. The four top level evidence-based treatments for PTSD as stated in the 2010 VA/Department of Defense Clinical Practice Guidelines are exposure-based therapies (ET) which bring up traumatic memories through imagined or acted-out scenarios, or through oral or written stories, while helping the client restructure thoughts, cognitive-based therapies (CT) which work with clients specifically to change the thoughts and beliefs connected to the traumatic event, though also often including relaxation techniques and general discussion of the event; Stress inoculation training (SIT) which teaches methods of breathing and muscle relaxation and also includes cognitive elements (self-dialogue, thought-stopping, role-playing) and often exposure techniques and Eye Movement Desensitization and Reprocessing (EMDR) therapy which uses alternating eye-movements combined with an exposure component (recalling the traumatic event), a cognitive component (reassessing thoughts and beliefs),and a self-monitoring of emotion and body reactions component.
Though I have not been formally trained in the other types of intervention, I am more than satisfied with the consistent results of EMDR therapy. EMDR has an exposure component but it is titrated in a flexible way determined by the client’s readiness and willingness to recall certain traumatic memories. Nothing is scripted in EMDR once a client begins to face and reprocess a traumatic memory, their attention goes where there brain takes it, not to where a therapist says to look. If the experience becomes overwhelming it is slowed down or stopped. The client is always in control of the treatment pace and allowed the safety of that control, transformational results are possible. In fact, clients are never required to even talk about their traumatic experiences. They can simply recall them internally as they work their way through the images and emotions of that experience. David Morris would not have had the disturbing experience he reports if he had received EMDR therapy.
The Wounds Within offers a detailed depiction of the EMDR therapy approach including a transcript of an Iraq/Afghanistan veteran facing and recovering from two traumatic memories.
To Morris’s point about VA’s being biased toward certain therapies, it depends. Having spoken with many colleagues across the country, some VA’s remain stubbornly committed to a certain approach favored at the top of their local administration, while others are adapting to what works. As compared to some behind the times VA’s, most active duty bases have readily caught up with the evidence-based effectiveness of EMDR therapy.
It is unfortunate that Morris’s quest for help initially backfired. Clearly with any therapy, the clinician’s skill in applying it is a fundament component. It is to his credit that Morris persevered and trusted his ultimate path to recovery. It is on all of us to make sure that our veterans can access well administered and proven trauma recovery therapies.
Mark Nickerson January 22, 2015