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A Veteran Drops Out of Prolonged Exposure Therapy

PE therapy works, but only for those who can tolerate it.

A U.S. Navy veteran of my acquaintance recently shared with me a troubling story of mental health treatment gone awry. Back in the early 2000s, back before al-Qaeda and OBL were figures of common parlance, his military duties involved him in what is euphemistically termed, “recovery work.”

As we all learned after 9/11, “rescue operations” last only as long as the last survivor could conceivably still be alive under the rubble. But after “rescue” seems a forlorn hope, “recovery” is all that remains. In recovery work, people take on the grim task of gathering bodies, parts of bodies, and, often, mere traces of human remains. They load their gruesome gleanings into Ziploc plastic bags of various sizes. The teller of this tale was somewhat late to the scene of the natural disaster that had killed countless people in a certain developing country. He spent more than a week working with a pick, a spade, and a trowel, gathering up as many human pieces as he could find, competing with feral dogs, and racing the tropical sun and its scion, decomposition.

He had been in the Navy for about five years and he had planned to make it a career. However, after performing the body recovery duty, things started to slip for him. He had trouble sleeping. He felt too wound up to fall asleep easily and he had nightmares in which he was again picking up human remains. Very soon, he was so exhausted that he would fall asleep while on duty. It seemed that as soon as he shut his eyes he was back on some smoking, hellish hillside, combing for bits of flesh. He started drinking – at first to help himself fall asleep, and then, just to make it through the day. “I didn’t want to feel anything anymore. I just wanted to numb myself out.” Unsurprisingly, he lost interest in the Navy, and the Navy lost interest in him. He failed to be promoted within the expected timeframe and he left the military with an Honorable Discharge.

With the help of his wife, he managed to quit drinking. The birth of his first child strengthened his resolve to stay sober: “I don’t want to miss this,” he thought. “I want to be here for this.” Unfortunately, without the numbing effects of alcohol, his Posttraumatic Stress Disorder symptoms came back in full force. He couldn’t sleep. He had nightmares so vivid and horrifying that his wife had to sleep in a separate room. He snapped at her over minor provocations and sometimes went for days without speaking to her at all. One day, he tailgated a driver who cut him off and followed him ten miles to a restaurant parking lot, where he brandished a firearm. He was afraid that if he was left alone with his son he would somehow hurt the child.

Finally, he sought help. He went to his local Department of Veterans Affairs Medical Center. He was assessed and diagnosed with Posttraumatic Stress Disorder. He wasn’t surprised. He was assigned to a therapist who told him that they would be doing Prolonged Exposure therapy. PE is the “gold standard” of PTSD treatment, she said. The VA psychologist seemed competent, experienced, and kind. He felt like he was in good hands, despite his misgivings. “During the very first meeting she asked me what was the very worst thing that I had seen when I was in the Navy. Well, right there, I knew we were in trouble. There wasn’t any way I was going to talk about that. I’d never told anybody about that. No one. I’ve still never told anyone. I can’t. I won’t. I told her about something else instead, something I didn’t think was so bad. But I could tell by her face that it was pretty bad – good enough for the treatment to work, I guessed. I felt sort of bad, telling her about that. Like it’s not bad enough that I have nightmares – now she’s going to have them too.”

“We were supposed to go over this one incident over and over again but all these other things that happened in the military kept coming up and I couldn’t take it.” In addition to the recovery work, this veteran had witnessed several traumatic, accidental deaths during his military service. “I’d be talking about my time in [developing country] and all of a sudden I’d see this shipboard fire I was in – I’d feel the heat on my face. After a couple of meetings, I was starting to have nightmares about my stepfather, how he used to hold my head under water when he was supposed to be taking me fishing. It’s not [the therapist’s] fault. She tried to help, but I just couldn’t – I couldn’t do it.”

Prolonged Exposure therapy “made everything worse. The nightmares got out of control. They put me on Prazosin and that didn’t work – it supposed to help with the nightmares but it just made them seem like they went on forever, like I couldn’t wake up from them.” The original plan had been for him to complete 12 sessions of Prolonged Exposure therapy, but after six sessions of treatment, he decided not to return. Feeling like a failure, he immediately relapsed to alcohol, after two years of sobriety. Six months after that he initiated use of methamphetamine: “I think I just wanted to be as far away from myself as I could get. I didn’t want to be me anymore.” Six months after that, he tried to kill himself by falling asleep drunk on some train tracks. Fortunately, a police officer spotted him and brought him to a hospital. “I really did want to die that night. I was just so tired of the nightmares.”

He was psychiatrically hospitalized for a week at a private hospital (“I told them not to send me to the VA”). Three months after his discharge he made another serious suicide attempt, this time by hanging. He was hospitalized again, this time for nearly a month. The post-discharge planning was better handled the second time. He was stabilized on antidepressant medication and handed over to an outpatient psychotherapist. “At first, I was like, no way, I’m not doing this again. But she was different. She didn’t rush anything. Hardly asked me anything about the Navy. We talked about my son, my wife, how we met. We talked about motorcycles. She didn’t know much about them at first but she’s a quick learner. She even talked about herself some. I was seeing her two times a week for a couple of months when she said that we could ease it back some, to weekly meetings. When I asked her how much longer I should keep seeing her, she said, Let’s revisit that question in a few months.”

Prolonged Exposure therapy can be a very effective treatment for PTSD. However, PE works because it is powerful, and because it is powerful it can also harm. Several studies have recently been published that noted high dropout rates for PE therapy. A 2016 VA study concluded that dropout “is a serious problem” and found that among veterans who started either PE or a similar treatment had a dropout rate of 38.5%.

In a recent study of 119 veterans with PTSD and Alcohol Use Disorder only 32% of those randomly assigned to Prolonged Exposure completed the planned 12 sessions of treatment, versus 66% of those assigned to a present-focused coping skills control group. At six-month follow up the remission rate was higher for PE (33% versus 15%) but this difference was not statistically significant (p=.08). A different study compared veterans with PTSD who were randomly assigned to receive either PE + sertraline (Zoloft) or sertraline-only. Those who received sertraline- only had a 26.8% dropout rate, but those who received sertraline + PE had a 40.6% dropout rate. The remission rates for the two groups were statistically indistinguishable (39.4% for sertraline only versus 37.7%. for sertraline + PE).

Lisa Najavits, a leading psychotherapy researcher, noted in 2015 that completion rates in Randomized Control Trials conducted by researchers were usually significantly higher than those found in real-world settings. In her review of PE studies, she reported outpatient completion rates as low as 2% and no higher than 32%. She suggested, quite reasonably, that the use of the term “gold standard treatment" should be reserved only for therapies that demonstrate “strong retention in real-world settings.”

Often when I present treatment options to a patient, I am asked, “What would you do if you were me?” I usually answer by reframing that question as, “What treatment would I want one of my loved ones to receive?” Well, if I had a loved one with PTSD I wouldn’t push him towards an 8 to 12 session treatment, no matter how many published studies purport its efficacy. I would be leery of any treatment that was heralded as “gold-standard,” as if it were a brand of dishwashing soap. I would be especially leery if the research showed that the treatment was poorly tolerated by many patients. Instead, I would want my loved one to form a therapeutic relationship with one of the best clinicians in town, and to meet regularly with that clinician for the many months it takes to recover from trauma.

Note: Details of the above case history have been significantly altered in order to protect privacy.