Therapy Born on the Battlefield May Help Ease Anyone’s PTSD

Nov. 17, 2023 – Army Reserve veteran Selina Jackson has years of combat experience … off the battlefield.  Growing up in what she refers to as a combat zone in upstate New York, Jackson often witnessed brutal fights between her parents that would leave her mother unconscious on the floor. She observed her alcoholic, drug-addled father savagely beat her older sister more times than she cares to remember. She was repeatedly sexually abused by the teenage son of her parents’ best friends. Her father burned down their home.  And yet, she kept these traumatic, often life-threatening events secret, until, that is, the COVID-19 pandemic hit, and she found herself stuck at home. “I was physically unable to do the things that I always did to distract myself,” she said, as she was working from home, “which for me was horrifying, because I was like, ‘Oh my God, I’m here, I’m in my house all day by myself, working.’”  Her PTSD “became overwhelming.” She couldn’t stop the symptoms during the day. “I still had such a heavy load of guilt and shame. I didn’t care if I lived or died,” she said. Jackson was eventually diagnosed with posttraumatic stress disorder (PTSD), a mental health condition that affects millions of people worldwide, twice as many women as men in the general population, and about 13% of young female veterans (vs. 6% of male veterans). Female veterans also disproportionately experience trauma and adverse childhoods before entering the military, experiences that are further compounded by high rates of sexual assault and/or sexual harassment during military service.  Unfortunately, these numbers don’t paint a complete picture. PTSD is often undiagnosed. Many patients either don’t recognize or run away from tell-tale signs and symptoms like flashbacks, guilt, and shame. And the range of symptoms linked to PTSD – such as depression, anxiety, isolation, substance use disorders, or suicidal thoughts – are also common in other psychiatric conditions. That can lead to misdiagnosis, incorrect treatment, and ongoing challenges. “For PTSD sufferers, the world gets smaller and smaller, they start avoiding relationships, work, pleasurable activities, things that they used to do,” said Tara Galovski PhD, director of the Women’s Health Sciences Division of the Veteran Affairs’ National Center for PTSD, and a psychology professor at Boston University School of Medicine.  “But the memories squeak out in different ways, like when people are trying to fall asleep and can’t because thoughts are racing through their minds. They affect concentration, irritability, and the way that PTSD sufferers see and think about themselves in the world.” Without treatment, Galovski said, these symptoms can become chronic and create other kinds of health impairments “across important ways we function.” Hitting Her Stride Through STRIVE Jackson , now 53 and living in Ohio, credits a program at the Ohio State University Wexner Medical Center  called STRIVE (Suicide and Trauma Reduction Initiative) with helping her deal with the PTSD and turning her life around.  “I love who I am right now,” she said. STRIVE was founded by clinical psychologist, professor, and retired Air Force veteran Craig J. Bryan, PsyD. The program is research-based and geared toward developing the best strategies for addressing trauma, gun violence risk reduction, and suicide in adults who are veterans or in the general population. Its origins are rooted in strategies used to treat psychological trauma in combat zone soldiers. “The origins of what we now refer to as massed therapy – a compressed format – naturally stems from deployment and being downrange in a combat zone where you don’t have the luxury of coming to therapy once a week for an hour over a few months,” Bryan said. “Most of the cases I was working on were people who had been blown up, who had vehicle rollovers, head injuries, and I had to make rapid decisions within a few days as to whether that person was going to be OK or needed to go home.” The battlefield provided a testing ground for the compressed, accelerated treatment that Bryan brought back to the U.S., first to the University of Utah and then to Ohio State.  The primary technique used by STRIVE therapists is cognitive processing therapy. First developed as a treatment for sexual assault victims by University of Missouri researchers, the therapy was also adopted and rolled out by the VA 16 years ago.  The framework for “CPT suggests that when a traumatic event happens, it has a huge impact on the way that people think, and for some, significantly changes their beliefs about why that trauma happened,” Galovski said. “It also impacts their beliefs about themselves and other people, about the world.” “We use the term ‘stuck points’ a lot,” Bryan said. “This is a belief that prevents natural, spontaneous, built-in recovery processes that help us move forward and get over an event. Common ‘stuck points’ include things like ‘It’s my fault.’ ‘I should have done things differently or worn a different outfit.’ ‘I should have never trusted that person.’” With cognitive processing therapy, doctors fashion identify patterns and teach patients to examine their own thoughts from a more “balanced, objective perspective,” Bryan said.  Essentially, the therapy helps patients learn to challenge and modify unhelpful beliefs (for example, I was raped because I was wearing a short skirt), and create a new, more realistic understanding around the event (such as, What else was going on? Have you ever worn a short skirt before? Do short skirts cause rape?). “This more balanced thought process then alleviates anxiety, fear, guilt, shame, and all of the other consequences of PTSD,” Bryan said.  Learning to Live Fully Again Ohio State’s program is offered in person or by telehealth over 10 daily, 1-hour sessions with a therapist. Patients are required to take part fully and complete daily assignments.  One of the reasons why STRIVE is effective is that it doesn’t leave room for patients to skip or cancel sessions. “The consistency, every day, having to do work at high, was very prescriptive,” Jackson said.  AnnaBelle O. Bryan, director of the STRIVE program and a retired Air Force veteran, said many patients start recovering between the fourth and sixth sessions, while others need the full gamut, and maybe an extra hour thereafter. But she underscores that the most benefit is gained when patients continue to practice and strengthen what they’ve learned. Currently, STRIVE boasts about a 76% recovery rate, which Craig Bryan said is similar to what studies have shown; 70% to 80% of patients who complete cognitive processing therapy have a significant reduction and improvement in symptoms.  Relapse is common in some people about 6 months after they leave the program, AnnaBelle Bryan said, and usually these flare-ups are reminders that something happened vs. a return to full-blown PTSD episodes.  “If they can get themselves through [these flare-ups] by using the skills they learn, then we don’t hear from them,” AnnaBelle Bryan said, noting that 50% of patients fully recover beyond 2 years. “We track their progress so they can see their progress happening as it is happening, which really helps with recoveries.” For the others who need more help, STRIVE offers 1-hour “booster“ sessions. Importantly, the program is free. Those who take part in it help with the organization’s research, and in return, they receive quality therapy.  With a new outlook on life, Jackson has plans to leave Ohio and move to upstate New York in the spring. She said STRIVE gave her the opportunity to finally be able to be a better person for herself, and for everyone else in her life.  “Rather than surviving, I will finally be able to live,” she said. For more information and resources, people – especially veterans – are encouraged to check out the  National Center for PTSD .  You can also learn more about STRIVE, including your  eligibility for the program . If you are feeling suicidal, help is available 24 hours a day, 7 days a week by dialing 988 (the Suicide and Crisis Lifeline). Veterans and their loved ones can dial 988 and press 1 to reach the  Veterans Crisis Line , or text 838255. STRIVE offers help through a separate program –  STRIVE BCBT – to current service members; veterans; first responders (such as law enforcement officers, dispatchers, firefighters and paramedics) without a military history; and their family members who are having symptoms of suicidal thought and behaviors.