A bit ago, I blogged on David Morris’ new book, “The Evil Hours: A Biography of Post-Traumatic Stress Disorder” and his NPR interview. [You can read my previous post here.] Having just finished reading the text, I want to highlight a few more insights about the book.
Morris does an excellent job describing his experience of trauma and then expanding to the history of PTSD and its impact, both on those going to war and those who have experienced civilian traumas. For those who wonder why Vietnam vets struggle more than WWII vets, Morris helps reveal the falseness of that belief in the beginning of chapter 5.
But the most important chapters of the book are chapters 6 through 9 where he examines therapies designed for PTSD, how research protocols designed to help us know which treatments work best may harm, how drugs and alternative interventions (e.g., yoga) may help and how to think about posttraumatic growth.
Though these chapters are his experience, I would highly recommend every MHP to read these chapters. Skip the first chapters if you must (you should not!) but these are paramount if you are going to work with traumatized individuals. Here are just a few reasons why:
- Following protocol for therapy can harm a patient. Don’t get me wrong, research IS necessary. But when a protocol is harming a patient, it is important to make sure that research goals do not become primary over the needs of the one who is in need.
- Prolonged Exposure, the gold standard treatment, has a HUGE drop-out rate. Somewhere around 54%. That should give us great pause. Surgery hurts. PE is like surgery but repeated opening of a wound. The dropout rate should tell us that imaginal work can re-traumatize. There are other methods that may work just a well but do less damage in the process. I think about the changes in the last 10 years for breast cancer. We are discovering that not everyone needs bilateral breast removal to survive. Not everyone needs 30 days of radiation as radiation at the time of lumpectomy may work just as well for some patients. So, we must be less fixed in our minds on treatment protocols and be considering if the patient can improve with less radical treatment options.
- Cognitive therapies are good but over-emphasize think right = feel right. Such work could ignore the moral complexity of life, especially for those who have moral injuries.
- The person of the therapist is more important than the treatment modality. This is not to say that the modality is of no consequence. Rather, that good interventions live or die on the capacity of the therapist to be truly human with clients.
- Recovery must be done in community. Gutting it out alone does not work.
- Alternatives, like yoga, works for some far better than talking, but shouldn’t be sold as a cure-all.
…yoga stands out as a uniquely effective treatment, precisely because it insists that people shut up and start listening to their bodies. Yoga works to correct the central lie of Western philosophy, which goes all the way back to Descartes, who said that the body and the mind are distinct entities that exist independent of each other. (237)
However, Morris acknowledges that yoga is, “ridiculous”, even “moronic.” Though he is also quick to say, “In the Marine Corps, we had a saying: ‘If it’s stupid but it works, then it isn’t stupid.” (238). “Placebo, wishful thinking, whatever. I’ll take the help where I can get it.” (246, discussing the mixed evidence for EMDR). Yet, be wary of proponents of any one treatment as a cure. They prey on desperate people.
The bottom line is that there is no ‘magic bullet’ for PTSD, and claims to the contrary should be taken with more than a grain of sand. (240)
- Growth happens but not apart from ongoing trauma symptoms and changes. Too often we expect recovery to mean the removal of symptoms. But, there is no going back. Identity changes, just as it would if you lost your spouse and then got remarried. Growth needs to be observed and underlined, but not assumed to eliminate strong, continuing reminders of trauma.
Musings on Faith and Psychology 
I’ve recently read, “The body keeps the score” by Bessel Van Der Kolk. I would also put that on a must read book list.
Thanks for this Phil. Much appreciated for one like me who is not a mental health professional but a victim-supporter and victim-advocate (and survivor of abuse myself who at times has had some PTSD like symptoms).
Can you please comment on the yoga recommendation a bit more? I can easily understand how it would be effective simply because it gets the sufferer to focus on his or her body, rather than blocking out or ignoring bodily sensations and muscular tensions. But as a Christian working with other Christians who often suffer from PTSD, I know that if I recommended this article of yours, I know that most conservative would flinch at any recommendation of yoga.
Is there a way you can endorse yoga as a therapeutic modality for PTSD while at the same time making it clear that you do not endorse any of the religious system (Hinduism) from which yoga has developed?
