Progressnotes - October/November 2012
- About MUSC Health
Trauma by its nature is sudden, unexpected. It can alter our normal sense of time, the predictable thread of events. Whether it be a soldier setting off an improvised explosive device buried in an Afghani dirt road or a woman surprised by a rapist as she unlocks the door to her apartment, such a traumatic moment rends the fabric of a life.
A moment removed from the normal course of time, the traumatic event haunts the survivor, ready to intrude itself into the present. Unlike other memories, which may dull over time, the traumatic memory remains fresh each time it recurs, and the sensations associated with it are experienced again as if for the first time.
Although the memory of a traumatic event and the situations and sensations associated with it (eg, a crowded market, the smell of diesel fumes) have no actual power to harm, they are perceived by trauma survivors to be a as dangerous as the traumatic event itself. Some survivors manage to defuse that sense of threat by speaking about the event with loved ones. Others, however, particularly those who develop posttraumatic stress disorder (PTSD), which is often accompanied by depression or substance abuse, will build elaborate strategies for avoiding situations or sensations that could trigger such a recurrence.
Ironically, the very attempt to avoid the traumatic memory or other sensory or situation reminders of the traumatic event does the real damage to survivors and also ensures that the traumatic memory will continue to haunt their lives. In other words, avoidance and withdrawal ensure perpetuation of the anxiety response.
This careful avoidance protects not the trauma survivors but the memory they wish to avoid. If they confronted the memory, it would begin to lose some of the seemingly omnipotent control it has over their lives. By avoiding the memory, by not exposing it to the test of reality, they inadvertently preserve its power.
Most of those with PTSD never seek treatment. Treatment means venturing out of their “safety zone” and facing the prospect of confronting that which they have structured their lives to avoid.
Telemental health, or the delivery of psychotherapeutic and psychiatric services via telemedicine, can help break through the patients’ defenses.
It brings the treatment right into their homes or into the area of the community (eg, rape crisis center, police department, community center, women’s shelter) where help is most needed.
MUSC’s telemental health program offers evidence-based PTSD treatment to survivors of both battlefield and civilian trauma. Ron Acierno, PhD, and Michael A. de Arellano, PhD, both Professors of Psychiatry & Behavioral Sciences at MUSC, direct telemedicine programs in home-based treatment for veterans with PTSD and school- and community-based psychotherapy for civilian survivors of trauma, respectively.
In bringing the treatment to the patient, home-based telemental health does not cater to the patient’s avoidance but rather offers the PTSD patient a means to overcome it. According to Dr. Acierno, who serves as both Director of the Older Crime Victims Clinic at MUSC and as Director of the PTSD clinical team at Ralph H. Johnson VA Medical Center, “it provides a foothold, a first step; it gets them to the point where they can leave the house and seek in-person therapy.”
Veterans with PTSD go to great lengths to avoid triggers that could set off a recurrence, whether that be a crowded department store, a loud noise, the act of driving a car. Many veterans check underneath their car before starting the engine or avoid bridges for fear a bomb. In an attempt to protect themselves, they may withdraw more and more from a threat-filled world, rarely venturing outside. Telemental health reaches out to them within their hiding place and helps reconnect them to the world. Indeed, according to Hugh Myrick, M.D., Associate Professor of Psychiatry & Behavioral Sciences at MUSC and Associate Chief of Staff for Mental Health at the Ralph A. Johnson VA Medical Center, who has done extensive work with treating PTSD through the Veterans Administration, “The idea of bricks and mortar facilities is going to be outdated one day. There is no reason patients can’t see their therapist or psychiatrist on their iPad or iPhone at an agreed-upon time in their own home.”
Studies by Dr. Acierno, Dr. Myrick and their colleagues show that outcomes of therapy for PTSD and depression are just as good when delivered via telemedicine as when delivered in person.1-3 Adherence to therapy is usually better because telemental health removes barriers to patient care, including distance, transportation costs, the necessity of missing a day’s work, and, perhaps most importantly, patients’ own avoidance strategies that lead them to seek excuses not to receive care.
Dr. de Arellano is the director and founder of the Hispanic Outreach Program-Esperanza (HOPE) and the Community Outreach Program-Esperanza (COPE) Clinics at the National Crime Victims Research and Treatment Center, programs that provide community-based psychotherapy to underserved children and adults victimized by crime or other traumatic events. He also directs the Mental Health Disparities and Diversity Program within the Department of Psychiatry.
