Prolonged Exposure Therapy and PTSD
"I could have been the poster boy for PTSD for Vietnam Veterans. I had isolated myself for over a decade. I decided to fully commit myself to going through the whole program, and I did it." Harlon
Triumph Over Painful Memories
According to VA Clinical Psychologist, Dr. Mathew Yoder, “The only way to get past the anxiety is through it, not to avoid it.” Dr.Yoder speaks of many Veterans with PTSD, “They’ve tried to push their trauma away, but it doesn’t work.”
A curve in the river draped with vine maple and thick with conifer doesn’t bother Harlon too much. It’s those long open stretches we see that jolt his memory from his ‘69-‘72 service in Vietnam as a “Brown River” Navy man working on a 300’ landing ship; a re-supply boat. “The Umpqua River in areas looks like the rivers in ‘Nam,” says Harlon. “That view made me anxious and think of memories that were too painful to endure, so I didn’t go there-mentally or physically; I didn’t spend time at the coast either. I couldn’t look at the bays…they reminded me of Cameron (Cam Rahn) Bay in ‘Nam.”
For Harlon, and another Veteran we will call “Joseph,” until they entered into the VA Roseburg Healthcare System’s Prolonged Exposure Therapy Program, (PE) their PTSD symptoms were out of their control. Joseph served in the Army from ’93-2006 and deployed to Iraq from ‘04-’05 as a Team Leader in charge of a humvee. Once home and out of the Military, his experiences while serving left him unable to be among crowds, he shopped at night, suffered from substance abuse, was hyper-vigilant and didn’t go to music concerts- one of his preferred activities before returning from deployment. He displayed classic symptoms of PTSD but did not speak of his Military experiences that led to it for about six years.
Interestingly, and according to VA Clinical Psychologist, Dr. Mathew Yoder, “The only way to get past the anxiety is through it, not to avoid it.” During an informational video supplied on the National Center for PTSD, Dr. Yoder speaks of many Veterans, “They’ve tried to push their trauma away, but it doesn’t work.”
When Dr. Yoder spoke of “through it,” he was referring to the therapy process of PE, which has been shown to be one of the most effective treatments for PTSD. For this reason, VA Roseburg Healthcare System is an active partner in providing PE therapy for our Veterans. We currently have five mental health providers administering PE for our patients within our system. Providers are located in Roseburg as part of the PTSD Residential Program, and in Eugene on an outpatient basis.
Harlon decided to enter the program at Roseburg. A friend talked to him because he was reclusive, anxious, and displayed classic symptoms of PTSD. Harlon had stifled memories of his experiences during Vietnam for 35 years, but after talking with his friend and working with staff at VA Roseburg, he decided to get some help. “I could be the poster boy for PTSD for Vietnam Veterans,” shared Harlon, “I learned about the program after being recommended to Dr. Bryan Nestripke (Dr. B) from Dr. Mendelson. I knew the program was tough…I had talked to a few guys who had gone through it, but it helped them. I knew I would have to identify and work on a trauma I experienced during Nam with Dr. B’s assistance. I decided to fully commit myself to go through the whole program, and I did it.”
After a traumatic event, many individuals experience distress and symptoms of PTSD. This distress may be highest when dealing with memories, thoughts, feelings, and situations that are related to the trauma. PE therapy is of the type that helps participants decrease distress about their trauma. It works by helping Veterans approach trauma-related thoughts, feelings, and situations that they have been avoiding due to the distress they cause. Repeated exposure to these thoughts, feelings, and situations helps reduce the power they have to cause distress.
Harlon explained his trauma like this:
“I was part of the leadership aboard the supply ship. We had church on Sundays and the guys did attend. They liked it. We made it fun to be part of. One Sunday we decided not to hold the church service on shore because it was too inconvenient….we had other important things to do that day, and I made the final decision on it. The guys were on the boat instead, in the chief’s quarters and aboard. Within five minutes of making the choice to not hold services, we were ambushed. The attack left more than a dozen killed.” Harlon shakes his head, pauses momentarily, some deep breaths… continues, “Seeing the bodies and the blood. I was on shore. Another pause. The guilt. I blamed myself for their deaths. That is the trauma that haunts me most, so that is what I worked on in the PE program.”
PE is one exposure therapy that works for many people who have experienced trauma. It has four main components:
Education- PE starts with education about the treatment. Veterans learn about common trauma reactions and PTSD. Education allows Veterans to learn more about their symptoms. It also helps them understand the goals of the treatment. This education provides the basis for the next sessions.
Breathing- Breathing retraining is a skill that helps for relaxation. When people become anxious or scared, their breathing often changes. Learning how to control their breathing can help in the short-term to manage immediate distress.
Real world practice- Exposure practice with real-world situations is called in vivo exposure. Veterans practice approaching situations that are safe but which they may have been avoiding because they are related to the trauma. An example would be a Veteran who avoids driving since he experienced a roadside bomb while deployed. In the same way, a sexual trauma survivor may avoid getting close to others. This type of exposure practice helps trauma-related distress to lessen over time. When distress goes down, a Veteran can gain more control over his/her life.
Talking through the trauma- Talking about a trauma memory over and over with a therapist is called imaginal exposure. Talking through the trauma helps get more control of thoughts and feelings about the trauma. Program participants learn that they do not have to be afraid of memories. This may be hard at first and it might seem strange to think about stressful things on purpose. Many people feel better over time, though, as they practice this. Talking through the trauma helps them to make sense of what happened and have fewer negative thoughts about it.
Talking and taking small steps is what helped Joseph. Working with Dr. B., he was encouraged to get out and about daily. He started with lower density locations, such as a park or other public places that were not too busy. “Eventually, I was able to work my way up to Sherm’s grocery store during the busy part of the day. The program is tough,” says Joseph, “I spend 3.5 months, but my quality of life has improved to the point I can almost function normally. I went to my first concert the other night…Music in the Park. I have to say though, the nightmares are not gone. The difference is I have the tools to understand the physiological and psychological responses that are going on in my world.”
And for Harlon, “I had isolated myself for over a decade. In the program, I went to social locations over and over again. I had homework every week. I am not saying I don’t still have flashes of anger, but I am much more easy-going. I did lots of journaling while I was in the program too. You know, I thought I didn’t have any problems…it was everyone else. I didn’t know that suppressing those memories for all those years would trigger late-onset PTSD. Anyway, considering the program, it has allowed me, and probably will allow others, to accept the screw ups of the war and allow them to forgive themselves and get on with their lives. It has for me. I went to the river. I won the battle. I went to the coast. I won the battle. I plan to go back.”
With the help of therapists, Veterans can change how they react to stressful memories. In PE, Veterans work with their therapists to approach trauma-related situations and memories at a manageable pace. Usually, they start with things that are less distressing and move towards things that are more distressing (The imaginal exposure actually focuses on their worst traumatic memory, but the in vivo exposure begins more moderately). A round of PE therapy most often involves meeting alone with a therapist for about 8 to 15 sessions. Most therapy sessions last 90 minutes. The therapy also involves homework activities the Veteran completes between sessions.
With time and practice, Veterans are able to see that they can master stressful situations. The goal is that they, not their memories, can control what they do in their life and how they feel. The therapy helps them get their life back by working through a trauma.
For more information about the VA Roseburg Healthcare System Prolonged Exposure Therapy Program, please contact:
Roseburg: Bryan Nestripke,Psy.D., at 541-440-1000 Extension 44688
Eugene: Jennifer Metheny, Ph.D. at 541-242-0440
Find the VA National web site:
http://www.mentalhealth.va.gov/PTSD.asp
By Carrie Boothe, Public Affairs
