Excerpted from cover: "Private John White" by Ivor Hele (Australian War Memorial)

Posttraumatic Stress Disorder (PTSD) and War-Related Stress

Information for Veterans and their Families

Treatment

Obtaining appropriate treatment for PTSD is not always as straightforward as one might think. First, the person has to accept that there is something wrong and see the benefit of seeking help. Getting help is often frightening – for many, it is a leap into the unknown – but without this first step, progress is not possible. Secondly, it is not always easy to find a helping professional who understands PTSD and to whom you can relate and trust. Sometimes it may be necessary to try a few different sources of help until you find the right one for you. As one starting point, contact details for some useful organisations are provided in the back of this booklet. Alternatively, try asking your general practitioner, community health centre, or veterans’ organisation for advice. There are many different aspects to treatment and many different approaches. However, this section will deal predominantly with the most common forms of treatment and the ones that have been shown to be effective. Most require the services of an experienced mental health professional.

Treatment for PTSD often involves several stages:

Crisis stablisation and engagement
Education about PTSD and related conditions
Strategies to manage the symptoms (such as anxiety, anger, depression, alcohol abuse, sleep problems, and relationship problems)
Trauma focussed therapy (confronting the painful memories and feared situations)
Cognitive restructuring (learning to think more realistically and re-evaluating the meaning of the event)
Relapse prevention and on-going support

It is important to remember that treatment can be painful and hard work. Unfortunately, there is no easy way to get rid of the memories or make them less distressing. There is no magic wand and no "sweet oblivious antidote". But the long term gains can be enormous: effective treatment can dramatically assist your recovery, helping you to live a normal life once again.

Macbeth consults a doctor about his wife being troubled with thick coming fantasies that keep her from rest. He demands of the doctor:

"Cure her of that:
Canst thou not minister to a mind diseas’d;
Pluck from the memory a rooted sorrow;
Raze out the written troubles of the brain;
And with some sweet oblivious antidote
Cleanse the stuff’d bosom of that perilous stuff
Which weighs upon the heart?"
The doctor replies:
"Therein the patient must minister to himself"

Shakespeare: Macbeth (Scene 1, Act 5)

Stabilisation Of A Crisis And Engagement In Treatment:

PTSD symptoms are not usually constant in their intensity. Rather, they tend to fluctuate and there may be times when they "flare up" or worsen. Although this can occur at any time, it is most likely to be triggered by things such as anniversaries or other reminders of the trauma and stressful life events (such as family arguments, problems at work, death of a friend or relative). Crises can occur at any time of the day or night. Several 24-hour telephone counselling services are available (for example "Veterans’ Line" – see the back of this book under "Resources"). Although talking on the telephone to someone you do not know may not sound like much help, it can often be very effective. At least it may help you get through the night or weekend until other support is available. During especially difficult times it may be necessary for the veteran to attend hospital as an inpatient. During his or her stay, the crisis may be treated with medication, psychotherapy, and general counselling. As well as stabilising the symptoms, a brief inpatient stay also provides a "time-out" period for both the veteran and their family to refocus on their direction.

It is important that any current life crises are resolved, or at least put "on hold", before the real treatment of PTSD can begin. It is not possible to devote the necessary concentration, time, and energy to your recovery if you are constantly worried about your job, your relationship, your children, or other important life areas. That is not to say that you have to be able to solve all those problems before you can work on your PTSD, but you will need to be able to put them to one side for a while to concentrate on your treatment. Therapy is hard work – there is no easy way to do it – and you will need to devote all your personal resources to the task.

The first part of treatment will often be devoted to developing a relationship with the therapist (or the treatment team if you are taking part in a group program). You will need to spend some time getting to know each other, and building trust, if you are to work on the difficult issues. We call this process "engagement". For many veterans with PTSD, this is a very difficult process – it may have been a long time since they really trusted another person, particularly someone who is not a veteran. In many cases, you will need to tell your therapist about experiences and feelings that you have never discussed with anyone before. We need to recognise that this is a difficult process that will take a lot of courage, but it will be worth it and it is the only way to recovery.