Dr. de Arellano has established outreach telemental health programs in schools (eg, Johnsonville High School), primary care clinics (eg, Northwoods Pediatric Clinic in North Charleston), crisis centers (a rape crisis center in Beaufort for Spanish-speaking women) and police departments (Walterboro Police Department and North Charleston).
These telemental health programs are meant to remove traditional barriers to care for survivors of civilian trauma, which includes domestic violence, rape, sexual abuse, community violence (eg, witnessing a homicide or assault, finding a body) and the death of a loved one. Many of the trauma survivors Dr. de Arellano works with are from underserved areas and do not have the resources to make repeated trips to Charleston for therapy sessions. They also fear that seeking counseling will carry a stigma. Gaye Douglas, the nurse practitioner working with the telemedicine program at Johnsonville High School, notes that telemedicine-based psychotherapy is more palatable to adolescents in small towns because they do not have to worry about running into their therapist at the local Friday night football game; they are reassured that they can say anything because their therapist is elsewhere, apart from their everyday lives. Some of the PTSD patients are Spanish speakers, and Spanish-speaking therapists are in short supply in South Carolina; MUSC is fortunate to have six who can provide these services to some areas of the state via telemedicine. This improved access by survivors of civilian trauma to PTSD therapy has led to improved adherence to therapy.
“I am incredibly excited about these telemental health initiatives because I get to provide cutting-edge treatment to patients who normally would not receive care,” notes Dr. de Arellano. “Without these services, kids would not be getting any treatment and certainly not evidence-based treatment—these programs are not just to help kids be OK with having PTSD—we want to help reduce PTSD symptoms using techniques supported by the literature.”
Prolonged exposure is an evidence-based treatment for PTSD arising either from battlefield4-6 or civilian trauma,7-9 which typically occurs over the course of 12 to 16 sessions. Because the traumatic memory does not dull, because it is experienced as a recurrence of the traumatic event itself, it is still treatable years after the event that caused the PTSD. Dr. Acierno and his colleagues even successfully treated a World War II veteran with PTSD. If the PTSD patient is finally to be desensitized to the traumatic memory, it must first be recalled in all its intensity. During each session of prolonged exposure therapy, the therapist asks the patient to recount the event using the present tense, as if he or she were reliving it, noting every detail and sensation. After the patient’s description of the event, the therapist and the patient “process it,” noticing which new details appeared in this iteration or if the patient’s reaction to the traumatic memory has changed. The description is also recorded and the patient is asked to listen to the recording every day as “homework.” The underlying theory is that the patient—through repeated exposure to the description and memory of the traumatic event—will gradually stop responding to the memory as if it were the event itself (ie, the PTSD response will be extinguished).
During the treatment period but outside of the therapy session, patients are also asked to begin to dismantle their avoidance
strategies. They are asked to choose the situation that provokes the most anxiety for them and then to begin, step by step, to confront that situation. For example, if they are afraid of the noise and crowds associated with large discount stores (as many are), they will be asked first to drive to the parking lot and wait 30 to 60 minutes in their car or until their anxiety is reduced by half before they leave. In subsequent attempts, they will walk to the door, enter the store and then perhaps visit the store at peak shopping times. Each time they wait the allotted time or until their anxiety diminishes by half, slowly defusing the tension associated with these everyday life situations.
After receiving therapy, many patients report a marked decrease in symptom frequency and intensity. One Vietnam veteran, who started therapy confessing that he had been unable to attend any of his son’s football games due to the crowds and noise, was able, on completion of prolonged exposure therapy, to join his family at his grandson’s games.
Survivors of trauma face a number of ironies. That which they depend on to protect themselves (avoidance) inflicts the real damage on their lives while that which they fear (the traumatic memory) has no real power to harm. Their attempts to protect themselves through avoidance in fact ensure that the traumatic memory will continue to haunt their lives because they never learn that it is just a sham, no longer able to harm.
If telemedicine, in its ability to erase distance, serves to help overcome that avoidance by removing barriers to and excuses for not receiving care, if a collapsing of space helps to correct a dysfunction of time, then irony for once works in the favor of PTSD survivors in helping them lay their ghosts finally to rest.