Military & Veterans
Q & A with Dr. Barbara Rothbaum
BrainLine sat down with Dr. Barbara Rothbaum, a professor in the Department of Psychiatry and Behavioral Sciences and director of the Trauma and Anxiety Recovery Program at Emory University School of Medicine and part of the Wounded Warrior Project’s® Warrior Care Network®. Dr. Rothbaum spoke about treating PTSD and her pioneering work in virtual reality exposure therapy.
Questions & Answers
- How would you describe PTSD?
- How does having PTSD affect people’s lives?
- What other challenges do people with PTSD tend to have?
- Are some people more likely than others to experience PTSD?
- Are there some misconceptions about PTSD that you would like to address?
- What is going on inside someone's head when they feel that they are re-experiencing trauma?
- Can you describe how our understanding of trauma and its effects has changed over time?
- What are the best treatments for PTSD?
- Many people with PTSD are actively trying to avoid thinking about these experiences but the therapies you describe involve spending a whole hour focusing on the experiences. I would think a lot of people would say “that’s the last thing I want to do.” How do you address that?
- If someone is adamant about not wanting to try prolonged exposure therapy, are there good alternatives? Can you do CPT on its own and would that be effective?
- When would you prescribe medication for PTSD?
- If you were seeing patients individually, would you always or almost always start with psychotherapy?
- What are the real-world barriers to people getting good treatment and sticking with it?
- Can it take a while for treatment to be effective?
- How do you address the impact of PTSD on other family members?
- What would you say to civilians or to veterans who are unhappy and want to do something about it but don’t know where to turn?
- How do you identify a professional who is a trained or skilled provider?
- What are you doing at Emory to help veterans and their families?
- And what kind of follow-up do you offer?
- What are the broader goals of your program?
- Are there promising new directions in research about PTSD?
BrainLine: How would you describe PTSD?
Dr. Rothbaum: The way I see PTSD is that someone is haunted by something that happened to them in their past, and the haunting nature comes out in what we call the re-experiencing symptoms. So they’ll have nightmares, flashbacks. It’s easy to trigger it, and when they think of it, it very often knocks them off kilter. They’ll feel it in their body, and sometimes it’s hard to get back to where they were. That can also include emotions. And so I think in general PTSD is a disorder of avoidance, but with our military service members and veterans, I think it’s even a bigger problem because they’re trained to disengage from their emotions. That’s a good thing if you’re in a war zone; you don’t want to have a big emotional response. But back in the United States and in treatment you want to be able to link the emotions with the memories.
BrainLine: How does having PTSD affect people’s lives?
Dr. Rothbaum: It really sucks to have PTSD. It affects people’s lives night and day in every aspect of their living. Very often they don’t feel completely safe anywhere day or night. Most of us even if we have a busy stressful day, we look forward to getting in bed, and that feels comforting and safe and we look forward to our night’s sleep. People with PTSD are hypervigilant and don’t feel safe even in their beds. They can’t look forward to a good night’s sleep because of the nightmares and the fear. It affects your work. It affects relationships. Very often for other people with PTSD it’s hard to get close to other people emotionally and to have physical relationships. And so then it’s hard for significant others not to take that personally. It doesn’t mean that people with PTSD don’t love their partners or care about them. PTSD affects every area of a person’s life, and as hard as it is to live with PTSD, it’s also hard to live with someone with PTSD.
BrainLine: What other challenges do people with PTSD tend to have?
Dr. Rothbaum: With PTSD comorbidity is the rule rather than the exception. There is almost no such thing as the clean PTSD patient. About half of the people with PTSD also have comorbid major depression. There are lots of other anxiety problems with PTSD, a lot of problems sleeping, a lot of thematic problems and medical complaints, and a lot of substance use and misuse when people are maybe self-medicating.
BrainLine: Are some people more likely than others to experience PTSD?
Dr. Rothbaum: Yes. About 70 percent of us will be exposed to a potentially traumatic event in our lifetime, but not 70 percent of us end up with PTSD. The PTSD symptoms are the normal response to trauma. But for most people they will decrease over time.
BrainLine: Are there some misconceptions about PTSD that you would like to address?
