A Different Approach

By the time a patient presents at my clinic, he's usually adopted a solution that compounds the problem: he presents as a sick person, with a condition that I, the doctor, am supposed to fix. So before therapy can proceed, I must reeducate him. This requires that I challenge his belief that he's ill, his symptoms are the inevitable result of his experiences, and his injury is permanent. Challenging a veteran in this way enables him to experience more options for himself. It holds him accountable, and is an essential part of his recovery.

This isn't easy work to do. The therapist must communicate compassionate understanding, maintain a stance of interested curiosity, and gently offer other possibilities for the veteran to consider. To begin with, the therapist is curious about how the vet understands having PTSD. What does that mean to him? What's he been told it means? Does he see PTSD as an injury or an illness? Is it like cancer, a cold, or Type 2 diabetes? Is there any role he sees for himself in the treatment?

The veteran typically regards his symptoms as produced somehow by combat itself, arising mysteriously as if from a virus and in ways beyond his control. So the therapist seeks to challenge this connection between the terrible events—the "injury"—and the client's symptoms (but doesn't challenge the veteran's experiences.) The method is to ask clients to slow down and connect the dots, break up their experiences into pieces, and examine the connections as they see them. By slowing down how they tell their stories, more aspects of their experience become known to them.

The therapist invites patients to pay attention to creative and resourceful aspects of the inner experiences they tend to miss in their rush to judgment. This allows them to access the full experience, in all its complication and uncertainties—which makes new connections and understandings possible and helps patients eliminate straight-line thinking.

As an example of this process, let's return to John. One source of his anger at the Army was how difficult the brass had made it to take emergency leave to be with his dying father, so I asked him more about his relationship with his dad. "He was a tough man," John finally admitted. "He constantly criticized me; nothing I did was good enough. After one baseball game in high school, where I'd pitched a no-hitter but allowed one walk, he ranted on and on, 'Why did you allow that walk and blow a perfect game?' That's when I finally lost it. I turned to him and yelled, 'If you don't stop criticizing me, I'll never play baseball or football again!' I meant it. He got a little better after that—but not much."

"So you were aware that your father got something for himself from your accomplishments?" I asked.

"Yeah," he said, "I'd seen him brag on me to his friends."

"Some of that must have felt good," I suggested, "But were you aware of any resentment about that?"

"Oh, yeah. I hated that he was so damn hard on me, and then took credit for what I did."

"Does that sound like he was protecting you the way he was supposed to?" I asked.

"No, it doesn't," he replied.

We explored other ways his father was supposed to protect John, yet repeatedly and painfully let him down. Eventually I asked: "Do you think your anger at your father played any part in your anger at your platoon sergeant?"

John looked away and shifted uncomfortably in his chair. "I never thought of it that way," he murmured.

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clieb   |Registered |2011-03-27 08:58:52 "The knowledgeable reader will note that the therapy I describe above is hardly specific to treating PTSD. Indeed, it's nothing other than basic psychotherapy." I currently work on a PTSD team in a VA clinic where all traditional therapy as you describe in this excellent article has been replaced by so-called "evidenced-based", manualized treatments which are solely focused on diagnosis and symptom reduction. My impression is that the author would find very few "knowledgeable readers" left within the VA or DOD who have had any training or practice in the type of non-straight-line therapy you describe. Am I right about this? I hope not. docsoc70   |Registered |2010-12-26 13:36:48 I appreciated Roy Clymer's article. I worked, as a psychologist with Vietnam veterans for 20 years and then wrote my PhD thesis on 'The Discursive Construction of PTSD'. I looked at the way the veteran constellation, ie veterans, the variety of mental and physical health providers, and the practices of our Veterans Administration, actually thought and talked about the disorder. I concluded 'Perhaps the reason for the conformity of opinion of those who judge the disorder (PTSD) as an 'already there' reality is that the communities of mental and physical health providers, in our secure consulting rooms, are circumscribed by the monocularaties of our practice. It is perhaps that we, who treat this disorder are trained to see and interpret what we are looking for, to satisfy the requirements of a needy population; the realities of government policy, and the dictates of VA practices specifically designed around 'Care, Compensat... ruffing  - The Puzzle of PTSD byn Clymer   |Registered |2010-11-30 10:24:28 My hat is off to Dr. Roy Clymer. He is not only insightful, honest and professionally ethical, but also daring. His excellent article will surely draw fire from those deriving benefits from their involvement with indivduals diagnosed as such. Dr. Clymer can surely take a place beside other brave insightful professionals such as Dr. William Glasser and James S. Gorden who challanged the diagnoses of depression as being a medical disorder and provided working solutions in their books Choice Theory and Unstuck. I am fortunate to have spent time as a student of the Dutch priest, Dr. Father Adian VanKaam, he often stated, "if you do not have an established self, you will seek a pseudo self". One of my assignments in the fifty five years of involvement in this fiel was to examine individuals seeking employment in law enforcement. It became very clear that individuals with no concept of self were seeking a pseud...

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