If you can explain this in a nuanced way, I will probably be putting this article on our Resources list at A Cry For Justice.
cheers — Barb
And btw, even though I tick the little box I don’t seem to get email notifaction of furhter comments on your posts. I may be wrong, but that’s how it has seemed to me. So if you can, could you kindly email me directly to let me know your response to my query. Thanks.
Not sure I can be nuanced. I am not a practitioner or well-versed in yoga myself. I am only saying that for some they find it very helpful. The focus it takes to stay in a pose, the awareness of the body in time and space, the final pose (laying on one’s back and just resting without thinking) are all things that help the sufferer to stay in the present and to be more in tune with the body. I do not believe that any one body position is associated with a particular religion. Christians have Christmas trees and aren’t practicing a pagan religion. Thus, certain bodily movements can be unrelated to Hinduism. I suspect this is more like Paul’s exhortation that eating meat or not eating meat sacrificed to idols is not the issue. Loving our brothers and sisters who may have a struggle is the issue. So practice yoga or don’t but be careful not to force it on those who have an issue.
There, not very nuanced. Oh and one more thing. I’m very sure that yoga is not some cure-all and is over hyped as one by those looking to cash in.
Phil, I know what he means by “a disease of time” but I don’t think that’s really the best description. I have PTSD and I know for sure that I am not getting mixed up in my mind between the past and the present, but I have times when my body is experiencing terror anyway. I am never confused about whether I’m “back then or “right now ” – but it’s like I’ve got this leftover terror which is experienced in my body, not my thoughts.
I do get somewhat disoriented occasionally, but that is more about location rather than time.
And regarding treatment, Janina Fisher says healing from trauma (especially interpersonal and complex trauma) is about experiencing safety (since trauma is about danger ). Diane Langberg says a similar thing, that healing requires a reversal of the experience of trauma, ie. empowerment, voice, safe relationships…
Katherine, I think the author would agree with you. He isn’t mixed up on whether he is still in Iraq or not but he feels his life is split between before and after. In that way he feels it is a disease of time. I suppose one could say that your body is reacting to a previous time despite being in the present. But anyway, if the analogy doesn’t work for you, that is okay. PTSD tends to elude description.
Phil,
Interestingly enough, a different format of Prolonged Exposure—DBT Prolonged Exposure—may prove to do “less damage.” I had the opportunity today to listen to Melanie Harned briefly present research findings on DBT PE. In an efficacy study she conducted at UW 73% of the participants that actually reached the exposure stage of treatment completed the treatment. Melanie also pointed to the Minneapolis VA Effectiveness Trial, which saw a 67% completion rate with a “significant reduction in symptoms” (0 participants dropped out during the PE protocol). The primary factor that may be aiding participants in completing this particular treatment is the wrap-around DBT skills training that participants receive prior to, during, and after the exposure phase. These skills—particularly the mindfulness, distress tolerance, and emotion regulation skills—seem to be assisting participants in withstanding the exposure.
Thanks Phil for your comments about yoga. Very much appreciated. I particularly like what you said about body postures:
“I do not believe that any one body position is associated with a particular religion. Christians have Christmas trees and aren’t practicing a pagan religion. Thus, certain bodily movements can be unrelated to Hinduism. I suspect this is more like Paul’s exhortation that eating meat or not eating meat sacrificed to idols is not the issue. Loving our brothers and sisters who may have a struggle is the issue.”
I hadn’t thought about yoga postures like that before, but it seems spot on. And I think you are right to relate it to Paul’s discussion about eating meat.
Just finished it today – thanks for the recommendation!
What did you make of his distinction (particularly as it related to the PE therapy he took part in) between having one traumatic experience vs. trauma over an extended period of time (i.e. his time in Iraq constantly having to be on edge about what could happen next)?
Is this an important distinction to make in deciding on a treatment approach? It seemed like he felt really unheard by his therapist who seemed to dismiss his concern that PE was wrongly reducing his experience to the one moment in Saydia.
Whit, this is a point I have made before. PE seems better with someone with one traumatic experience while multiple (especially early experiences like in complex trauma) do not do very well with PE. The incredibly high dropout rate shows this as well. Finally, I agree that once he started to express concern, it would have been best to consider alternatives. But, if all his therapist could offer is PE or if the research protocols pressed clinicians to complete therapy, then it would be unlikely that he would be heard.