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Education And Information

Trauma can sometimes feel like an incomprehensible cloud that hangs over all areas of the person’s life. The first step in treatment is to understand exactly what trauma is, why we have the symptoms we do and, therefore, why it is treated the way it is. In this regard, it is hoped that the current booklet is a first step in understanding the disorder. You need to know what the common signs and symptoms are, and you need to recognise that you are not alone – many people who have experienced traumatic events have responded in exactly the same way as you have. You need to understand why the symptoms have appeared – the fact that they were very useful for survival while the traumatic events were happening but that they are no longer useful. They have become "maladaptive" and now only serve to create problems and distress for you. You need to understand what treatment will involve and how it may affect you. It is very important that you feel able to ask your therapist questions about the nature of your problems and the process of treatment. He or she will not have all the answers, but together you will reach a better understanding of what has happened and how you will recover.

Sometimes, people who have been through a traumatic event have trouble understanding what happened and why it happened. This is because, when we are under threat, our attention is very focussed on the source of the danger and we do not take in all the other things that are happening around us. We may end up with a distorted and confused memory of the experience, so that it becomes difficult to understand and make sense of the event. This confusion often stops us from being able to put the experience behind us. For this reason, your therapist may help you to find out more about what happened during the event. (Although we have put this under the heading of "Education and Information", it is actually something that may happen at several stages throughout treatment). This process is important in being able to "put the pieces of the jigsaw puzzle together" and make sense of your experience. A good understanding of exactly what happened and why it happened often facilitates recovery. Unfortunately, of course, this is not always possible. Sometimes we may never find out exactly what happened or, more commonly, why it happened and we have to learn to live with that uncertainty.

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Symptom Management

As already noted, PTSD has many symptoms that interfere with the traumatised person’s daily functioning. Part of treatment usually involves providing the person with strategies to cope with and manage these symptoms. Medication will often play a part in this stage of treatment. Unfortunately, such strategies rarely make the symptoms go away altogether. However, they help sufferers to carry on with their day-to-day functioning, no longer being "helpless victims" of the symptoms. A range of strategies may be used and some of the more common are outlined below. However, it is important to keep in mind that the following is just a guide; an experienced and qualified therapist can help you accomplish these techniques.

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Anxiety Management: Techniques aimed at reducing levels of anxiety and arousal are an important part of treatment. These techniques may include:

Relaxation training to reduce overall levels of anxiety

Breathing techniques to reduce panic-like symptoms

Thought stopping methods to break the tendency to ‘ruminate’ or think excessively about the past

Rational self-talk to help manage high anxiety situations and depressing thoughts

Techniques to help you organise your time effectively, scheduling enjoyable and productive activities and providing some structure to your days

Anger Management: Techniques to reduce levels of anger and irritability with others is always an important part in helping the PTSD sufferer. Not only does it help them to be more relaxed, but it assists them in relating to others and being part of normal society. Strategies that are commonly used include:

Education to understand the nature and purpose of anger

Methods of identifying early warning signs of stress and irritability

Methods of identifying high risk situations and hoto prepare for them

Methods of realistically re-evaluating the situation, keeping it in perspective

Strategies to reduce arousal and stay calm in difficult situations

Effective communication methods (verbal and non-verbal)

Differentiating assertive from aggressive behaviour

Problem solving strategies to effectively deal with disagreements

Distraction and removal techniques to avoid ‘flare-ups’

Practice in imagined and real-life situations

Management of Depression: As mentioned above, people with PTSD frequently develop symptoms of depression. Therefore, strategies to reduce and manage depression are frequently employed as part of treatment. Strategies may include the following:

Increasing positive, enjoyable events and scheduling these into daily living

Methods of understanding the underlying assumptions and beliefs about the self (e.g., "I’m a worthless failure") or the world (e.g., "Nobody cares about me") that can lead to feelings of sadness and depression

