Walking Wounded

Walking Wounded

How Emory is helping veterans recover from the traumas of war.

by Dana Goldman, illustrations by Brian Hubble

Barbara Rothbaum

Ursula Kelly

On the home front: Barbara Rothbaum(top left) and Ursula Kelly(bottom) help vets recovering from trauma to stabilize and feel safe.

As members of the U.S. military, they’ve driven Humvees through desert roads laced with buried explosive devices. They’ve spent years away from family and home, living in cramped tents, barracks, or submarines. They’ve followed orders to search out those who would like nothing better than to see them dead.

If they are lucky enough to survive, they get called heroes. But sometimes acting heroically can take a psychological toll. That’s where Emory’s Barbara Rothbaum and Ursula Kelly come into play. They are leading research that explores what it takes to help new generations of veterans adapt emotionally once they’ve physically returned home.

Battling stigma

Post-traumatic stress disorder (PTSD) became an official diagnosis in 1980 in response to patterns of behavior among Vietnam veterans who were experiencing difficulty in adapting to civilian life. These vets could be shopping in a suburban grocery store, hear a loud bang, and suddenly feel transported back to the jungles of Vietnam—ducking behind produce bins, vigilant for an attack coming from the frozen dinner aisle. At night, while most of their neighbors might leave doors unlocked and windows open, they would sleep with a gun under their pillows, alert to the slightest noise. Their actions made complete sense in a war zone but were hard to stop once they were home. 

Around this same time, Emory psychologist Barbara Rothbaum was starting a career that focused on researching and treating anxiety disorders. On a job interview, she told her prospective boss, “I don’t know anything about PTSD.” The boss, a preeminent anxiety researcher replied, “That’s all right, we don’t know anything either.”

But it was time for Rothbaum and the mental health community to learn. For many veterans, flashbacks and hyper-vigilance made it hard to keep a job and maintain a relationship. The stigma against seeking help was strong, and many tried to self-medicate their anxiety and depression with alcohol and drugs. For these reasons, a fifth of homeless people today are veterans, and half of all homeless veterans served during the Vietnam era, according to estimates from the Veterans Administration and National Coalition for Homeless Veterans. (Since the 1970s, psychologists have determined that PTSD also can result from rape, abuse, traumatizing accidents, and other life events.)

To combat PTSD, Rothbaum started focusing on exposure therapy. “One of the things that maintains PTSD is avoidance,” she says. When something traumatic happens, “it’s so painful to think about that all those with PTSD want to do is push it away. But it’s unfinished business, and they haven’t really processed it. Emotionally, it haunts them.”

Rather than avoid their trauma, Rothbaum hypothesized that veterans needed to face it head-on in controlled, safe environments. “Going over and over and over it helps decrease their distress, and they can look at it,” she says. “So we do the exposure therapy repeatedly and in a therapeutic way to help them see that they can handle it.”

Fighting the virtual war


Research evidence showed that exposure therapy worked well. But exposing veterans to wartime conditions wasn’t as easy as walking a client with a height phobia up a flight of stairs. So when gains in virtual reality technology came in the 1990s, Rothbaum teamed with a Georgia Tech computer scientist to create a virtual Vietnam. And when the war in Afghanistan and then Iraq began, she began working on a new virtual reality system. The resulting program has since been incorporated in Emory’s Trauma and Anxiety Recovery Program, which Rothbaum directs.

Computer programmers developed sounds and scenes intended to replicate a Middle Eastern war zone. The 360-degree, 3D environment includes the noises of gunfire, prayer calls, dogs barking, military radio chatter, and Humvee engines as well as the sights of aircraft overhead and desert roads. The therapist is able to manipulate the virtual perspective to match the memory of a particular vet, whether he or she was a Humvee driver, passenger, or gunner. In addition, the patient’s chair can vibrate during the session to further simulate the feeling of explosions or sitting in a Humvee with the engines on.

Once a veteran straps on a helmet and earphones, therapists can replicate the specific set of circumstances in which his or her particular trauma occurred. “They’re describing their most traumatic events from Iraq or Afghanistan, and the therapist is matching what they’re describing in the virtual reality,” says Rothbaum. During five one-and-a-half hour sessions, the vet undergoes the virtual reality experience and, equally important, has time to talk about it. 

