March/April 2014 Issue

Treatments for Veterans With PTSD — Outside the Traditional Toolbox
By Kate Jackson
Social Work Today
Vol. 14 No. 2 P. 18

Evidence-based practice is the gold standard for treating PTSD, but there’s growing recognition that complementary and alternative therapies may be useful adjuncts to meet the needs of some veterans who’ve experienced trauma.

According to Paula Schnurr, PhD, acting executive director of the National Center for PTSD and research professor of psychiatry at the Geisel School of Medicine at Dartmouth College, current guidelines point to three types of primary treatments for PTSD in veterans: a trauma-focused cognitive-behavioral therapy, such as prolonged exposure therapy, mixed cognitive-behavioral therapy, or eye movement desensitization and reprocessing (EMDR); stress-inoculation techniques; and pharmacological therapy, typically involving selective serotonin and serotonin norepinephrine reuptake inhibitors.

But there’s growing acknowledgment among veterans and health care providers that these aren’t the only options in the toolbox for clinicians and therapists working with afflicted veterans. There’s increasing recognition that these first-line treatments alone may not be adequate to meet every need of all veterans who’ve experienced trauma, and that even when they’re successful, nontraditional therapies may be useful adjuncts that boost overall wellness.

“Not all people who have PTSD present with the same needs or the same symptoms, and no one prescriptive approach works for everyone,” says Karen Soltes, LCSW, MAED, E-RYT, a founding partner of Warriors at Ease, which trains yoga and meditation teachers to support military communities.

That’s why spending some time in downward dog may be just what the clinician orders—or should consider—for veterans with PTSD. The Department of Defense and the VA increasingly are embracing a wide range of complementary and alternative medicine (CAM) techniques, such as yoga, meditation, and acupuncture, in the treatment of veterans with PTSD. Among the many sites highlighting the use of CAM techniques with soldiers or veterans are the Warrior Resilience Center at Fort Bliss, TX; the VA Women Veterans Comprehensive Health Center in Durham, NC; and the Warrior Combat Stress Reset Program at Fort Hood, TX. Other CAM techniques being offered to veterans include tai chi, biofeedback, massage, hypnosis, guided imagery, and relaxation therapy.

Not only do some of these techniques have the potential to bring relief and reduce dependency on medication, they also may help motivate reluctant veterans toward traditional approaches and lead those already in treatment to be more engaged and compliant. Awareness of using CAM techniques to treat PTSD can help social workers bring peace to minds disquieted by the stresses, horrors, and catastrophes of war and heal bodies battered by combat and weakened by emotional distress.

Toward an Evidence Base
While research hasn’t yet placed CAM therapies on the frontline of PTSD treatment, there’s strong evidence for their role alongside primary treatments. “Right now, I think the majority of use of these approaches is adjunctive, either to treat some specific problems associated with PTSD or to promote wellness,” Schnurr says. “Certainly, there are exceptions, and there has been a very small amount of research examining these treatments as primary interventions for PTSD. To the best of my knowledge, there’s been only one well-done study in this area, and it was a study done some time ago on acupuncture. That single study said that acupuncture was effective and comparably effective to group cognitive-behavioral therapy.”

While Schnurr notes that there currently isn’t a solid evidence base for using these therapies as primary treatments for PTSD, CAM approaches are of great interest to researchers, and their role in PTSD treatment in the future looks promising. She says researchers need to tease out which techniques may be effective as primary treatments, which may help with specific associated problems, how they might be tailored to veterans’ specific needs, and which can be used by veterans as part of their recovery or to promote wellness. “Over the next years, we will have a lot more information,” she says.

In the meantime, while CAM therapies can’t necessarily replace traditional approaches, evidence indicates they can help veterans with a range of issues related to PTSD, including pain, stress, anxiety, depression, insomnia, and social isolation. “We know from survey data of veterans and military personnel and the general public that many people use CAM approaches outside of the traditional medical care they receive, so it’s helpful for social workers to be open to the idea of integrating CAM as part of a therapeutic strategy for a given patient,” Schnurr says. “Social workers work very much on the whole person, and wellness issues are an important part of care. Now the evidence base is stronger for using CAM to promote wellness, and that’s very valuable.”

