In part one of "WHO CARES? Veterans Denied Access to Top PTSD Treatment," we began to explore how political decisions by leaders of Institutional Military Medicine, the Department of Veterans Affairs (DVA) and the Department of Defense (DoD), have negatively impacted the lives of potentially hundreds of thousands of members of the warrior class and their families, by wrongfully restricting veteran's access to all of the highest quality PTSD treatments available and recommended by its own 2004/2010 Clinical Practice Guidelines for Treating Post-Traumatic Stress Disorders (e.g., Eye Movement Desensitization and Reprocessing (EMDR)] -- simply because they can, and apparently with complete impunity, even after a public outing by a 2011 Government Accountability Office (GAO) report.
"Why GAO Did This Study?
... Because of the importance of research [my emphasis] in improving the services that veterans receive, GAO was asked to report on VA's funding of PTSD research, and its processes for funding PTSD research proposals, reviewing and incorporating research outcomes into clinical practice guidelines...and determining which PTSD services are required to be made available at VA facilities.
According to GAO, "Specifically, VA officials told us that their decision to include cognitive processing therapy and prolonged exposure therapy in the Handbook was influenced by the fact that both of these had been graded as level "A" treatments in the 2004 PTSD CPG (indicating that the intervention is always indicated and acceptable)," and that "VA officials told us that prior to issuing the Handbook in 2008, VA had already begun investing considerable resources to implement national training programs for cognitive processing therapy and prolonged exposure therapy in 2006 and 2007, respectively." In their report, the GAO mentions in a footnote that "two other psychotherapies, stress inoculation training and eye movement desensitization and reprocessing, were also graded as level "A" treatments for PTSD in the 2004 PTSD CPG, but were not included in the Handbook."
Why not make all top PTSD treatments available to war veterans -- why only two?
March 30, 2010: Stars and Stripes -- "Mullen criticizes DoD, VA failures in mental health treatment"
"Mullen" of course, is former Joint Chiefs Chairman Navy Admiral Mike Mullen, the highest ranking U.S. military officer in the land. Uncharacteristically, the Admiral was publicly lambasting military Institutional Military Medicine within earshot of the military's newspaper (Stars and Stripes) reporters. According to the report, Chairman Mullen openly expressed "frustration and disappointment" with the "slow pace of treatments" for war stress injuries like PTSD saying, "after eight years of war, military officials should have better answers." Adding fuel to the Admiral's ire, was that since 2005, over $400 million have been spent by the DoD for researching PTSD treatments, sparking the Chairman's remark, "While millions of dollars have been invested into research on PTSD, traumatic brain injuries, and mental health issues, military leaders have not produced enough treatment options and outreach programs to stay ahead of the problems." In conclusion, Admiral Mullen stated that "caring for the wounded veterans will take decades of funding and attention from government leaders."
Lead Agencies Responsible for Researching Treatments of War Stress Injury?
The Military Health System describes itself as "a source of innovative education, medical training, research, technology and policy that strives to provide a bridge to peace"
DoD's Defense Center of Excellence for Psychological Health and Traumatic Brain Injury
On 30 November, 2007, in collaboration with the DVA, the DoD's "Defense Center of Excellence (DCoE) for Psychological Health (PH) and Traumatic Brain Injury (TBI)," was established to "integrate knowledge and identify, evaluate and disseminate evidence based practices and standards for the treatment of psychological health and TBI within the Defense Department." In fiscal year 2010, a total of $638 million in funding was allotted for PH and TBI across the military services.
National Center for PTSD
In 1989, the National Center for PTSD (NC-PTSD) was established within the DVA in compliance with Public Law 98-528, to "advance the clinical care and social welfare of America's veterans through research, education, and training on PTSD and stress related disorders." The NC-PTSD reports having an extensive network of relationships with the DVA, DoD, and other government agencies.
Staffing. Dr. Matthew Friedman, the NC-PTSD Executive Director, is a nationally recognized psychiatrist and expert on the psychopharmacology of PTSD. The NC-PTSD staff is impressive, consisting of many well-respected academicians and clinical researchers written extensively on cognitive-behavioral and "exposure" therapies for PTSD with war veterans; "Virtual Reality Therapy," a prolonged exposure-based treatment and "Cognitive Processing Therapy (CPT)" originally designed for sexual assault trauma but now, along with "Prolonged Exposure," represents the bulk of PTSD treatment and research in the DVA and DoD.
