Treating PTSD with Cognitive-Behavioral Therapies

Edward Chandler Wright

Q & A with Dr. Edward C. Wright

BrainLine sat down with Dr. Edward C. Wright to discuss PTSD. Dr. Wright is a board-certified clinical psychologist in the Home Base Program of Massachusetts General Hospital, focused primarily on providing treatment for PTSD. He is also part of the Wounded Warrior Project’s® Warrior Care Network®, which helps veterans transition to civilian life. Dr. Wright spoke about PTSD and his use of cognitive-behavioral therapies to treat anxiety and depression.

Questions & Answers

BrainLine: At what point after a trauma would you consider diagnosing someone as having PTSD?

Dr. Wright: In prolonged exposure therapy, we talk about PTSD as a disorder of impeded recovery. We say that because we know that about 70% of people will go through a trauma at some point in their lives. It’s normal and common that people will have symptoms that look like PTSD. In a lot of cases, those symptoms clear up in the days and weeks that follow. So, you typically don’t give a person a diagnosis of PTSD until a whole month has gone by and the symptoms are still lingering around.

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BrainLine: What are prolonged exposure therapy and cognitive processing therapy?

Dr. Wright: In prolonged exposure therapy, we do two types of exposure. One is called "imaginal exposure". That’s where you’re talking about the trauma memory in sessions as well as listening to a recording of it outside of sessions. Prolonged exposure involves reducing your avoidance of the traumatic memory and intentionally facing it and talking it through on a regular and repeated basis. That can be challenging, but it’s also a really effective and powerful way of reducing the disgust that the memory brings up. It’s also giving a person a chance to look at the trauma from different angles and think of it in new ways that they might not have considered.

And then we have to do something called emotional processing, where we take the time to think through any meanings the individual has taken away from the trauma, then start to probe at those to see if they’re accurate based on the details we’d discussed. And to see if there might be a more balanced or helpful outlook you can take.

The second type of exposure we do in prolonged exposure is called in "vivo exposure". This involves facing physical reminders of the trauma (like pictures, movies, certain sounds/smells), as we experience situations that aren’t dangerous but feel threatening because of the trauma. For most veterans, this includes crowded, busy public places. By confronting these things, the patient finds out firsthand that nothing bad happens, they can handle the distress it brings up, and it actually gets easier with repeated practice.

Then there’s cognitive processing therapy. There is no exposure component per se, but you focus sessions on addressing the patient's unhelpful takeaways from the trauma. Again, in a very structured, systematic way, like weighing the evidence for or against the beliefs that they’ve developed. We’re looking at any unhelpful thinking patterns that they’re falling into, like over-generalizing and thinking about it in all-or-nothing terms, or maybe discounting some of the positives and focusing on the negatives.

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BrainLine: How do people’s expectations of therapy compare to how it actually works?

Dr. Wright: Doing trauma-focused therapy can be much different from what people might imagine from media or from their own past experiences with therapy. It’s not necessarily the kind of treatment where you’re going to feel better that same day or feel better at the end of the hour because you talked something through. I think of it more as tough exercise where you’re going to work really hard and you might feel sore or exhausted afterwards, but that hard work and that repeated effort leads to a longer-term improvement that accumulates over time. I think people, when they go into treatment, they’re not necessarily expecting that they’re going to feel worse before they get better. And we know that the things we ask of them in exposure therapy may be in direct contradiction to what’s most comfortable for them or what they think is keeping themselves safe or helping them deal with the trauma. Because with prolonged exposure, we’re trying to actively target that avoidance. Avoidance is a very understandable coping strategy that people have developed and that’s helping them manage their symptoms, but it’s really preventing them from recovering in the broader sense or in the longer-term.

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BrainLine: How do you address that? The veterans are feeling terrible already and the therapy might make them feel even worse. How do you help them embrace the belief that it will help in the long-term?

Dr. Wright: We highlight that we’re really not putting anything new into their thoughts. We emphasize the fact that the stress doesn’t last forever. It’s trading some very short-term discomfort for a much longer term benefit. There are ways of going about trauma-focused therapy that can help a person ease into it. For example, within vivo exposure, where we ask people to go out into crowded places, we start at a level that’s just one step outside of their comfort zone. So, we’re not asking them to go to a football game on day one, or to go straight to a mosh pit or anything like that. We might have them just sit with their back to the front door of their own home. Or go to a coffee shop when it’s not too crowded and work on not watching the door to see every person who comes in. There’s always a manageable level we can start a person off with to at least get them moving in the right direction. And as they do that and see that they’re able to handle it and actually like moving forward and making progress, that progress can give them encouragement to keep at it.

