Let’s Talk about… post-traumatic stress disorder
Dr Loretta Poerio
Senior Mental Health Adviser
Department of Veterans’ Affairs
There is a lot written about post-traumatic stress disorder (PTSD), and it is important to be able to distinguish the hype from the evidence. PTSD is one of the most common mental health conditions in military populations.
Research focused on ADF personnel indicates that the estimated rate of PTSD among current serving members is 8%, rising to 17.7% among ex-serving; the rate in the Australian population is estimated at 5.7%.
Despite what you may hear and read, we know a lot about what works and what doesn’t, and also what complicates treatment outcomes. What we need to get better at is knowing what works for whom, when and under what circumstances. This is especially the case given that in the military and veteran population, there is more likelihood of co-occurring mental and physical health conditions.
Military-related trauma is often associated with problematic anger, substance misuse, sleep disturbance, depression, guilt and shame, as well as chronic pain and other physical health conditions. This can lead to a reduced response to treatment for this population. Stigma also plays a part in reluctance to get treatment.
PTSD symptoms may start years after the incident, or they may come and go over time. They can be exacerbated by life events and time of life. The symptoms most common to PTSD are:
- reliving the event/s, sometimes in the form of flashbacks
- avoiding anything that reminds a person of the event/s
- having more negative thoughts and feelings than before the event/s, including anger, fear, shame and guilt
- feeling on edge or keyed up.
These symptoms are common after a traumatic incident but they usually start to resolve within a few weeks. If symptoms don’t resolve themselves, and are leading to problems in your life, such as problematic anger and interpersonal difficulties, and you’re becoming emotionally numb and socially isolated, then you may meet criteria for a PTSD diagnosis.
PTSD can be debilitating and can impact a person’s ability to function as a parent and/or partner. It can lead to stress within the family and its needs not being met. In fact, one of the most common reasons that people seek help can be the strain these symptoms put on their relationship.
PTSD is a condition that can be treated. Effective treatments for PTSD are available, including the use of adjunctive treatments such as exercise, yoga and assistance dogs. Australia has developed guidelines, to help guide clinicians, veterans, children and adults. You can find these on the Phoenix Australia website (phoenixaustralia.org).
Treatments include therapy, medication, or a combination of the two. Recommended counselling approaches for adults that target the traumatic memories include trauma-focused cognitive behavioural therapy, cognitive processing therapy, trauma-focused cognitive therapy, prolonged exposure, and eye movement desensitisation and reprocessing.
Enhancements to interventions are also being studied and include psychedelic-assisted psychotherapy and brief and intensive trauma-informed therapies. DVA continues to monitor the research and has developed a webpage to provide information to veterans and their families (Look for ‘Emerging and Adjunct Treatments for Common Mental Health Conditions Affecting Veterans: A Rapid Evidence Assessment’ on the DVA website.) It is important to note that emerging treatments should be tried only after evidence-based treatments have been found to be ineffective.
What we know about treatment is that it is not one-size-fits-all, that it takes time, it takes trust, and it requires using a range of interventions that we know work. As a clinician, it is often a difficult juggling act to know where to start as there are often a range of difficulties present, all vying for attention and intervention.
As avoidance is a hallmark of PTSD, and if you use unhelpfully avoidant coping strategies as your go-to, then it is likely that treatment may be delayed for years. A way of dealing with distressing symptoms is to try and drink them away, or use other mind-altering substances. This, of course, just makes the problem worse.
Anger is another area to be addressed. It is often a way for people to avoid engaging with people and dealing with difficult memories and situations. Problem anger is strongly associated with PTSD and other mental health conditions, such as alcohol abuse, in veteran and military populations. It is increasingly seen as an important consideration in trauma-impacted populations, and as a mental health issue in its own right.
Adding to this complexity is the fact that veterans experiencing poor physical health and chronic pain are often also likely to have heightened levels of distress, anger and irritability, which diminishes their capacity to manage their emotions. Add other mental health symptoms such as depression and alcohol and other drugs, as well as sleep difficulties, and the complexities become apparent. DVA is working to better support providers treating veterans with complexities, through support for case coordination and comprehension care of medical and psychiatric issues through the CVC program, and funding of rehabilitation programs.
Another factor is that therapy is a two-way-street. Treatment requires that you are an active participant and that you trust your clinician enough to engage with the therapeutic process. There are treatments that work that can make a significant difference to a person’s quality of life. Often, because there are many areas of intervention, a range of treatments will need to be used in parallel or consecutively, and treatment may take some time. Clinicians at Open Arms – Veterans & Families Counselling are well trained in dealing with military trauma and are a great place to start (www.openarms.gov.au).
Treatment can comprise a series of stages, with different interventions at varying ‘doses’ or intensities, depending on the need of the individual veteran. This may include couple and/or family therapy. It may be the case that you are not ready to work on your trauma memories, but that does not mean that you can’t focus on other areas that are creating difficulty, such as sleep, anger or relationship difficulties. It also does not mean you will never be ready.
As a final note, this is my last article for Vetaffairs as I will be leaving the Department at the end of the year. I thank you for your feedback and kind wishes over the 7 years of writing the mental health column.