Clinical research. The NC-PTSD reports being "a world leader in research into the prevention, causes, assessment, and treatment of traumatic stress disorders." During FY 2010, NC-PTSD researchers were involved in over 130 research projects, up from previous years. For example, according to the NC-PTSD's 2006 Annual Report, a total of 95 research projects were conducting, leading to over 165 publications, supported by $95,668,340 in total research funding. In regards to PTSD treatment research, the NC-PTSD has focused almost exclusively on cognitive-behavioral and psychopharmacology approaches. Since its inception, the NC-PTSD has prided itself by supporting the military through training and research.
2012: Current Status of EMDR Training and Research in Military Populations
At the time of this writing in mid-2012, there has been notable progress in terms of increased opportunities for DoD clinicians to obtain EMDR training and ensuring military beneficiary access to EMDR therapy, however the Military Health System has never researched EMDR since its 1989 inception, a remarkable gaffe given frequent reports of EMDR's effectiveness by military mental health practitioners. Moreover, to date, the Military Health System has spent well-over $400 million in researching PTSD and TBI, but has yet to conduct a single randomized clinical trial (RCT) on EMDR -- despite a decades-long war and an irate Joint Chief of Staff. Meanwhile the lead agency for training and research in Institutional Military Medicine, the DVA's National Center for PTSD, continues its staunch all-out resistance toward EMDR. In fact, despite PTSD research funding increasing from $9.9 million in fiscal year 2005 to $24.5 million in fiscal year 2009, the DVA has refused to fund a single clinical trial on EMDR since 1998. This is entirely mystifying given the significant positive results from the VA's last RCT on EMDR.
Why Should Institutional Military Medicine Research EMDR?
Other than the fact that EMDR has been identified as one of a handful of evidence-based PTSD treatments in the DVA and DoD's own Clinical Practice Guidelines, along with every other credible domestic and international expert panel, the executive leadership need only listen to their own mental health clinicians and researchers in the field.
In 1998, Dr. John Carlson and his research group at the VA Medical Center, Honolulu, Hawaii, noted that the main purpose of his team's study was to address the contradictory findings from the DVA's previous RCT on EMDR as compared to highly supportive reports from the civilian-sector[1]. Carlson et al. (1998) carefully designed a research using the "gold standards" for RCT of the time, in order to satisfy DVA skeptics and EMDR advocates.
Results. Carlson et al.'s (1998) more pragmatic approach to researching EMDR on Vietnam War veterans with chronic, combat-related PTSD, revealed that after twelve EMDR sessions, targeting multiple memories, 77 percent of combat-veterans no longer met criteria for PTSD with results maintained at three- and nine-month follow-up[1]. So what happened next? Unfortunately, Carlson's et al. (1998) study has been the last word in the National Center for PTSD's abbreviated flirt with EMDR in fulfillment of its stated mission of "searching for highest quality PTSD care."
1996-1998: The First EMDR Trainings in the Military
As for the U.S. Armed Forces, the first known EMDR training was organized by Army psychiatrist Colonel James Stokes in 1996, at Fort Hood, Texas, Commander of an 18-member Army Combat Stress Control (CSC) unit pending deployment to Bosnia. In 1994 an article appeared in the Army Medical Department Journal [2], reporting recovery from "battle fatigue" dramatically improved by EMDR. In conclusion, the author's call for rigorous studies on EMDR were rejected by military medicine.
2003-2009: Field Research on Treating Military Personnel with EMDR
Jumping ahead to the 21st century, four battlefield medical evacuees were referred to the author by medical staff due to severe, destabilizing combat-related acute stress disorder (ASD) or acute PTSD[3]. All four received one session resulting in significant symptom reduction and stabilization. In April 2004 U.S. Medicine ("The Voice of Federal Medicine") repeated the author's call for EMDR research which was sharply rebuked by the Pentagon's top mental health advisors, rejecting the mere idea of investigating EMDR (Sandra Basu,"Navy Used ID, Prevention To Ease Combat Stress," U.S. Medicine, April 2004). For example, a senior Navy psychiatrist and adviser to the Marine Corps, expressed the belief that EMDR should not be researched because "PTSD is often a treatment resistant problem. It is better to prevent it altogether, than treat it." Similarly, the Director of the DoD's Center for the Study of Traumatic Stress, flatly rejected the request to research EMDR confidently citing "the new elements related to eye movements are not central to the effectiveness of the treatment."