Dr. Rothbaum: One that pushes my buttons is that when a veteran engages in violence, the media will call me and they'll want to attribute it to PTSD. And just because someone has PTSD does not put them at risk for engaging in violent behavior against others. There are other things that create that risk. I also think a lot of times the media will portray, for example, the in-depth flashback. And in fact flashbacks are — really true flashbacks are fairly rare, but the media, it’s dramatic and they love to depict those flashbacks. And when people do have flashbacks they are usually very, very brief. But for a split second it almost feels like they’re back in danger and then they realize that they’re not, but still it’s very disturbing.
BrainLine: What is going on inside someone's head when they feel that they are re-experiencing trauma?
Dr. Rothbaum: There are a lot of different ways to re-experience trauma. So it can be something that is not even a memory but something that triggers a reminder of what you experienced. For example, even a smell in the air, a changing of the season, a smell of cigarette smoke or perfume or food — any of this can trigger a reaction in the body.
BrainLine: Can you describe how our understanding of trauma and its effects has changed over time?
Dr. Rothbaum: As a field we are looking a lot more at genetic and biological predisposition. In the past 20 years a lot of studies have been done on what we call G by E, genetic by environment. If you have a certain genetic predisposition and then certain things happen to you in your life, and then you’re more likely to experience PTSD. It’s actually even more complicated than that. PTSD may be most common when you have a genetic predisposition and then maybe things happen to you in your early life and then you experience a traumatic event as an adult and then you see. So it’s a very complicated milkshake.
BrainLine: What are the best treatments for PTSD?
Dr. Rothbaum: Two guidelines to PTSD treatment were published in 2017: The VA and Department of Defense guideline and the American Psychological Association guideline. And the treatments that they recommended for PTSD and what we’ve been doing for are called trauma-focused treatments. And the one that has the most evidence is called prolonged exposure. We abbreviate it PE. In PE we help the person confront the memory of the traumatic event and the reminders of the traumatic event, but in a therapeutic manner so that something changes. A lot of our folks will say doc, what are you talking about? I think about the trauma a hundred times a day. How is this different? What is different is the way we do it. The way they do it, they might think about it and then they avoid it. They shut it down. And we’re going to have them go through it in their mind’s eye, describe the traumatic event out loud. And we do it over and over and over and we tape record it and get them to listen to it at home. And then we do what we call process it. So we talk about some of the stuff that comes up. Talk about the guilt that maybe they didn’t do enough. Talk about the fear or other things that are holding them back. So that’s prolonged exposure, and that’s being used throughout the Department of Defense and the VA.
Another treatment is called CPT for cognitive processing therapy. And what they do in CPT, as the name implies, it’s very cognitive. If looking at what they call “stuck points,” which are the thoughts or interpretations that may be preventing you from recovering. And very often the therapy touches on things like trust and guilt and intimacy and safety and trying to help the person through those stuck points.
BrainLine: Many people with PTSD are actively trying to avoid thinking about these experiences but the therapies you describe involve spending a whole hour focusing on the experiences. I would think a lot of people would say “that’s the last thing I want to do.” How do you address that?
Dr. Rothbaum: I will sometimes make analogies that you may feel like coming here like most of us feel about going to the dentist. You know, it’s not something that you really look forward to, but it’s something you know you need to do. And this treatment does take courage, and I don’t use that term loosely. Courage is being scared and doing it anyway. And if they weren’t scared, then they wouldn’t have PTSD, but the fact that they have PTSD and it’s a disorder of avoidance means that inside they’re telling themselves I don’t want to do it, but they see why the treatment makes sense. They understand that there really is no way to the other side of the pain except through it. And so most people, you know, we just explain why we do it and we explain how well it works. And once they start and make a commitment, most people do see that benefit.
BrainLine: If someone is adamant about not wanting to try prolonged exposure therapy, are there good alternatives? Can you do CPT on its own and would that be effective?
Dr. Rothbaum: Yes. The good news is we have several plan A’s. So, if somebody said no, they’re not really going to try PET — and they really are adamant, then we do have some other treatments that we can offer.
BrainLine: When would you prescribe medication for PTSD?