Identifying patterns of depressive thoughts on a day-to-day basis

Realistically evaluating and challenging negative beliefs and thoughts

Rational, realistic coping self-talk

Medication Self-Management: Medication is frequently used to help manage severe PTSD symptoms (although, on its own, it will not change the underlying problems and should be combined with other treatments). To minimise unintended difficulties associated with medication, the following strategies are frequently used:

Education about the use and effect of the drug

Education about possible side-effects and activities or substances to avoid

Methods of keeping track of medication use

Discussing the effects and desire to change medication with your psychiatrist

Methods of reducing and stopping medication intake

Substance Abuse: As mentioned, many people with PTSD attempt to cope or "self-medicate" with excessive amounts of alcohol and inappropriate drug use (including prescribed drugs). Treatment for alcohol or other drug use can include:

Education about the use and effect of the substance

Decisions regarding total abstinence versus controlled use of the drug

Recording "danger" times and identifying patterns of use

Developing coping strategies for high risk times

Assertiveness training for when others are applying peer pressure

Planning and scheduling activities not associated with the substance

Response prevention – methods of resisting the ‘urge’

Sleep Disturbance: Many sufferers of PTSD report disturbances of sleep. Several strategies may be useful in addressing the difficulty of going to sleep, waking repeatedly throughout the night, or waking early in the morning. It is common for therapists to assist clients in developing a healthy sleep routine in line with the suggestions provided above. Other strategies, including medication, may be adopted when those are not proving effective. (See the earlier section on Sleeping Better).

Relationship Difficulties: People who have been traumatised often lose track of who and what they can trust in the world. This often has a major impact on relationships. To address the difficulties that can occur between couples and family members, PTSD sufferers are frequently taken through a range of strategies to improve relationships. Some of the methods used may include active listening (how to really listen to your partner or children), communicat-ion training (how to say effectively what you need and feel), and problem solving (how to solve everyday problems without fighting). Some of this may occur with the veteran alone and some with their partner. Separate support and counselling for the partner is often beneficial. Sometimes family therapy is provided, where the whole family meet to address their issues, with the aim of developing a healthy environment for all.

Exposure Therapy – Confronting Feared Situations

Anxiety frequently causes people to stay away from the frightening situation. It is quite normal for people to want to escape or avoid situations, thoughts, memories, or feelings that are painful or distressing. However, this is one of the major impediments to recovery. Avoidance and escape provide temporary relief – the anxiety reduces. Unfortunately, the next time the person encounters that situation again, he or she is likely to become anxious long before it is planned to occur. We call this "anticipatory anxiety". The more the situation is avoided, the more the person continues to believe that it is dangerous. Further, even if the person does not avoid, the anxiety may continue to build once they are in the situation. You may have had this experience in a range of situations, such as going to a shopping centre or watching a movie about war. Very often people believe that if they do not leave the situation they will "lose control", "go crazy", "have a heart attack", or have some other dire consequences. At the very least, they are likely to believe that the unpleasant feelings will be intolerable. Exposure therapy aims to show that this is not the case by helping the person to confront the feared situation. This is done in a very controlled and gradual fashion, overseen by therapists who are experienced with the procedure, so that discomfort is kept to a minimum. By building upon repeated successes in facing these feared situations, the person is eventually able to confront them without anxiety and they are no longer avoided.

In many ways, this approach is common sense. Let’s take an example of a little boy who is standing on the beach when a big wave knocks him over. He becomes very frightened of the sea and refuses to go to the beach the next day. How would his mother or father help? In order to overcome the fear, his parents may take him for a walk along the beach, staying away from the sea, holding his hand and reassuring him. Gradually, they walk closer and closer to the water’s edge. Eventually, the boy is able to go into the sea again unaided. This is a simple example, but exactly the same process applies to treating more severe and complex fears in adults.

In conducting exposure treatment, your therapist will work with you in constructing a hierarchy – a list of feared situations in order of difficulty. Treatment involves tackling each item, one at a time, and moving on to the next only when you are confident to do so. More difficult items may be broken up into several steps. Exposure treatment can be difficult and painful, but it is the most effective way of treating many anxieties.

