Many American veterans, after having served their country, face new challenges when they return home. As a result of experiencing the trauma of war, they often have difficulty reconnecting with their families and former life and some experience anger, hyperarousal, nightmares and anxiety. These issues, if not addressed, can lead to alcohol and drug addiction as well as family and work problems.
Humans tolerate mild to moderate stress with few repercussions. In fact humans often find mildly stressful situations fun and exciting. Imagine the positive stress of going on a roller coaster ride or skiing down a snowy slope. We even seek these stressors to add fun and excitement to our lives. These stressors are usually controllable and predictable and only rarely result in extreme fear, injury or death. From childhood we develop coping skills that enable us to tolerate the normal, moderate stress of daily life.
Humans, however, are not designed for extreme stress, and those who experience traumas like combat, sexual abuse or terrorism may develop a condition called posttraumatic stress disorder (PTSD). PTSD is a normal response by normal people to an abnormal or highly stressful situation. We say that PTSD is a normal response to an abnormal event because the condition is completely understandable. The symptoms make perfect sense because what happened has overwhelmed normal coping responses.
A trauma is a wound, and PTSD represents the unseen deep emotional wounds suffered by those who are exposed to extreme stress. The traumatic events that lead to PTSD are typically so extraordinary or severe that they would distress almost anyone. These events are usually sudden. They are perceived as dangerous to self or others and they overwhelm the person's ability to respond adequately. 1
The Ranch - PTSD and Trauma Related Disorders Treatment
The Ranch is located on 2,000 historic acres in Nunnelly, Tennessee where Native American artifacts are plentiful and a Southern Plantation once stood. Used cooperatively as a hunting ground by Shawnees, Cherokees, Creeks and Chickasaws, the land nourishes the body and spirit today as it did centuries ago.
The Ranch was established in 1999 with the belief that traumatic experiences underlie many substance use and psychiatric disorders. Numerous studies support this hypothesis. Researchers have found incidences of traumatic stress as high as 64% in populations being treated for a serious mental illness. Likewise, there is a high correlation between substance use disorders and traumatic stress with some studies finding incidence rates as high as 82%. Now with eight successful years of trauma treatment experience, the Ranch is opening a new Posttraumatic Stress Disorder program for veterans and others who have disorders of extreme stress. The Ranch provides in-depth, evidence based trauma treatment including Cognitive Behavioral Therapy and EMDR in conjunction with spiritual renewal, healthy lifestyle management, healing ceremonies and family support. Together these treatments eliminate or significantly reduce the symptoms of PTSD including hyper-vigilance, extreme arousal, anger and sleep disturbances. Therapists at The Ranch are Master’s level trauma specialists who hold Level II EMDR training. Experienced milieu managers provide support and containment continuously during the day and night at our recovery homes. Visitors to The Ranch often say they feel a healing presence. Healing is witnessed at The Ranch every day.
How Common is Posttraumatic Stress Disorder (PTSD)?
PTSD is common. In the entire population, an estimated 6.8% of Americans will experience PTSD at some point in their lives. About 5.2 million adults have PTSD during the course of a given year. In people who have experienced a traumatic event, about 8% of men and 20% of women develop PTSD after trauma. The traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse. The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.
PTSD is more common in ‘at-risk’ groups such as those serving in combat. About 30% of the men and women who served in Vietnam experience PTSD. An additional 20% to 25% have had partial PTSD at some point in their lives. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced “clinically serious stress reaction symptoms,” PTSD has also been detected among veterans of other wars. Estimates of PTSD from the Gulf War are as high as 10%. Estimates from the war in Afghanistan are between 6% and 11%. Current estimates of PTSD in military personnel who served in Iraq range from 12% to 20%.
Who is most likely to develop PTSD?
Most people who experience a traumatic event will not develop PTSD. However, the risk for developing PTSD increases if a person:
- was directly exposed to the traumatic event as a victim or a witness
- was seriously injured during the trauma
- experienced a trauma that was long lasting or very severe
- saw them self or a family member as being in imminent danger
- had a severe negative reaction during the event, such as feeling detached from one’s surroundings or having a panic attack
- * felt helpless during the trauma and was unable to help them self or a loved one.
Individuals are also more likely to develop PTSD if they:
- have experienced an earlier life threatening event or trauma
- have a current mental health issue
- have less education
- are younger
- are a woman
- lack social support
- have recent, stressful life changes
Understanding PTSD Symptoms
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) states that the essential feature of Posttraumatic Stress Disorder is:
The development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person: or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1).