Dr. Rothbaum: We have two medications with an FDA approval for PTSD, sertraline or Zoloft and paroxetine or Paxil. They are both SSRIs. And we got those indications about 20 years ago. There have been no new medications explicitly for PTSD in that time. A number of companies are working on it, and I think that that’s great. Those are antidepressants. Their effect on PTSD is moderate. The guidelines for PTSD treatment consider the trauma-focused therapies to be first-line treatments. Those are strongly recommended. The SSRIs are not first-line treatments, and they’re a little bit more lukewarmly recommended. Many people with PTSD have depression. If the PTSD is primary, if that’s the main problem and they have depression as a result of having PTSD, if we treat their PTSD, almost always their depression responds as well. However, if somebody has an independent depression or a primary depression, we can treat it with CBT, cognitive behavior therapy, or we can treat it with medications like the SSRIs, and very often they’re effective. So probably the majority of our patients come to us already on these medications, and that’s fine. It doesn’t decrease the efficacy of the therapy, but in a couple of studies that have been conducted, adding the medication and the psychotherapy from the start is no more effective than just the psychotherapy.
BrainLine: If you were seeing patients individually, would you always or almost always start with psychotherapy?
Dr. Rothbaum: If they come in and they’ve never had any treatment, they’re not on medications, everything else being equal, we’ll usually start them on the psychotherapy because usually that’s got a good chance of helping and there’s not a lot of relapse after it. And most people would prefer not to be maintained on medication for the rest of their lives. And for PTSD they’ve shown if you’re just getting the medication and even when it works, you pretty much need to stay on the medication for it to continue to work. If you discontinue the medication, there’s a higher rate of relapse.
BrainLine: What are the real-world barriers to people getting good treatment and sticking with it?
Dr. Rothbaum: There are so many barriers it breaks my heart. To start with, there are not a lot of therapists out there trained in evidence-based therapy for PTSD. So it’s hard to find someone that does what we do, especially in rural communities, and that’s going to make it unlikely that there’s a trauma-focused therapist in their community. There are also barriers on the PTSD sufferer side. As much as everybody has tried to decrease the stigma of having PTSD, unfortunately I think that there is still some stigma, and especially in military populations a lot of people view it — in themselves, — as a weakness or that they’re just not handling it well. And they might not even recognize that it’s PTSD. They might just think that this is because I screwed up or I didn’t do it well or it’s my fault, and that’s one of the main messages I hope that you can give people is that treatment works. So many people, and especially military folks and veterans will say how could treatment possibly help? You can’t change what happened. And that’s true, we can’t change what happened, but what we need people to understand is the problems that they’re having now are a result of PTSD, not a result of what happened, and we can treat the PTSD. PTSD is a disorder of avoidance, and so most people understand if they go to see a doctor or a therapist, they’re going to have to talk about it, and that’s exactly what they don’t want to do.
It’s also hard for regular outpatient therapy. Some of our veterans have told us they would have to drive about an hour to get to their appointment, be expected to open up, you know, kind of rip the Band-Aid off, talk for an hour about it, then close it back up, drive for an hour back into their lives, and it wasn’t going to happen. So, I think that there are a lot of real-world barriers and a lot of barriers because it’s the nature of the beast.
BrainLine: Can it take a while for treatment to be effective?
Dr. Rothbaum: Yes. And you have to know if therapy just worked in one session, that’s what we would have designed it for. It takes longer than that, and patients have to make a commitment to doing all of it. They have to make a commitment to coming back the next session even though their bodies are going to be telling them don’t go there, that makes you feel bad. They have to know that this is what they need to do.
BrainLine: How do you address the impact of PTSD on other family members?
Dr. Rothbaum: At a basic level, when we do prolonged exposure in one of the early sessions we go through what we call common reactions to trauma and we give people a handout. And we will very often tell them to share that with their significant others. A lot of times that does wonders because significant others can take it personally when they can see and feel their partner not having loving feelings, not wanting to be intimate, getting angry with them, and it feels personal. And when they read about it under common reactions and understand that that’s PTSD, then a lot of times that can help a lot. We also do focused family and couples’ therapy here, and that is an evidence based couples’ therapy specifically for military couples. We also conduct what we call relationship checkups, and that is not exactly therapy, but it’s usually very helpful for couples, and it’s only one or two sessions. And it’s really designed to happen every year kind of like dental checkups to correct the decay that naturally happens in relationships, and that can be a nice thing to do. So, there are different levels. In our program here at Emory for the IOP, the Intensive Outpatient Program. We really want them eating, breathing, and sleeping this program. So, we involve family members via telemedicine. So, we’ll educate them and have family sessions, but the family member is not here on the premises with them.