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BrainLine: Can you give a general description of how people with PTSD react to circumstances that evoke their past trauma?

Dr. Wright: PTSD is definitely a multi-faceted condition and it’s part of why we talk through the common reactions in trauma. We want to give people a better understanding that all of the things they’re experiencing are often tied back to the trauma. So, there are four clusters of symptoms. One is called reexperiencing symptoms. These are ways in which the experience of the event tends to keep coming back up and intruding on a person’s life. It looks like nightmares or memories of the trauma popping into their head out of the blue. It can involve what we call triggers, where certain sights or sounds or smells will evoke a really strong emotional response. The trigger connects back to the trauma and brings up the memory of it. Or sometimes the triggers don’t even bring up the memory explicitly, but there’s a conditioned response where a certain smell just creates a whole lot of anxieties and adrenaline and that fight or flight response. So, that’s reexperiencing.

The second cluster is avoidance. There’s avoidance of talking about the trauma memory, avoidance of thinking about it, avoidance of the emotions that go along with it, as well as avoidance of reminders of the trauma, or avoidance of situations that feel unsafe because of the trauma. So, a big part of treatment involves reducing or eliminating that avoidance in order for that recovery process to kick in.

The third cluster involves changes to a person’s mood and outlook: feeling persistently guilty, beating themselves up about the trauma, isolating themselves, changing their outlook on the world or themselves or other people, having trouble experiencing joy or positive emotions.

The final cluster is called hyper-arousal. This is another group of symptoms where people are jumpy, easily startled, on edge, watchful, constantly scanning for threats, sometimes engaging in reckless or risky behavior, having trouble focusing and concentrating or having trouble winding down and going to sleep.

As you can imagine, trauma comes up in a lot of different ways. Sometimes we’ll see second or third order effects, where the symptoms will feed off of each other or even snowball. Then that can lead to disruption in a person’s life that creates even more symptoms or difficulties. One example might be if a person is avoiding going in a house because they’re feeling anxious around strangers and that can interfere with participating in activities with their family. Then if their family goes out without them, then maybe they’ll feel guilty and down about themselves or feel hopeless. That can come out as a negative mood or irritability, which can further alienate their family or the people around them. That, in turn, could lead to increased feelings of guilt, which could lead to drinking to numb themselves, which distances them further. These impacts start to evolve. A person might lose their family, lose their friends, lose their career, or lose access to the things that make life enjoyable in the first place.

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BrainLine: So, you’re seeing people who in many cases who are in a lot of pain.

Dr. Wright: We’re often seeing veterans who have been struggling with PTSD for years and years and have had treatments multiple times but haven’t really found that thing that’s going to help them get unstuck and get their life back to the way it used to be.

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BrainLine: What have you learned from your patients about their experiences?

Dr. Wright: I have developed a really intense appreciation for what veterans and their families go through and what they have to deal with. The stories we hear are incredible. And I’m amazed every day that people are able to volunteer for service and to get on that plane and deploy and face these life-threatening situations day after day after day. And then to come back and to still function in the civilian world. So, I’ve learned a lot about their resilience. I’ve learned some of the things that were protective in that military environment may make it harder to recover when a bad experience happens.

We talk a lot about responsibility in trauma-focused therapy and that’s a huge part of military culture, where people feel responsible, especially for their subordinates within the chain of command. They feel responsible not just like you would feel responsible for an employee, but more like a parent feels responsible for their child. I mean that in the sense that whatever happens to them is your fault or your responsibility even if it’s something that’s totally outside your control. There’s this natural question of “What more could I have done?” or “Why wasn’t I able to prevent that?” And then that responsibility can even extend to colleagues or people at the same rank you are. There’s this very cohesive collective identity that develops where everyone is looking out for each other, everyone is watching each other’s back. So, when someone gets hurt or killed, it’s natural then that everyone’s asking themselves “What should I have done better?” or “What didn’t I do right?”

I think also, in order to get themselves into the right mindset to face the challenges of missions, that sometimes service members will be in the mindset that they have more control than they do. I always talk to patients about this and they agree with me, that if their leadership told them “Hey, you’re going out on a mission. There are going to be hidden bombs. There’s going to be ambushes. We can’t really predict these things. We can’t really control them. So, just go out there and do your best and hope for the best,” it would be pretty tough to go out. It would be very demoralizing to think there’s such unpredictability and chaos out there.