Exposure Therapy – Confronting The Memories

A form of exposure therapy is also used to treat distressing memories of the trauma. In cases of PTSD, the memories are the "feared situation". These memories are so frightening, and cause so much distress, that the person tries to avoid or escape from them by blocking them out. Often, exposure treatments are used to assist in confronting the memories. Exposure is only one term used to describe this process. Some people talk about "trauma focus work", "working through the trauma", "coming to terms with the experience" or simply "confronting the memories". There are many analogies used to explain this process to PTSD sufferers before treatment commences. The following analogies may help you to understand the process.

"Very often, after a trauma we tend to pack the event away into a box. We try to file away what happened, putting it to the back of our mind. We then use a little strength to keep the lid tightly closed and try to leave it undisturbed. However, over time, two things happen. Firstly, our strength begins to wane and it becomes more of an effort to keep it sealed. Secondly, due to the pressure, the box begins to lose its shape and small cracks begin to appear. What we experience as symptoms (such as memories of the trauma, and having nightmares and disturbed sleep) is like the content of the box spilling out through these cracks. This is usually very frightening, so we try to avoid anything that reminds us of the trauma. We try to stop thinking and talking through what happened and how we felt. In this way the content of the box becomes a "ghost" which we have learned to fear. As part of therapy, we are going to open the box and inspect the content for what it really is. In this way we can talk through what happened and how you felt. We will be inspecting the "ghosts" that have been created and throwing away any maladaptive and distressing beliefs you may have about the event. We find that once the trauma has been dealt with in this manner the symptoms become much less severe and less frequent."

Another analogy talks about the dentist:

"When dentists work on a decayed tooth, they don’t just slap the filling on top of the decay. If they did, it may be fine for a few weeks or months, but the problems would keep coming back as the tooth continued to deteriorate. Instead, they spend some time drilling and scraping, cleaning out all the decay before putting the tooth back together. This is a very unpleasant and painful process, but we know it is worth going through this short term pain for the long term gain. Traumatic memories are a bit like tooth decay. We need to make sure that we have confronted all aspects of the trauma before we try to put the event behind us. We need to give ourselves time to face up to even the worst parts of the experience so that there are no skeletons in the closet to come and haunt us in the future. Like the dentist’s drilling, it is a painful process but an important part of recovery".

A final analogy comes from the work of Edna Foa, one of the leading experts in the treatment of PTSD:

"Suppose you have eaten a very large and heavy meal that you are unable to digest. This is an uncomfortable feeling. But when you have digested the food, you feel a great sense of relief. Flashbacks, nightmares, and troublesome thoughts continue to occur because the traumatic event has not been adequately digested. Treatment will help you to start digesting your heavy memories so that they will stop interfering with your daily life".

Exposure based treatments are not for everybody. In some cases, if the memories are not causing too much of a problem, it may be best not to drag everything up again. You may wish to talk to your therapist about whether this approach would be beneficial for you.

Cognitive Restructuring

Following a traumatic experience, people may be left with a range of negative interpretations or beliefs about what happened, as well as about themselves and the world. For example, they may think that they are bad or evil for acting in the way they did; they may think that what happened was their fault; they may see themselves as weak or inadequate; they may think that the world has become a dangerous place and that other people are nasty, cruel, and out to take advantage. Sometimes, there may be elements of truth in these thoughts. Often, however, they are completely untrue or, at least, grossly exaggerated. This kind of thinking leads to all sorts of unpleasant emotions such as depression and guilt, anxiety and fear, and anger. Sometimes therapy will be aimed at helping the person to identify those maladaptive thoughts, to challenge and dispute them, and to replace them with a more realistic view of themselves and the world.

In a similar vein, people often believe that certain events cause specific reactions. For example, one may believe that being in a crowded shopping centre causes panic, as if there is some automatic connection between shopping centres and panic. However, the anxiety that people feel is not the result of the event itself. An inanimate object such as a shopping centre cannot make someone anxious by its own doing. It is our interpretation about the situation that creates the anxiety, and this interpretation is based upon beliefs we hold. In the above example the active belief may be that one is in danger of being trapped. Therefore, when the person is in a shopping centre they may have thoughts such as "I’m trapped, I can’t escape, I’m going to lose control". It is these thoughts that cause the feelings of panic.