- military combat
- violent personal assault (sexual assault, mugging, torture)
- natural or manmade disasters
- observing the serious injury or unnatural death of another person
- learning about the sudden, unexpected death of a family member
The person’s response to the event must involve intense fear, helplessness, or horror (Criterion A2).
The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B)
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C),
- recurrent and intrusive recollections
- recurrent distressing dreams
- dissociative states during which components of the event are relieved (flashbacks)
Persistent symptoms of increased arousal (Criterion D).
- deliberate efforts to to avoid thoughts, feelings, or conversations about the traumatic event
- avoid activities, situations or people who arouse recollections of the event
- “psychic numbing” or emotional anesthesia
- feeling detatched or estranged from other people
- having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality
- sense of a foreshortened future (not expecting to have a normal lifespan, career, marriage or children.)
- increased anxiety
- difficulty falling or staying asleep
- exaggerated startle response
- irritability or outbursts of anger
- difficulty concentrating or completing tasks
The full symptom picture must be present for more than 1 month (Criterion E).
And the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).
The symptoms may be acute, chronic or with delayed onset.
The Etiology of Combat-Related PTSD
The destructive force of war creates an atmosphere of chaos and compels service members to face the terror of unexpected injury, loss, and death. The combat environment (austere living conditions, heavy physical demands, sleep deprivation, periods of intense violence followed by unpredictable periods of relative inactivity, separation from loved ones, etc.) is itself a psychological stressor that may precipitate a wide range of emotional distress and/or psychiatric disorders. Psychological injury may occur as a consequence of physical injury, disruption of the environment, fear, rage, or helplessness produced by combat, or a combination of these factors.
The psychiatric differential diagnosis for military patients at war is quite broad. The clinical picture will vary over the course of a war depending on individual characteristics (e.g., personality traits, coping skills, and prior illness) available social supports, and the amount of time that has passed between clinical presentation and the precipitating event(s). Thus, it is useful to consider the range of emotional responses in the context of the multi-phasic traumatic stress response.
- an immediate phase characterized by strong emotions, disbelief, numbness, fear, and confusion accompanied symptoms of autonomic arousal and anxiety;
- a delayed phase characterized by persistence of autonomic arousal, intrusive recollections, somatic symptoms, and combinations of anger, mourning, apathy, and social withdrawal, then finally;
- a chronic phase including continued intrusive symptoms and arousal for some, disappointment or resentment or sadness for others, and for the majority a re-focus on new challenges and the rebuilding of lives (Benediket al., 2001; Ursano et al., 1994)
Principles of Healing and Recovery
Why Seek Help at The Ranch?
The Ranch offers a supportive, full spectrum treatment program for veterans and civilians experiencing PTSD symptoms. Dealing early on with any effects that PTSD symptoms have on one’s life will help to prevent more severe problems in the future.
PTSD symptoms influence your life and relationships.
PTSD symptoms can make life hard to manage. One may withdraw from friends and family or have difficulty getting along with others. One may also be on edge or even violent. Turning to someone for help is the first step in addressing the impact of PTSD in one’s life.
PTSD is disabling and related to other health problems.
If one is having trouble sleeping, concentrating, working or experiencing chronic pain or other health problems it could be related to their traumatic experience. Having posttraumatic symptoms does not mean one has have PTSD. While it may be tempting to identify PTSD for oneself or someone else, the diagnosis generally is made by a mental-health professional. The licensed mental health professionals at The Ranch have received advanced training in the diagnosis and treatment of PTSD.
Evidence Based Treatment for PTSD
Treatment of PTSD
Today, there are good treatments available for PTSD. When one has PTSD, dealing with the past can be hard. Instead of telling others how they feel, someone suffering from PTSD may keep their feelings bottled up. But talking with a therapist can help them get better.
Cognitive-behavioral therapy (CBT) is one type of counseling. It appears to be the most effective type of counseling for PTSD. There are different types of cognitive behavioral therapies such as cognitive therapy and exposure therapy. There is also a similar kind of therapy called Eye Movement Desensitization and Reprocessing (EMDR) that is used for PTSD. Medications have also been shown to be effective. A type of medication known as a selective serotonin reuptake inhibitor (SSRI), which is also used for depression, is effective for PTSD.
Motivational Interviewing is both an assessment and a treatment technique. Motivational Interviewing helps the client determine their level of willingness to make life changes that will support healing. The therapeutic approach of Motivational Interviewing keeps in the forefront those motivators that inspire the client. Examples of clinical motivators include goals such as wanting to have a better family life, wanting to return to school or work in a particular profession. Emotional motivators may include wanting to feel better, wanting to maintain a sober lifestyle or wanting to reduce flashbacks.
Cognitive Behavioral Therapy
What is cognitive therapy?
