Dear Veteran, Thank you for taking the time to revisit the notion of trauma treatment and for your continued understanding as the field continues to develop better treatments as well as better providers. I strive each and every day to make the best choices regarding your care, and I will continue to do so learning from each mistake I have made along the way.
My instruction for trauma-focused work was very limited in the beginning of my career, as I suspect it is for most clinicians. I had basic skills of Cognitive Behavioral Therapy and Solution-Focused Therapy, but limited education regarding the impact trauma on our bodies. Initially, my training came from an “Evidence Based Practice” called Prolonged Exposure, an intensive and excruciating treatment that seemed to offer benefits dependent on the type of trauma endured. I was ill-prepared for trauma work, largely having a background working with the chronically/severely mentally ill Veteran population. Our daily tasks focused much more on maintenance and case management services.
My initial training for the treatment of PTSD was called Prolonged Exposure. PE focused mostly on cognitive distortions and the general reduction of diagnostic symptoms. Distortions are better explained as those thoughts, beliefs, opinions, and attitudes of the world that are irrational, illogical or somehow harmful to ourselves. These distortions may be thoughts such as, “I am weak. I am unlovable. I am a failure.” The PE approach toward resolution involves choosing one trauma the client felt was the most bothersome or upsetting. How is a client to choose only one trauma if they’ve experienced three deployments, multiple suicides, and the death of a child? PE advertises treating the most complex event first in hopes the other incidents will resolve themselves. Looking back, I could never choose between the devastating loss of my best friend in combat versus losing my two-year-old to heart failure. If I cannot accomplish this how can my Veterans? PE requires the Veteran to revisit the event in chronological order, taking note of sights, sounds, tactile and physical sensations for weeks at a time. For most Veterans this is an excruciating process. While desensitizing is a large part of the treatment, I found Veterans were returning to my office within a few months to a year with no long-term resolution. If the PE curriculum was a success, they had no issues with the trauma we targeted but this was only the case for one Veteran I had treated. If there were multiple traumas, the others became problematic and the physical sensations of anxiety, anger, and fear remained constant and unwavering even after we had concluded the PE sessions.
It was not until two years later that I began learning more about trauma and the physiological impact that remains so strong. This concept was discussed in an EMDR (Eye Movement Desensitization Reprocessing) training, and challenged the concepts of dealing with trauma through our cognitions. Instead the EMDR is much more emotion based and sensation oriented. What does this actually mean? It means I had been continually failing my beloved Veterans week after week. Such a disservice I had unknowingly inflicted, as we had not addressed hardly any of the emotions or sensations that accompanied trauma. The sensations I had addressed in PE were shallow at best, only discussing what the “gravel beneath your feet” felt or sounded like. I realized that the present-day sensations were far more ingrained than I previously thought. The anxiety was being experienced through nausea, stomach cramps, panic attacks, passing out or profuse sweating. I had not discussed these issues in Prolonged Exposure. How could I possibly have expected long-term benefit when all I had dealt with was the frontal lobe of rationalizing trauma? The real “trauma” was being aggressively rekindled in each Veteran’s limbic system or emotional brain every single day. As time passed, I began learning more about The Polyvagal Theory proposed by Steven Porges, and realized that my Veterans were having greater success if I focused on the sensations of past trauma coupled with present day life, not cognitions as I had once thought.
As a result of what I consider to be a personal and professional failure, I now approach trauma very differently focusing on present-day sensations and disturbances Veterans experience as a result of the fight/flight/freeze response being initiated. I have had substantially lower drop-out rates, notably improved responses from Veterans, and genuinely happier more secure Veterans leaving my office each week.
My sincerest and most heartfelt apologies to those who agonized through weeks of Prolonged Exposure with no benefit. Undoubtedly, I think of you each day in hopes that you return for a reconciliation of the past, as we work to provide better outcomes for your future.