So, I think sometimes people will almost trick themselves — in an adaptive and productive way — into thinking “If we all just do our job and everyone does everything right then things will turn out okay.” Which helps boost morale and helps get them out there, but then when something bad happens, they’re naturally interpreting it as a failure or as something that someone on their team did wrong, even when we know that’s not quite realistic and probably isn’t the case.

So, a big part of treatment can be undoing some of the things that they’ve told themselves in order to take those risks in the first place and to face that danger.

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BrainLine: So in the therapy you might be looking at the traumatic experience itself and asking, “What’s your narrative of it? How do you see it?” and then discussing those perspectives.

Dr. Wright: Absolutely. That’s something that we address both in prolonged exposure therapy and cognitive processing therapy. It’s just that in prolonged exposure there’s more emphasis on repeatedly talking through the details of the narrative so they can get acclimated or, as we call it, habituated to the direct details themselves. So, as they talk the narrative through repeatedly, their distress in response to it comes down gradually. But then we also have an opportunity, just like in CPT, to look at the takeaways or the explanations they’ve come up with about why these events took place.

A big part of PTSD, and I think especially with service members, are narratives involving self-blame, or a sense of responsibility or a sense of guilt or survivor's guilt. There’s what we call just world beliefs: thinking that this happened because someone did something wrong or because we somehow deserved it because of a failing or a shortcoming in how we went about things. Therapy involves challenging those beliefs a bit and developing a more balanced or nuanced perspective, where you’re able to see the things that were in your control and the things that were outside your control and to accept those.

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BrainLine: Does the therapy tend to work well?

Dr. Wright: There’s a wide range of outcomes and responses where sometimes you’re having the same kind of conversation over the course of two weeks or maybe 10 to 15 weeks, and you’re touching on the same theme over the whole course of therapy. Other times just the right detail comes up as a patient is talking through the trauma narrative and it changes their entire perspective on it. Or just by allowing themselves to fully face the details of what happened, they’re finding either exonerating details or things that put sometimes put the entire event in a different context. So they make a major shift in just one session. But I wouldn’t want to set that as an expectation for anyone. They can’t just talk about it once and assume everything is going to be different. But sometimes there are those “aha” moments where there can be a big shift in one session.

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BrainLine: What are the barriers to finding good treatment for PTSD?

Dr. Wright: There are not very many providers who are doing evidence-based therapies for PTSD. There was a national rollout of prolonged exposure and cognitive processing therapy in the VA system, so there should be a lot of providers within the VA who are trained or able to provide these therapies. But in the civilian world, there just aren’t nearly as many therapists undertaking this level of effort to learn the therapies so they can deliver the best level of care. If therapists aren’t learning these therapies it’s a lot harder for us to connect people with good therapy when they leave our program.

We know that doing prolonged exposure or cognitive behavioral therapy is going to be effective and helpful in the majority of cases, but it does place a bit of a burden on the provider to get that training and to learn a new protocol. That can be a lot of work up front and when people are busy and they’re involved in their own practice, they aren’t necessarily incentivized to take that extra step.

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BrainLine: Are there clear descriptions out there of what effective treatment looks like?

Dr. Wright: There are some guidelines from the American Psychological Association and the VA and the Department of Defense in terms of clinical practice guidelines based on a systematic review of the evidence for which therapies are effective for PTSD. So, there are pretty clear recommendations on which treatments work. I think it’s just a matter of therapists getting that training and then actually integrating it into their practice, which is a whole other challenge.

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BrainLine: If you’re a civilian therapist who doesn’t know much about the military, does that present difficulties?

Dr. Wright: I believe so, because there’s got to be that level of familiarity with military culture and that credibility level. We know a lot of veterans are a bit skeptical about civilian therapists and their ability to relate to or understand their experiences. It’s not just like working with any other population. Veterans have their own norms and experiences which are so much different from most civilians. They even have their own language in terms of the sheer number of acronyms. So, if a patient comes in and they tell you that they were hit by IDF on an FOB every day, I don’t know if most civilians would know what the heck they’re talking about. They could be talking about being on a forward operating base where they would spend most of their time, a military base that’s overseas in a combat environment. And IDF is Indirect Fire. So, it’s more like mortar attacks. I think it can really hurt the rapport and the credibility building if a patient tells you something like that and you say, “What’s an FOB?” or “What’s IDF?” That’s going to tell them right away that you just don’t know anything about where they’re coming from or what they’ve experienced.