In cognitive therapy, a therapist helps the client understand and change how they think about their trauma and its aftermath. The goal is to understand how certain thoughts about trauma cause stress and make symptoms worse.
Clients will learn to identify thoughts about the world and themselves that are making them feel afraid or upset. With the help of a therapist, clients will learn to replace these thoughts with more accurate and less distressing thoughts. They also learn ways to cope with feelings such as anger, guilt, and fear.
After a traumatic event, people might blame themselves for things they couldn't have changed. For example, a soldier may feel guilty about decisions they had to make during war. Cognitive therapy, a type of CBT (Cognitive Behavioral Therapy), helps one understand that the traumatic event they lived through was not their fault.
Cognitive Therapy may occur in both individual and group sessions.
What is exposure therapy?
The goal in exposure therapy is for a client to have less fear about their memories. It is based on the idea that people learn to fear thoughts, feelings, and situations that remind them of a past traumatic event.
By talking about your trauma repeatedly with a therapist, clients will learn to get control of their thoughts and feelings about the trauma. They will also learn that they do not have to be afraid of their memories. This may be hard at first. It might seem strange to think about stressful things on purpose. But clients will feel less overwhelmed over time.
With the help of a therapist, clients can change how they think about and react to the stressful memories. Talking in a place where they feel secure makes this easier.
Clients may focus on memories that are less upsetting before talking about worse ones. This is called "desensitization," and it allows them to deal with bad memories a little bit at a time. Therapists also may ask their client to remember a lot of bad memories at once. This is called "flooding," and it helps them learn not to feel overwhelmed.
Clients may also practice different ways to relax when they are having a stressful memory. Breathing exercises are sometimes used for this.
Many people want to talk about their trauma with others who have had similar experiences.
In group therapy, clients talk with a group of people who also have been through a trauma and who have PTSD. Sharing their story with others may help them to feel more comfortable talking about their trauma. This can help clients cope with their symptoms, memories, and other parts of their lives.
Group therapy helps clients build relationships with others who understand what they have been through. They learn to deal with emotions such as shame, guilt, anger, rage, and fear. Sharing with the group also can help them to build self-confidence and trust. They will learn to focus on present life, rather than feeling overwhelmed by the past.
Eye Movement Desensitization and Reprocessing (EMDR)
All humans are understood to have a physiologically based information processing system. This can be compared to other body systems, such as digestion in which the body extracts nutrients for health and survival. The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related thoughts, images, emotions, and sensations. Learning occurs when new associations are forged with material already stored in memory.
When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. For example, a rape survivor may “know” that rapists are responsible for their crimes, but this information does not connect with her feeling that she is to blame for the attack. The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed. When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like she is reliving it, or may experience strong emotions and physical sensations. A prime example is the intrusive thoughts, emotional disturbance, and negative self-referencing beliefs of posttraumatic stress disorder (PTSD).
It is not only major traumatic events, or “large-T Traumas” that can cause psychological disturbance. Sometimes a relatively minor event from childhood, such as being teased by one’s peers or disparaged by one’s parent, may not be adequately processed. Such “small-t traumas” can result in personality problems and become the basis of current dysfunctional reactions.
Francine Shapiro, who developed EMDR, proposes that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories. These can be memories of either small-t or large-T traumas. Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in the future. A variety of neurobiological contributors have been proposed.
Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant medicine. These can help you feel less sad and worried. They appear to be helpful, and for some people they are very effective. SSRIs include citalopram (Celexa), fluoxetine (such as Prozac), paroxetine (Paxil), and sertraline (Zoloft).
Chemicals in your brain affect the way you feel. When a person has depression, they may not have enough of a chemical called serotonin. SSRIs raise the level of serotonin in the brain.
There are other medications that have been used with some success.
PTSD can impact the entire family. Children and partners may not understand why a parent or partner gets angry sometimes, or why they are under so much stress. They may feel scared, guilty, or even angry about the person’s condition.
Family therapy is a type of counseling that involves the entire family. A therapist helps the family communicate, maintain good relationships, and cope with tough emotions. The family can learn more about PTSD and how it is treated.
In family therapy, people can express their own fears and concerns. It's important for everyone to be honest about feelings and to listen to others. The person suffering from PTSD can talk about your their symptoms and what triggers them. The family can also discuss the important parts of treatment and recovery. By doing this, the family will be better prepared to help.
The Ranch offers individual therapy for PTSD symptoms and family therapy to help relationships.
The components of Family Therapy at The Ranch are individualized to meet the needs of the client. These components may include a family-of-origin workshop, conjoint psychotherapy and experiential therapy.