Undeterred, a joint DoD/VA regional training program provided the unprecedented opportunity to collect clinical data on the "real-world" effectiveness of EMDR therapy outside of artificial laboratory settings, in actuarial military and operational healthcare settings. Eight DoD clinicians submitted a total of 72 EMDR treatment cases of military personnel, including 48 cases diagnosed with combat-related ASD/PTSD [4]. Clinically significant symptom reduction was reported after an average of four EMDR sessions, eight sessions if wounded [8]. In sum, published accounts of EMDR total 120 military personnel, 79 cases within the U.S. military alone, submitted by 16 different therapists, within militaries of the U.S., U.K., and Germany. Diverse treatment settings include operational environments such as frontline combat stress units and field hospitals, as well as regular military outpatient and inpatient clinics.
Tone Deaf: Impunity of Maladaptive Resistance and Harmful Politics
Despite everything above, billions of dollars in research funding, positive research findings from military and VA clinicians in the field, and even an irate Joint Chief of Staff, none has been sufficient to penetrate Institutional Military Medicine's misguided policy to ban EMDR research at any and all cost.
- Acupressure
- Acupuncture
- Animal Assisted Therapy (AAT)
- Art therapy
- Cognitive Processing Therapy (CPT)
- Cranial Electrotherapy Stimulation (CES)
- Deep Brain Stimulation (DBS)
- Fluoxetine (Prozac)
- Geodon (Ziprasidone)
- Hyperbaric Oxygen Therapy (HBOT)
- Imaginal Exposure & D-Cycloserine
- Mirtazapine and SSRI
- Modification of Cognitive Processing Therapy (CPT-C)
- Oxytocin-Intranasal
- Prolonged Exposure
- Reiki, Therapeutic touch
- Repetitive Transcranial Magnetic Stimulation (rTMS)
- Virtual Reality Therapy (VRT)
- Yoga
- Telemedicine-Prolonged Exposure
- Δ9-THC (cannabis)
- Transcendental Meditation to name just a few, anything and everything except one of the top evidence-based PTSD treatments the DVA/DoD recommend.
Sources: www.research.va.gov; www.army.mil; Military Health Service: www.health.mil; ClinicalTrials.gov; Deploymed ResearchLink; U.S. Army Research Institute for the Behavioral and Social Sciences; National Center for PTSD www.ptsd.va.gov.
Why Should Institutional Military Medicine Be the Lead EMDR Researcher?
The fact that something like EMDR works as well as prolonged exposure, cognitive processing, and virtual reality therapy despite violating nearly every principle of psychotherapy and therapeutic change-is a true scientist-practitioner's dream. If ever properly researched in good-faith and earnest, we don't know what direction may follow. Perhaps, it ends nowhere and we learn EMDR is a therapeutic placebo. Or, perhaps it can revolutionize how we think about psychopathology, learning, and the brain's inherent ability to heal itself. We don't know and won't know until EMDR is researched and dissected to find out what everyone agrees is missing-the reason why it works! That's right, the question "does it work?" has long been settled-why EMDR works is the burning question that apparently Institutional Military Medicine does not want to know, or us to find out.
Final Remarks
There is no greater duty for a society and its government, when it calls upon its warrior class to sacrifice their health, and possibly their lives, then to ensure that Institutional Military Medicine fulfills its sacred obligation to care for their wounds during times of war and peace. An implicit understanding exists within military populations that war is inevitable, no-one returns from war unchanged in ways good and bad, and if injured, they may never be fully-restored. Tragically, history has repeatedly shown that when it comes to anticipating and responding to the certainty of war stress injury-Institutional Military Medicine and the nation has profoundly failed. The EMDR issue reflects the same mind-set as the 400 PTSD diagnoses overturned by the Army.
Question Is: Will Anyone Care Enough To End This?
References
[1]Carlson, J. G., Chemtob, C. M., Rusnack, K., Hedlund, N. L., & Muraoka, M. Y. (1998). Eye movement desensitization and reprocessing for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3-24.
[2] Miller, J. R. (1994, September-October). Eye movement desensitization reprocessing: Application on the battlefield. Army Medical Department Journal, (PB-8-947/8) 33-36.
[3] Russell, M. (2006). Treating combat-related stress disorders: A multiple case study utilizing eye movement desensitization and reprocessing (EMDR) with battlefield casualties from the Iraqi War. Military Psychology, 18(1) 1-18
[4] Russell, M, Silver, S, Rogers, S, & Darnell, J. (2007). Responding to an identified need: A joint DoD-DVA training program for clinicians treating trauma survivors. International Journal of Stress Management, 14(1) 61-71.
Note. In June 2012, Antioch University Seattle established the first-ever Institute of War Stress Injuries and Social Justice, dedicated to identify and eliminate the root causes of repeated failure to meet mental health needs of the warrior class.