We do have some trainings online through our Home Base website. We have an education institute where we have some military cultural trainings that help the therapists in the community get more familiar with those aspects of the military. We also have an initiative where we’re providing training for community providers in prolonged exposure and cognitive processing therapy. We do follow-up consultation calls with them while they’re seeing patients in order to practice delivering these therapies. That can be a big part of actually getting civilian providers to implement the treatment. It’s to get that additional consultation after the training to make sure that they have some support as they first start to deliver these treatments.

All of these trainings are free online on our website.

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BrainLine: If someone doesn't live close to Home Base, what would you suggest to a spouse or the veteran who says, “I’m upset. I can’t get out of bed. I’m depressed. I’m irritable. What do I do now?”

Dr. Wright: Fortunately, there are similar sites to Home Base. We’re part of the Warrior Care Network and there are sites at Emory [in Atlanta], Rush [in Chicago], and UCLA [in Los Angeles] that have similar programs. If that’s, for whatever reason, not an option, I would absolutely recommend that the veteran go to the VA or a vet center, if that’s more accessible. Or they can look online on at Center for Treatment and Study of Anxiety. Dr. Foa’s clinic at Penn. They have a list of providers who have been certified in prolonged exposure therapy and it’s broken down state by state. So, I would recommend that they look on there for a civilian provider who’s been certified in PE or look online for a certified cognitive processing therapy provider.

The PE credential is offered by Dr. Foa’s group at Penn. They do four-day intensive trainings in prolonged exposure therapy and then offer a certification for that.

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BrainLine: What do you offer specifically at Home Base to veterans and their families?

Dr. Wright: We have multiple programs now. We have the two-week intensive clinical program, or ICP, where we have a PTSD track and a TBI track. We have an outpatient clinic where people can get more traditional therapy. If they’re local, they come in on a weekly basis for individual therapy or couples therapy. They can bring the family in or their family can come in and get support as well. We’re just rolling out a four-day weekend intensive program, which basically condenses the intensive clinical program even further. So, that one’s more intensive exposure therapy over the course of four days to try to accommodate people’s careers or lifestyles that would prevent them from doing the two-week program. And we’re also starting an intensive outpatient substance use program because we know that’s another thing that a lot of veterans are struggling with.

The two-week program is at no cost to the veterans or family members and we fly them in from around the country or even around the world. We’ve had veterans located in other countries who’ve flown in from there. We put them up in a hotel that’s about a block away from the clinic and they enter the two-week program along with a cohort of other veterans. They all praticipate and graduate as part of the same group. They’ve got that kind of cohesion and support as they’re going through these challenging treatments. They’re in the clinic from about 7:45 AM until a little bit after five in the evening. And then there are evening and weekend activities as well. It’s a pretty packed schedule, pretty demanding and challenging at times. I always tell the patients the first word in ICP is "intensive" and that it really lives up to that.

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BrainLine: What does therapy consist of during Home Base program?

Dr. Wright: They get treatment involving individual trauma-focused therapy for an hour every day, as well as different group therapies, including in vivo exposure groups and DBT skills.

DBT, or Dialectical Goal Behavior Therapy, teaches emotion regulation skills. It’s basically practical steps they can take to manage their distress or to be effective and get what they want when they’re feeling upset. And to not escalate things and make them worse, but to engage in active coping.

Then there’s a group called Resilient Warrior, which teaches relaxation, meditation, mindfulness.

And then a cognitive health group, which addresses concentration, memory strategies, scheduling, providing structure. Basically, ways to be more effective and efficient even when they’re dealing with the distractions and concentration problems that come up when they’re dealing with PTSD or TBI.

We also have a health and wellness component where in the early evenings they’re either doing fitness, tai chi, or yoga. They also have art therapy.

And they do evening activities where they will either go on a tour of Boston or a historical site. On weekends we send them to a farm nearby where they get equine therapy and get to go horseback riding, do quilt making, leather work, things like that. So, that’s intended to not be clinical, just a laid-back break from the rigors of being at this clinic for a whole week straight.

We bring the family members in on Wednesday evening. It could be a family member or a friend or a support person basically. The family members get two full days of programming that teaches them a lot about PTSD and PTSD treatment, and basically walks them through the interventions that their loved one is getting. So, they have a mini-course in DBT skills and a mini-Resilient Warrior course.