Following the Gulf War, American troops marched proudly as their country welcomed them home. Many a Vietnam veteran shed a tear and found the ceremonies vicariously healing.
Rituals are structured activities that help people heal. They help focus thoughts and feelings. The rituals also help people experience the feelings, and process them. They help people consider the meaning of what has happened, grieve losses, receive support, develop helpful new ways to view themselves, and move ahead. Some rituals are formally structured; others can be quite simple. The Ranch uses several healing rituals to assist in the processing of traumatic memory. These include Medicine Wheel Activities, Walking the 12 Step Trail, and participating in the Sweat Lodge Ceremony.
PTSD authority, Dr. Don Catherall has suggested that most rituals generally contain seven parts.
- A location might be a sacred religious structure, a place where someone experienced a traumatic event, or a beloved spot in nature.
- A symbol helps people to experience their feelings. The Vietnam Veterans Memorial is a powerful symbol. The visitor descends into what feels like a dark valley of death, pauses to pay sacred respect to the fallen individuals, then walks upward toward life and light again. A family at the grave symbolizes a new family – not diminished but unified.
- Props. These include flowers, candles, photos, or written speeches.
- Personal Support. People verbalize love and support, and communicate it nonverbally through hugs, touch, or caring expressions.
- Healing words.
- Remembrances help to put traumatic events and individuals’ lives in perspective.
- Meaningful poems, songs, or music and invoking divine comfort can also promote healing.
- Expressions of hope for the future and enduring commitment to relationships helps survivors see beyond the traumatic event.
- A knowledgeable, trusted guide or director. This might be a recognized leader, like a clergy person, or one who has gone through similar difficult times and rituals before. Sometimes it is simply a family member or friend who is perceived as trusted and caring. Some people may also choose to lead their own ritual.
- Farewells. Placing a rose at a memorial site communicates acceptance of a person’s passing, the wish to preserve loving memories, and the reality of moving into the future.
What to Expect from Treatment
How long does treatment last?
For some people, treatment for PTSD can last three to six months. If you have other mental health problems as well as PTSD, treatment for PTSD may last for one to two years or longer.
What if someone has PTSD and another disorder? Is the treatment different?
It is very common to have PTSD at that same time as another mental health problem. Depression, alcohol or substance abuse problems, panic disorder, and other anxiety disorders often occur along with PTSD. In many cases, the PTSD treatments described above will also help with the other disorders. The best treatment results occur when both PTSD and the other problems are treated together rather than one after the other.
What will be worked on in therapy?
- When a client begins therapy, they, along with their therapist, should decide together what goals they hope to reach in therapy. Not every person with PTSD will have the same treatment goals. For instance, not all people with PTSD are focused on reducing their symptoms.
- Some people want to learn the best way to live with their symptoms and how to cope with other problems associated with PTSD. Perhaps they want to feel less guilt and sadness. Perhaps they would like to work on improving their relationships at work, or communication issues with their friends and family.
- The therapist should help to decide which of these goals seems most important, and they should also discuss which goals might take a long time to achieve.
What to expect from a therapist?
- A therapist should give a client a good explanation for the therapy. Clients should understand why the therapist is choosing a specific treatment, how long they expect the therapy to last, and what they expect the results to be.
- The two should agree at the beginning that this plan makes sense and what will happen if it does not seem to be working. The therapist should answer any questions about the treatment.
- Clients should feel comfortable with their therapist and feel they are working as a team to tackle the problems. It can be difficult to talk about painful situations in life, or about traumatic experiences. Feelings that emerge during therapy can be scary and challenging. Talking with a therapist about the process of therapy, and about hopes and fears in regards to therapy, will help make therapy successful.
- If a client does not like their therapist or feel that the therapist is not helping, it might be helpful to talk with another professional. In most cases, the client should tell their therapist that they are seeking a second opinion.
A lapse is often part of a larger pattern of recovery and (some people) may have to cope with a future lapse in order to continue on (their) way. (Dr/ Francis Abueg and colleagues, 1993)
Life is not linear. It is comprised of ups and downs. It would be nice if once a client was headed on a good course at a good pace no slips, setbacks, or falls would occur. However, as a person moves ahead he will undoubtedly have periods where some PTSD symptoms return. Such troubling periods are normal in PTSD and do not invalidate a client’s recovery work or detract from his gains. The Ranch assists clients in anticipating and preventing symptoms and situations before they occur and exploring ways to prevent the return of some symptoms from evolving into a full-blown relapse. Relapse prevention includes:
- Understanding the dynamics of relapse
- Identifying and anticipating high-risk situations or cues
- Developing a sound coping plan
- Rehearsing the plan
- Trying out the plan in “real life”
- Evaluating and making improvements if needed.
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