BrainLine: What would you say to civilians or to veterans who are unhappy and want to do something about it but don’t know where to turn?
Dr. Rothbaum: There’s so many resources out there, and there are a lot of websites. For example, the NCPTSD website, National Center for PTSD, and it is a VA website, but it works for civilians as well. They explain PTSD. They explain what the different treatment options are. If someone is a veteran and eligible for VA care, all of the VA hospitals now offer telemedicine. So even if they’re rural and it’s hard to get physically to a VA facility, if they can get there once, they can probably be signed up for telemedicine services. There are also other websites and other resources that can help find community providers who are trained in the trauma-focused therapies.
BrainLine: How do you identify a professional who is a trained or skilled provider?
Dr. Rothbaum: The International Society for Traumatic Stress Studies has a website that can help you find a trained professional in your own community. And even if they’re not close enough, I would suggest you reach out to them or call them and they might know of someone who’s just not a part of the organization or not on that website. So it might take a little bit of networking to try to find the right person. The other thing people can do if they have insurance, is look at the providers that are on their insurance. And even if no one says PTSD, to call someone up and ask them if they know anyone trained in trauma-focused therapy in their area. So it might take a little bit of detective work, but the resources are out there.
BrainLine: What are you doing at Emory to help veterans and their families?
Dr. Rothbaum: The Emory Healthcare Veterans Program is funded by the Wounded Warrior Project, and we’re part of the Warrior Care Network. There are four of us across the country: here at Emory in Atlanta; going up the coast Mass General, the Home Base program in Boston; the Road Home Program at Rush in Chicago; and Operation Mend at UCLA in Los Angeles. And we all have what we call intensive outpatient programs. Emory’s is a two-week IOP.w We can bring in veterans from all around the country. We put them up at a hotel right across the street from our clinic. They don’t pay for lodging, for travel, for food, for therapy. Everything is at no cost to the veteran. This is for post-9/11 veterans. And they get a lot of therapy every day for two weeks. They get about as much therapy in two weeks as most people might get in a year. It’s evidence-based therapy. And what we’ve been able to see is it works. We’re seeing significant and clinically significant reductions in PTSD, in depression.
At Emory we also look at what we call psychophysiological measures. For example, an exaggerated startle response is part of PTSD. So we measure that before and after treatment. We measure the heartrate response. We measure when you get sweaty. And we are seeing significant decreases after just two weeks of treatment in those physical signs of threats as well. We have over a 90 percent completion rate, and that is what I think is the really important number. PTSD is a disorder of avoidance, and that can mean avoiding treatment too. So, there’s a very high dropout rate from regular outpatient treatment for PTSD. In the IOP at Emory we can start six new veterans every Monday. That means at any given point we can have 12 veterans. At any point half of them are new, that’s their first week, and half of them have already been here a week. And if somebody doesn’t show up for their session, we’ve got veteran outreach coordinators that can go across the street to the hotel, knock on their door, and say let’s go, get over there. They’ve got the support of other veterans who are going through the exact same thing, and they’ve got the support of our entire team of psychologists, social workers, psychiatrists, veteran outreach coordinators, sleep doctors, neuropsychologists, everybody who’s trying to help them get better. So it’s a really powerful healing environment that is designed to break down a lot of the barriers to care. Prior to this I’d never seen anything like it. It’s really a new model for treating PTSD, and I think it is the model for treating PTSD. So even folks who are local that could come because we also have an outpatient program, even if they’re local, we will usually recommend if they can do it, to attend the IOP just because we know it optimizes their chances for success.
Brainline: And what kind of follow-up do you offer?