Yoga and Meditation
Yoga and meditation, particularly mindfulness meditation practices, are widely embraced in the active military and throughout VA medical centers because they offer myriad benefits. The physical practice of yoga helps relieve pain, stretches the body, and brings comfort to people’s bodies, according to Soltes. “For many people with PTSD, and especially those with chronic pain, sleep is a challenge. Their nervous systems are hypervigilant; it’s as if they’re still on guard duty even though they may have been home from the war for months, years, or even decades,” she explains.

Soltes teaches iRest Yoga Nidra, a guided meditation practice featuring the elements of mindfulness-based practice to relax the nervous system and improve sleep as well as to help heal the impact of trauma. Among the primary benefits of yoga and meditation is the ability to downregulate and soothe an overstimulated nervous system, Soltes says, “to shift into the parasympathetic response, the relaxation response, as well as to help the nervous system regain resiliency and be able to shift between the fight/flight/freeze response and the parasympathetic response.”

To be effective, the practices of yoga and meditation must be tailored specifically to the needs of individuals with PTSD. “For example, creating a sense of a safe space is essential for people who have had trauma. And what might feel good to some of us, such as soft lighting, might not work for someone with trauma. People with PTSD may not want to have their back to a door and may need to know what’s in every cabinet before they can relax,” Soltes explains. They may not be comfortable closing their eyes in a group of relative strangers or with physical adjustments by the teacher, she adds. “Coming up behind someone when they are in a pose may create more vigilance,” she notes.

Certain types of practices and approaches work better than others for individuals with trauma, Soltes says. “Most people with PTSD have an overactivated sympathetic nervous system. It’s as if the fight/flight/freeze response is turned on much of the time, even when the external conditions are not an immediate threat. Practices that relax and soothe the nervous system—in yoga the term is langhana—are typically best for them,” she explains.

Acupuncture
Acupuncture is another CAM therapy increasingly gaining traction in PTSD treatment. The Military Stress Recovery Project, a program of Acupuncturists Without Borders, provides free acupuncture to veterans in more than 25 clinics in the United States to treat what its staff, in an effort to reduce stigmatization, calls PTS, says codirector Carla Cassler, DAOM, LAc, “to take the disorder off the name.” And because, in most situations, PTS becomes a family system problem, she says, it’s important to help families as veterans go through recovery, so the program extends its services to spouses, partners, and even children. “Acupuncture has a long history of use for pain and addiction, but its use in trauma and for PTS is relatively new,” Cassler says.

There’s agreement that drugs alone aren’t effective, may have troubling side effects, and contribute to addiction in those with PTS, according to Cassler. And while cognitive therapy is useful, obstacles include lack of access and poor compliance, she notes.

The active military has embraced the use of acupuncture as an alternative to expensive and mind-altering pharmacological approaches to fight pain and stress without diminishing soldiers’ ability to carry out their duties, she says. And Schnurr notes that “according to a 2011 VA survey, acupuncture is provided at 58 of 125 VA health care systems that offer CAM.”

Research is leading to increased knowledge about brain plasticity, Cassler says, and medical technology that opens a window on the brain has shown how acupuncture influences hemodynamics. “You can see the redirection of blood to the frontal cortex away from the limbic system.” Changes in blood flow promote cellular healing, she adds. Among the benefits are reduced pain, stress, anxiety, and depression, and improved sleep. These benefits, in turn, allow veterans to reduce their use of medications, so acupuncture becomes an addiction treatment as well. “You’re using one treatment to reduce the dependence on drugs as well as help the brain heal,” Cassler says.

