No, PTSD is NOT a chronic condition (at least it doesn't have to be)
by Craig Bryan, PsyD, ABPP
The recent NYTimes piece (https://www.nytimes.com/2015/09/20/us/marine-battalion-veterans-scarred-by-suicides-turn-to-one-another-for-help.html?_r=0 )about a unit of Marines who have struggled with combat-related PTSD and suicide has reignited public conversation about military and veterans mental health, suicide prevention, and mental health treatment. During the course of these discussions, many myths and misconceptions about PTSD and its treatment have arisen. Because some of these misconceptions could potentially serve as barriers to good, effective treatment, I wanted to take some time to desconstruct and address two myths about treating PTSD among military personnel and veterans.
Myth #1: Suicide among military personnel and veterans is the result of combat trauma
First, I want to make sure to remind us all that less than half of veterans who die by suicide deployed in any capacity, and even fewer experienced combat directly. I realize that the NYTimes piece focused on a combat unit and their struggles with suicide, but if there’s one thing I’ve learned over the past decade, it’s that when we hear poignant and tragic stories such as this one, we easily forget that trauma and suicide impact even those service members and veterans who have not deployed.
Myth #2: PTSD is a chronic condition that cannot be effectively treated
Second, I would like to address what appears to be some misconceptions about trauma and PTSD. Specifically, I want to address the implication that (a) PTSD is a chronic, untreatable condition, and (b) that treatment for PTSD must be long-term by default. We now have approximately 30-40 years of research clearly demonstrating that PTSD can be effectively treated to remission, but these effects seem to be limited to only a handful of therapies. Unfortunately, most mental health clinicians don’t know how to do these therapies, and (even more stunning) very few even know that they exist.
There is now overwhelming consensus by trauma experts that certain forms of trauma-focused therapy (e.g., prolonged exposure therapy, cognitive processing therapy) are incredibly effective and lead to remission from PTSD in 2 out of 3 cases on average, and in some cases in as many as 9 out of 10 of cases (Institute of Medicine, 2008). These treatments typically last for only 10-12 outpatient sessions on average. If you were to deliver these therapies in the typical one-hour-per-week format, this means recovery can occur in less than 3 months on average. We now have anecdotal evidence, published case reports, as well as controlled scientific studies that these therapies can be administered every day instead of once per week (like usual) and you can get the same benefits (Ehlers et al., 2014). Indeed, in my own clinical work, I periodically accept military veterans for two weeks of intensive cognitive processing therapy in which we meet every morning for therapy instead of just once per week. This intensive approach leads to the loss of PTSD just as often as it does when I meet with a patient at a slower, more traditional pace of once per week. This is incredibly hopeful news for trauma survivors: it is feasible to be effectively treated for PTSD very quickly, and the effects last for up to 10 years (Resick et al., 2012). This is a very different picture from what we have historically believed about PTSD.
The good news is that we’ve learned a LOT about treating PTSD during the past 40 years, and we’re now very good at doing so. Even more encouraging is the emergence of new data from recent and ongoing PTSD treatment studies that these really good therapies also reduce suicidal ideation (Gradus et al., 2013), contrary to a very common and pervasive myth that trauma survivors cannot be safely treated with trauma-focused therapies because they are “too fragile” or “can’t handle it.” I personally find this perspective amongst clinicians to be especially heartbreaking, as it communicates to the patient that he or she truly is broken, that they really can’t handle things, and that they are indeed incapable of living lives worth living. Is it any wonder that so many trauma survivors don’t get better when this is the message they are receiving, even if only implicitly, from the very individuals who are supposed to be trained to help them recover?
So… why do so many people (mental health clinicians included) believe that PTSD is chronic? Because the vast majority of clinicians were never trained to use state-of-the-art therapies, and the vast majority of trauma survivors have never received these therapies. The “status quo” right now is to use antiquated or untested techniques based on outdated and/or pseudoscientific ideas. We are, in essence, stacking the deck in such a way that we can only confirm the very (mis)conceptions about PTSD we hope to disconfirm.
I can’t stress this enough: it is no longer true that PTSD *has* to be chronic. It is also untrue that a trauma survivor will never be able to see and experience a reality that is not colored by their tragedy and suffering. With the right kind of therapy delivered by the right kind of clinician, recovery from PTSD can occur in a stunningly rapid period of time for the majority trauma survivors, to include military personnel and veterans. Trauma survivors no longer have to live in darkness and despair, and they don’t have to spend years of their lives and untold fortunes for “therapy” that doesn’t work. Some treatments work better than others. We need to ensure that these better treatments become the first (not the second or the third or the tenth) treatments that trauma survivors receive.
It is easy to wave the banner of “providing the best care possible for our veterans,” but I have yet to see a concerted public effort to demand that mental health professionals receive training in anything other than scientifically supported treatments. It is also easy to beat the drum for “improved access to care” and “treatment works,” but calls for improved access to care without any discussion about the quality of that free/low cost/convenient care is not helpful. Easy access to bad therapy (even if it’s free) is not good enough.
To me, the most troubling question implicated by the NYTimes piece was not “Why doesn’t the VA do more?” but rather “Why was the VA the *only* viable option available to these men?” It’s easy to point our collective fingers of blame at the system, but we should also keep in mind that what this story implies is that these men did not have access to *any* appropriately-trained mental health professional in their communities, to include non-VA options. This is a tragedy that we must fix, not only for our veterans, but for all of our family members and friends.
Dr. Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist and the Executive Director of the National Center for Veterans Studies at The University of Utah. He is a veteran of the Iraq War, and is a nationally-recognized researcher and clinician in the areas of trauma and suicide.