Dr. Rothbaum: We follow up with people 3 months, 6 months, and 12 months after they leave here. We design treatment programs that are individualized for that exact veteran’s needs. If they are eligible for VA care, very often we’re going to help engage them in the VA. We have a full-time VA social worker who works with us at Emory. And if the veteran is eligible for VA care, that VA liaison can help sign them up and really facilitate that process, can help connect us with their home team, can help with that whole coordination of care. If they’re not eligible for VA care, we have other networks that we can tap into. Our social workers, the case managers, are amazing. They have a huge list of resources and are really, you know, doggedly looking for any resources that the veteran needs. So very often it’s going to be a continuation of what they’ve been doing here if they’ve been doing prolonged exposure, and it depends on where they are when they leave. Some people don’t need any more. You know, their PTSD is pretty good. Some people might need someone to manage their medication. Some people might need work on maintaining sobriety or watching their substance use. Some people may need work on emotion regulation skills and distress tolerance skills. So, whatever they need, we try to find them those resources.
BrainLine: What are the broader goals of your program?
Dr. Rothbaum: We’re able to offer a lot of interventions at the same time, and that’s on purpose. We don’t want to just treat their PTSD; we really want to set them up for success in life. And most of us who aren’t impaired by PTSD, we’re going to work daily, we hopefully have relationships that we can manage and manage when stuff comes up in them. We’re exercising and eating right. We’ve got good sleep habits. And so we really want to teach them the habits for wellness and to maintain that wellness and especially to fill in the spots when their PTSD improves. We have some people come in — I had one guy who told me he moved a mini fridge into his bedroom so now he didn’t even have to leave his room to eat, you know, before he came into treatment. So their lives have become so narrow, and what we want to do in treatment is help them to expand their lives again. So, a lot of the recreational activities, we take them on. They’re called recreational, but they’re really therapeutic. Very often people with PTSD and especially veterans with PTSD avoid crowds. They don’t feel safe. So we’ll take them to Braves games and Hawks games and Falcons games and let them be in crowds, you know, as part of treatment and as part of the group to see and really learn in our brains and our bodies that it doesn’t pose the same threat and that people can get back out there and live. We’ve got one of our postdocs who was interviewing to be a faculty member here, and he was saying this is the best job ever. Where else do you get to change someone’s life every two weeks? And it sounds dramatic, but it’s true. For many of the people who go through our program, it’s transformative. I mean their families are saying I almost don’t recognize them. It really is transformative. So many of our patients have said that this have given them their lives back.
Brainline: Are there promising new directions in research about PTSD?
Dr. Rothbaum: About 70 percent of us will be exposed to a traumatic event, but not 70 percent of us end up with PTSD. So trying to figure out who is at risk for PTSD and then trying to figure out which treatment is best for whom. So even of the effective treatments nothing works for everyone. And so if we can — it’s called personalize medicine — and some of that is going to be looking at biomarkers, genetics, how our brain responds to certain things, how our bodies respond to certain things. If we can use that information to learn about PTSD and to learn which treatment each person needs and then give them that treatment, then I think that that’s very exciting. We are now partnering with Cohen Veterans Bioscience to look at biomarkers before and after treatment in the IOP to try to get to that information and figure out which treatment is best for whom. There’s a little bit of data that TMS, which is Transcranial Magnetic Stimulation — it’s a magnet put over the head. It doesn’t hurt. People don’t feel it, but if you combine that with the trauma-focused therapy, it can boost the response in people who aren’t having a full response. So, we’re trying that clinically and then we’ll also look at it in research.
We’re also looking at what’s called medication-assisted psychotherapy. So, for example, the SSRIs like sertraline/Zoloft or paroxetine/Paxil. You have to take those every day, and it takes about a month before it builds up in your bloodstream and has any therapeutic effect. With medication-assisted psychotherapy, you don’t take it every day. You don’t take it chronically. It’s only you have it onboard for the psychotherapy session, and then the idea is that it might make that more effective. So for example, we have been doing research here at Emory on MDMA. On the street some people call it ecstasy, but this isn’t ecstasy because you don’t know what’s in ecstasy. This is pharmaceutical-grade MDMA. And it’s shown a lot of promise combined with psychotherapy for PTSD and especially for people who have been treatment resistant. They haven’t responded to other treatments for PTSD. We do what’s called translational research. So going from animals to humans and back to animals. And in our animal study the MDMA did facilitate the extinction of fear. Now we’re doing a study of healthy humans looking at that same question. And soon we’re going to do a study combining MDMA with prolonged exposure for people who are treatment resistant.