There’s another joint group called Reducing Avoidance that we just implemented, where the family member and the veteran work on ways in which they can collaborate on doing exposures once they get back home. Because we want the family members to feel empowered but also informed about what’s going to be helpful for the veteran and encourage them to keep up with their homework and their exposure therapy, their self-directed work. Spending time figuring out what the veteran is going to be open to hearing in terms of facing these challenging situations.

Some people might say, “I want you to just kick me in the butt and tell me ‘You’ve just got to do this. Go get it done.’” And other people say, “Don’t come at me too aggressively or I’m going to have a negative response but here’s some words you could use to gently encourage me that I’ll be open to hearing.”

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BrainLine: Do you have any data yet as to how well the program is working?

Dr. Wright: We published an article with some initial findings back in 2018. We found, I think it was about a 17.5 or 17.4-point drop on the PTSD checklist, which is a symptom questionnaire. A 17-point drop is a large effect size. And we’ve had about a 93 to 95% graduation rate over the course of the program. We’re finding that under these circumstances the dropout does not need to be high. That people are able to tolerate this treatment even when it’s delivered in this two-week intensive format. And there are a lot of different reasons why that could be. It could be the support of the other veterans in the cohort. It could be the health and wellness activities. It could be because they’re all the way out here. They could leave at any time, but they are in a way a captive audience because they’re here to do this work and they’re able to just leave all the distractions of home behind.

So, we don’t really know why we’re getting such a great retention rate, but it at least shows that under the right circumstances it’s entirely possible for the vast majority of patients to get through these challenging treatments, even in an intensive format.

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BrainLine: How do we go about addressing these issues for all people who are not going to enter an intensive program like yours?

Dr. Wright: That’s just the kind of thing we’re working on right now and I know the Wounded Warrior Project is collaborating with a group called Head Strong in order to identify a network of vetted providers who will actually deliver evidence-based therapy for PTSD. We’re also doing our own community consultation program where we’re training providers.

So, I think it’s just a matter of continuing to identify and vet providers, continuing to train them and support them. We know just because of resourcing that most individuals with PTSD aren’t going to get access to this level of wraparound care and services. But we see really good outcomes with evidence-based treatments for PTSD in the community when people stick with it.

I think if an individual has access to good, standard of care, evidence-based PTSD treatments, there’s a comparable opportunity to make a large improvement in their symptoms.

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BrainLine: Do you have any thoughts on how to reduce dropouts?

Dr. Wright: I think involving the family could be a big part of it. That’s something that a lot of veterans are very appreciative of. We support any ways in which the veteran can reach out to other veterans and connect with them on that level and encourage them to stick with it. I think any ways in which we’re able to integrate the treatment further into the veterans’ broader system, it’s going to provide some more support and encouragement. We know it can be easy to drop out, when it’s just you and your therapist. You can just stop showing up whenever you want. But if your family is involved, and there’s some increased encouragement or increased accountability, you might stay with it. And I know even just publicizing a goal can make a person more likely to stick with it. So, maybe encouraging patients to talk to more individuals in their lives about the fact that they’re in treatment, and what they’re working towards could help get them that support and that accountability.

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BrainLine: Are there any misconceptions out there that you wish would be dispelled?

Dr. Wright: I think the number one misconception that we hear from a lot of our patients is this idea that PTSD lasts forever and that once you get it, you’re stuck with it. It’s a bit nuanced because PTSD absolutely can last forever. I’ve heard accounts of World War II veterans who are still experiencing nightmares on a nightly basis. So, I wouldn’t want to frame it as if it’s a short-term problem. But just to let people know that with the right treatment, you absolutely can recover. And that in the majority of cases, when someone experiences a trauma, even if they have those reactions initially, that those PTSD reactions do subside over time. It’s just that some people get stuck due to avoidance or unhelpful perspectives on the trauma. Treatment is actually really effective at helping people get unstuck and helping them reduce the avoidance and work through those unhelpful perspectives on the trauma.

I try not to frame it the way some people say, “Time heals all wounds.” It’s not about time. It’s about doing some tough work over time. And then recovery can take place in a matter of weeks or months. If they’re really dedicating themselves to these gold standard treatments, then it doesn’t need to take years and years. The recovery process is usually one of a few months. I don’t say that in any kind of a critical way. I would never want anyone who’s been suffering for years to take it that way. But to actually instill hope and let people know that there are things they can do if they get connected with the right provider. And that this absolutely doesn’t have to last forever.

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Posted on BrainLine August 29, 2019.