For a number of years, Rothbaum has paired virtual reality therapy with the use of a fear-extinguishing drug, d-cycloserine (DCS). The hypothesis is that sessions and debriefings are made more effective by DCS, which has been used since the 1960s to fight tuberculosis. In recent years, Emory researchers have come to see that DCS also enhances the treatment of anxiety and phobias. In their studies with rats, Emory researchers Michael Davis and Kerry Ressler conditioned the rodents to be scared of a specific light or sound. Ridding the rats of that anxiety required exposing them to the same light or tone a full 60 times without any negative consequences. But when the rats were given DCS, the researchers found that only 30 exposures were needed to reduce the fear. In other words, DCS allowed therapeutic exposures to be cut in half. That finding has since been replicated in studies with people who have height phobias.

Unlike most drugs used to fight anxiety disorders, DCS works in single doses. Says Rothbaum, “Most of the drugs we use in psychiatry have to be taken every day. And you have to take some every day for a month before they build up in the system. For this one, you have to take it only the day of the session and only right before the session.”

Accordingly, in Rothbaum’s study, each veteran takes a DCS pill (or comparison medications) before each of five virtual reality sessions. “We’re underdosing the virtual reality,” says Rothbaum because the expectation is that DCS will make each session twice as effective as it would be without it. While fewer sessions are appealing to therapy-weary veterans, the shorter time frame makes economic sense for health care providers as well.

Since the virtual reality therapy research at Emory is ongoing, no formal results have been announced as yet. But Rothbaum is hopeful that results in the next year will show that virtual reality therapy in conjunction with DCS is as effective as other kinds of treatment for PTSD in veterans, if not more so. Many younger veterans have grown up playing video games, and Rothbaum sees signs that they are more comfortable with virtual reality therapy than traditional talk therapy.

“It’s a younger gaming generation,” Rothbaum says. “So something with virtual reality feels less stigmatizing.” And so far it looks like a game the veterans are winning.

Recovering from sexual assault

Nancy Collop

But not all military traumas result from enemy attack, a fact that Emory nurse scientist Ursula Kelly knows all too well. Through her joint appointment in Emory’s Nell Hodgson Woodruff School of Nursing and the Atlanta VA Medical Center, Kelly works with female veterans who were sexually assaulted or threatened and harassed by fellow service members during their service. And while sexual assault can lead to PTSD, sexual assault by a comrade in the military (known as military sexual assault trauma, or MST) can lead to its own specific aftereffects.

Particularly if one is assaulted by a fellow service member. “Soldiers are supposed to have each others’ backs. That involves an incredible betrayal of trust,” says Kelly. “Military is family, so it’s really going to impact your relationships in a different way than combat trauma would.”

Unfortunately, that betrayal is all too common. Studies show that about one in every four female soldiers has experienced MST. If incidents of ongoing threatening harassment are included, upwards of 40% of female soldiers report MST. Meanwhile, up to 15% of male soldiers also report surviving sexual trauma perpetrated by fellow soldiers.

Like PTSD, MST has been linked with physical and emotional problems including depression, chronic pain, and cardiovascular disease. It’s unclear whether PTSD is causing these issues—or is simply correlated—but the link is obvious nevertheless. “Both MST and PTSD are associated with a variety of mental health disorders, substance abuse, negative health behaviors, a plethora of physical symptoms, and acute and chronic medical problems,” says Kelly.

Veterans can experience social problems as well, and they may distance themselves from their spouses, children, and friends. “Depending on the severity of the symptoms, MST and PTSD affect both men and women’s ability to function socially, to have meaningful relationships, and to be able to work and be productive,” says Kelly.

Nationally, the VA is mandated to provide treatment to veterans who are dealing with health problems associated with MST. The Atlanta VAMC goes one step further, with a dedicated MST/PTSD treatment team that has 300 active patients, with about five new referrals each week. Kelly says this singularly focused team of clinicians and researchers is crucial for helping female veterans regain their footing. “It’s important to help women access care in the male-dominated environment of the VA,” she says, “and to develop treatment plans that address women’s specific concerns.”

Those treatment plans are based on the three-stage trauma recovery model developed by psychiatrist Judith Hermon in the 1990s. During the first stage, clinicians work with female veterans on issues around stabilization and safety—everything from making sure they have a safe place to live to helping them re-regulate sleeping and eating. “Usually people come in because they are in crisis,” Kelly says. “Nobody comes to therapy for fun.”

In a PTSD 101 group, the female vets learn that they are not “crazy” and things are happening in their brain, which are not willful. In addition, they participate in a weekly skills group for three to four months to learn how to manage their emotions and foster their relationships. “The class is about getting stabilized and safe, learning to work with emotions so the women are not in a constant state of having their fears triggered,” says Kelly.

In stage two, veterans begin the work of processing the trauma through trauma-focused therapy—for example, prolonged exposure. But discussing assault and other traumas can be a challenge to many patients. “There are some who start and just don’t continue because it’s so distressing,” Kelly says. “It’s scary.”