Acupuncture is most effective as a primary prevention when used immediately after trauma because it changes blood flow in the brain, “changing the chemical cascade in the body so morphological changes don’t occur,” according to Cassler. It’s typically used as an adjunct treatment in veterans with more long-term trauma patterns. The more acupuncture is introduced into the active military, however, “there’s more chance that it can be one of the first therapies after trauma exposure, which hopefully will reduce the need for other therapies later,” Cassler says.

Final Thoughts
With acupuncture, as with other nontraditional therapies for PTSD, social workers are the vanguard, and as research emerges to support nontraditional approaches, they can be a force in helping promote culture change to benefit their clients. “Social workers have been the most progressive practitioners in the VA system and the strongest proponents of acupuncture in terms of referrals,” Cassler says.
Whether working in VA clinics or private practice, social workers can advocate for veterans’ access to the whole range of treatments that can positively influence their lives and can help build the evidence base that will support continued and expanded use of CAM in the treatment of PTSD.

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.

A Veteran’s Best Friend
Research into the neurobiology of the human-animal bond points to the benefits animals may provide for veterans with PTSD. But it’s an effect that’s evident to anyone who’s ever observed the interaction between a human and an eager animal.

The idea for Warrior Canine Connection (WCC), a program through which veterans with PTSD train service dogs for fellow veterans afflicted with physical mobility–limiting injuries, arose in 2006 when social worker Rick Yount, MS, LSW, combined his clinical experience and service dog background.

Now executive director of the organization, he recalls the first week of his pilot program when he walked an eight-month-old golden retriever puppy near a Marine. “The veteran was not responding to any of the doctors or nurses, not even other Marines,” Yount says. “It wasn’t going well.”

The dog began nudging the Marine, who turned the other way. Undaunted, the dog went over to his other side, and the veteran turned away again. Yount watched from the corner of his eye, pretending not to notice, aware that this was his one shot at connecting with this veteran in hopes of recruiting him to the program.

The dog tried three times, four times, side to side and back again, and the veteran turned away each time. Finally, the persistent animal climbed on the veteran’s lap and planted a kiss on his cheek. When the veteran cracked a smile, Yount knew he had his opportunity and engaged the Marine, soliciting his help with the dog. He offered the Marine a program application and, much to everyone’s surprise, he filled it out.

The veteran finished the program, which “flipped a switch in him,” Yount says. He stayed in contact with Yount through the years and got in touch this summer asking for a letter of support for his MSW application.

It’s one of many success stories for WCC and other programs that match dogs and veterans. At the simplest level, the dogs provide companionship and touch, which brings about physical changes in the human, including reduced blood pressure. It’s a nonpharmacological means of combating anxiety, according to Yount. But there are myriad benefits in having a veteran train a service dog for another veteran, including reduced isolation, increased communication skills, improved relationships, and stress reduction, he says.

There are benefits not only to the veteran but to his family as well. “Service members go through a lot of training to be able to keep emotions from interfering with what they had to do in war,” Yount notes. “When they come back and they are transitioning from being a warrior to being a spouse or a parent, there’s a need to do some retraining.” The additional emotional numbing that can result from combat doesn’t bode well for parenting, Yount says. Dog training, however, by its nature, draws out affect and helps the veterans retrain themselves as they train the animals.

“There are clear parallels between the methodology of training a service dog and that of effective parenting,” Yount says. It teaches relationship skills that veterans can use when they return to their families. Training dogs requires patience, the ability to use emotionally based praise as a reinforcement, to regulate emotion, and to set boundaries and correct behaviors appropriately, he explains.

Yount notes that veterans commonly experience survivor’s guilt, having experienced significant loss, perhaps even having had their friends die in their arms. That guilt may lead to resistance to treatment due to their perception that they don’t deserve to get better.

“Sometimes the best thing for survivor’s guilt is to do something tangible to help another vet, in this case, training a service dog for them,” Yount says. “We’re tapping into that warrior ethos, that core value.” Participation gives them a continued sense of purpose, which opens them to the other benefits that can follow.

— KJ