I applaud the timeliness of your focus on post-traumatic stress disorder (PTSD) in the January issue and the recommendation that psychologists be trained to deal with the wave of returning veterans from Iraq and Afghanistan.
However, I was concerned by the Institute of Medicine's critique that evidence-based outcome studies are too often being conducted by researchers with theoretical ties to the method being studied. It is true that certain researchers showing efficacy of a particular approach are practitioners of that approach, so self-fulfilling prophecy determines which methods get approved as evidence-based. These methods then become part of training programs on PTSD, and students continue to document the efficacy of the method. Further, a high drop-out rate is endemic to studies on PTSD;this raises the question of what can truly assess the efficacy of methods used to address PTSD.
One problem is that the definition of PTSD is recent. It is mostly defined in concrete behavioral or physiological terms, and the research that captures these symptoms is reductionistic. Lost is the complex human phenomenon of PTSD; it is not a set of symptoms, but a lived experience that includes-as well as the physiological and psychological disruptions-disruptions in one's worldview, culture and sense of belonging, disruptions to a sense of meaning and coherence, and all kinds of collateral damage to family, friends and social contexts. The kinds of research that can address this multi-layered phenomenon are narrative, phenomenological, nonverbal and in-depth, single-case designs.
Treatment must also reflect the multiplicity of the phenomenon. Recommended is a whole-person approach to trauma that takes into consideration existential, religious and cultural factors.
Ilene A. Serlin, PhD
As a clinical psychologist who has spent many years working with veterans and others suffering PTSD and related phenomena, and a veteran myself, I was dismayed at reading about retreads being touted as new "findings" without any recognition of academic and professional precedent. All the themes in "prolonged-exposure therapy" were central to my psychoanalytically oriented training nearly 30 years ago. The veterans' groups developed by Ken Wilbur, PhD, in the early 1960s, in which soldiers talked with each other and a psychologist about their experiences, had the same principles.
For that matter, the cognitive principles of questioning limited or self-defeating beliefs about one's self and the world, as in cognitive behavioral therapy, are also generic to competent psychotherapy of any persuasion, and the significance of this for PTSD sufferers is no different.
The principles of talking about traumatic experience, in gradations that one can bear, of finding words for the unspeakable and giving shape to one's inchoate feelings, and of re-evaluating one's experience in less self-destructive ways, have been the hallmark of psychodynamic and humanistically oriented therapies since Freud. It is what thousands of competent psychologists, of varying theoretical orientations and eclectic mixes, do every day.
Roger Brooke, PhD
It was disappointing that the Institute of Medicine (IoM) panel findings gave so little coverage to Eye Movement Desensitization and Reprocessing (EMDR). As a clinician in private practice who has treated active-duty military personnel, the clear advantage that EMDR has over the other treatments for PTSD is how quickly it works and that it is less painful for the client. Exposure therapy can be excruciating for the client and has a high drop-out rate as a result. Medication for PTSD only treats the symptoms and does nothing toward a cure. Would our profession prefer for the sake of our financial status to continue to use treatments for PTSD that take longer? What prevents psychologists who are entrenched in cognitive behavioral treatment from learning something new, especially a cost-effective treatment that tends to be less painful for clients? Granted, EMDR is a complex and advanced form of psychotherapy, but we psychologists ought to be up to the task.
Although I am relatively new to EMDR and have used it for only about two years, it has become clear to me that it is a treatment that has the potential to revolutionize the way we do talk therapy. EMDR's effectiveness with PTSD has been well established. Now, the research should focus on expanded applications of the bilateral brain stimulation that is central to the treatment. In addition to reviewing the literature, the IoM panel should have surveyed clinicians who treat PTSD every day. The chasm between research and practice continues to get wider.
Dawn S. Wilkinson, PhD
APA's policy on torture
I have been an APA member for almost 20 years, all through graduate school and afterward. The letter in the January 2008 Monitor from Milton Schwebel, PhD, urging members not to resign over the current APA policy on torture is compelling, and I respect his position of trying to change the APA from within. However, to me it is unacceptable to retain membership in an organization whose leadership is willing to equivocate over inhumane policies that are abhorrent to so many in its membership and should be abhorrent to anyone concerned about human rights. Over the last two years, I have felt ashamed to be an APA member and will not renew my membership until the APA joins other professional associations such as the American Medical Association and the American Psychiatric Association in refusing to have any role in prisoner interrogations. We all have to choose our battles, and I don't want to use my energy fighting an organization that should be upholding the highest of ethical values.
Francesca Raphael, PhD
Milton Schwebel's letter urges APA members "not to resign in protest of its policies on torture." Comparing Abu Ghraib and Guantanamo with Nazi prisons, he blames APA's shameful willingness to condone the participation of its members in these "Frankensteins" on our leadership and urges us to make it clear that we will not support leaders who violate APA's stated purpose of serving human welfare and doing no harm. I find it quite ironic that a large portion of the remainder of the issue is devoted to trumpeting psychology's success in treating PTSD. While our shame is that we fail to prohibit the participation of psychologists in the intentional traumatizing of torture victims, we also boast that we can heal the very wounds inflicted by such activities. Whatever happened to the idea of cognitive dissonance?
John C. Rhead, PhD
I have become immune to the extreme, anti-Bush liberal bias in many of the articles and letters in the Monitor, especially regarding the "torture" controversy. However, I can't remain silent in the face of the comment made by Dr. Schwebel on what he terms the "Bush/Cheney prisoner interrogations." (I wonder if he also uses the term "the Kennedy Bay of Pigs debacle?") He writes that "Guantanamo and Abu Ghraib bear frightening resemblances to Nazi prisons." As someone who lost countless family members to the Nazis, I feel I must protest this absurd and insulting comparison. How can you compare a Nazi government that set out with the expressed intent to wipe out millions of innocent victims who posed no threat to Germany with a U.S. government trying to protect itself from terrorists who have declared their intent to attack U.S. citizens? While you can certainly disagree with U.S. policy and protest when soldiers abuse their power, to make the comparison to the Nazis is ludicrous. The victims of the Nazis would have wished to trade Auschwitz for Guantanamo.
Ben Sorotzkin, PsyD
The concern over the ethics of psychologists' participation in government efforts at interrogation has been too narrowly focused upon the particular actions done with too little concern about the psychologist's role as a professional. Our concerns should reflect that, as a profession, we uphold professional standards and do not uncritically accept the problem definition provided by the client. Our obligation when we are asked to provide a service is to understand for what purpose it is requested. If we unquestionably accept the client's claim, we move from professional to hired henchman.
When a federal government agency, as our client, tells us that interrogation is needed to fight against terrorists we need to ask questions:
Who is being defined as a terrorist?
Does this definition include anyone seeking to expel a foreign armed force from its national boundaries?
Does this include people who may be willing, from fear, bribery or professional psychological efforts at persuasion, to provide names of neighbors who might support such activity?
Is there any evidence that such questioning actually leads to the capture of individuals who engage in acts of terror?
Is there any evidence to show that a reduction in acts of terror through such effort is not outweighed by the resentments and incitements to engage in acts of terror against a force seeking to divide, isolate and destroy those kin and friends who support the resistance?
Will those using the information we provide assure us, convincingly, that it will not be used to harm humans?
There is more to professional responsibility in interrogation than the question of whether one actually cracks the whip or turns the thumbscrews. As professionals, we carry a responsibility to know what the client hiring us is attempting to do with our assistance.
Marc Pilisuk, PhD
Please send letters to Sara Martin, Monitor Editor, at the APA address. Letters should be no more than 250 words and may be edited for clarity or space.