Cognitive restructuring is a procedure whereby people’s thoughts, beliefs and interpretations about past experiences are identified and mistakes in thinking are highlighted. (Cognition is just a technical word for thoughts). For example, it may be that the person is thinking in "black and white terms" – seeing things as all good or all bad – when in reality the world holds much that is "grey". It may not be perfect, but it’s not all bad either. The person may be overgeneralising (e.g., "no-one can be trusted") or over-focussing on the negatives and minimising the positives in most situations. They may see one negative thing as confirmation that they are not coping, while ignoring other evidence that they are, in fact, coping quite well. Once these erroneous thoughts and patterns are discovered, it is the goal of cognitive therapy to replace these with more adaptive, realistic and flexible beliefs. This, of course, includes re-evaluating our experiences and, in particular, the traumatic event. It is a difficult process that can take a lot of hard work, but it can be very effective in minimising and managing unpleasant emotions.

Psychodynamic Psychotherapy

Therapists working with a psychodynamic approach attempt to integrate the person’s traumatic experience with his or her life as a whole. They do not focus on symptoms alone, but seek to make connections between the traumatic experience and vulnerabilities in the person’s earlier life. They try to understand how current situations evoke traumatic responses even though the original trauma is past. The psychodynamic approach seeks to understand the way in which the individual continues to interpret the world in distressing and often self-destructive ways.

Disruptive and traumatic experience earlier in life can predispose the individual to more deeply troubled responses to trauma later in life. So, for example, even though he would not have been responsible, a young boy may feel that he caused his parents’ relationship to break-up, leading to divorce. Later in life, as a young man, he may feel responsible for the death of his comrade in the war, even though in fact he would have been powerless to prevent his friend’s death. Psychodynamic psychotherapy can bring to light connections between such experiences. By means of this process, it may free the individual from excessive and unreasonable guilt (for example), once these experiences have been worked through.

However, the focus of the therapy is on current life experience and persisting difficulties. The past is re-visited only to the extent that it is being replayed in the present, often in self-defeating ways. Psychodynamic therapy is usually a longer term therapy and is not suited to all people.

Relapse Prevention

In some people, even following treatment, PTSD can be a chronic disorder with lapses from time to time. Preventing a recurrence of symptoms is most important for veterans with PTSD. Times of stress (for example, family or work problems, bereavements, and financial difficulties) may lead to a recurrence of symptoms in some people. When this happens, it is important to remember that it was expected and not to feel that you are back to square one. As long as it is not too severe, and does not last too long, you can deal with it.

As part of treatment, it is common to provide specific help directed towards maintaining the gains made during therapy and, as far as possible, avoiding relapse. In order to do this, the coping strategies listed above are integrated into all areas of the person’s life in order to minimise causes of stress and it’s intensity. Education and discussion to identify the early warning signs of a relapse is important – the earlier you recognise that things are going wrong, the more chance you have of doing something about it. Skills acquired during treatment can then be applied to cope with the recurrence of symptoms. At times, additional help may be required – do not hesitate to seek professional assistance if you think you need it. Possible sources of help in case of relapse should be identified as part of treatment so that you know where to seek help quickly if you require it.

Alternative and Adjunctive Treatments

There are a host of other treatment techniques ranging from homeopathy to hypnosis that, while not being "run of the mill", can help some people. It is our suggestion that these alternative techniques are used only when more mainstream methods have proved ineffective or as an adjunct to those treatments when appropriate. Everyone is different in their reaction to therapy and, occasionally, some treatments may do more harm than good, especially in the hands of inexperienced practitioners. Therefore, we suggest that, before embarking upon these treatments, the sufferer discuss the possibilities with a skilled mental health professional who is knowledgeable in all available resources for the treatment of PTSD.

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