Those who do successfully stay with the program then advance to a third phase that is focused on moving forward and thriving with peer support, check-ins with therapists, and, in some cases, continued medication management.

And while many women successfully recover, Kelly knows her job isn’t over. “Among our patients, more than 95% experienced at least one other lifetime trauma in childhood or adulthood—either emotional, physical, or sexual abuse,” she says. Kelly and the MST team are working to figure out how to address those past traumas in treatment. Part of their research is focused on whether specific kinds of traumas make developing PTSD and related health issues more likely.

As a part of her work, Kelly is exploring which factors help some female veterans bounce back and which make recovery more complicated “because, of course, there are people who experience multiple forms of abuse and trauma who do not develop PTSD,” she says. “We need to know what makes women resilient and how we can foster that. It’s important for us to understand that more fully to develop effective treatment programs.”

Resilience and healing

For both Kelly and Rothbaum, fostering this resilience and healing isn’t always easy, especially when it involves hearing patients’ horror stories. Listening to a patient’s tale of terror can take a toll on those hearing the story too. “When you’re working with PTSD, you have to be prepared to hear about life’s worst moments,” says Rothbaum. “You hear about evil. It’s not the kind of stuff you can talk about over the dinner table.”

But both researchers maintain hope. They are encouraged that the stigma surrounding PTSD has dropped dramatically over the past two decades, and they know that the field of trauma research with veterans is growing quickly. As scientists who are practicing clinicians, they have both the direct experience with patients and research expertise to help pave the way forward.

And most important, they know it’s possible to heal not just from physical injuries but from psychological wounds as well. Recovery is possible.-EH


Web Connection: To lessen the stigma of mental illness, Emory is partnering with the Atlanta Braves to publicize the signs of PTSD and to reach out to returning vets. A BraveHeart initiative offers education, resources, screenings, and support to veterans throughout the Southeast. Learn more at braveheartveterans.org. In addition, Emory is raising funds to support Rothbaum's ongoing research in PTSD. If you are interested in how you can contribute to these clinical and research efforts, please contact Matt Boyle at 404-727-8253 matthew.boyle@emory.edu. Read further about MST at mentalhealth.va.gov/msthome.asp.



Intervening after trauma

Barbara Rothbaum
Barbara Rothbaum

Even as Barbara Rothbaum has discovered better ways of treating patients with PTSD, she’s had a nagging thought in the back of her head: What if PTSD could be avoided in the first place?

No one can stop traumatic events from happening. Natural disasters, car accidents, and war injuries are often unavoidable. And for a long time, clinicians also assumed that PTSD was unavoidable.

But Rothbaum started to wonder if early intervention could stop PTSD in its tracks. “In so many people, what happens immediately after the event can make things worse or better,” she says. So for the past three years, Rothbaum and a team of clinician researchers have camped out in the Grady Memorial Hospital emergency room, seeing what can be done to make things better for trauma survivors.

Here’s how it works: when a patient comes into the ER and is waiting for medical treatment, trained psychotherapists assess those who have just survived a trauma such as rape, a car or industrial accident, a shooting, or a knife attack. Half are then randomly chosen to receive an intervention.

Using a version of exposure therapy, therapists tape record the patients talking about the trauma and then assign homework to them—listening to the tape every day. “We also help them look at unhelpful thoughts of guilt or responsibility,” says Rothbaum. “We teach them a brief breathing or relaxation technique, and we talk about self care.” The clinicians explain that it’s beneficial to not avoid the place or thing associated with the trauma (such as driving, for car accident survivors).

The entire intervention takes less than an hour, so it doesn’t get in the way of medical treatment or affect discharge times. Patients then return to be assessed for trauma symptoms at four and 12 weeks. Rothbaum’s hypothesis is that those who receive the intervention will present significantly fewer symptoms of PTSD than those who have not received the intervention.

While results won’t be available until later this fall, anecdotal evidence seems to prove Rothbaum is on the right track. “For the most part, people are pretty compliant. For the most part, it makes sense to people,” she says. Patients like having tangible tasks to do in the wake of a traumatic event, and while many people might not listen to the tape of their trauma every day, most report listening to it at least a couple times—enough to have a healing effect.”

If the intervention does work to prevent the development of PTSD, the implications are immense. “If we know what to do, and it’s something we can train emergency workers to do in large scale, it can help on the battlefield, in natural disasters, and after criminal assault,” Rothbaum says. “It really can be implemented in emergency rooms throughout the country.”

In other words, patients wouldn’t wait to seek help only after symptoms become unmanageable. They would receive help before symptoms even start. “That’s the world we envision,” says Rothbaum.

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