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Prolonged exposure therapy aids recovery for PTSD patients

Capt. Felicia Keith, 60th Medical Operations Squadron director of psychological health, listens to one of her patients during a treatment session at David Grant USAF Medical Center at Travis Air Force Base, Calif., June 25, 2018. Keith and her team of professionals have treated more than 200 people who displayed post-traumatic stress symptoms over the past year. Badge blurred for security reasons. (U.S. Air Force photo by Tech. Sgt. James Hodgman)

Capt. Felicia Keith, 60th Medical Operations Squadron director of psychological health, listens to one of her patients during a treatment session at David Grant USAF Medical Center at Travis Air Force Base, Calif., June 25, 2018. Keith and her team of professionals have treated more than 200 people who displayed post-traumatic stress symptoms over the past year. Badge blurred for security reasons. (U.S. Air Force photo by Tech. Sgt. James Hodgman)

TRAVIS AIR FORCE BASE, Calif -- Suffering from post-traumatic stress is an unfortunate reality for many service members.

Post-traumatic stress disorder it is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, such as combat, a natural disaster, a car accident or sexual assault. People often have upsetting memories, feel on edge, or have trouble sleeping for extended periods of time after experiencing trauma.

Left untreated, PTSD can lead to severe depression and anxiety. According to ptsdunited.org, an estimated 24 million people suffer from the disorder at any given time.

For active-duty service members suffering from PTSD and post-traumatic type symptoms, help is available at David Grant USAF Medical Center’s Mental Health Clinic at Travis Air Force Base, California.

“Our goal is to provide the best care to our patients with evidence-based and ethical, effective care,” said Capt. Felicia Keith, 60th Medical Operations Squadron director of psychological health.

Keith said for patients being treated for PTSD, prolonged exposure therapy is often an effective method used to treat the disorder.

“Prolonged exposure therapy is an evidence-based practice that has been found to be a beneficial treatment for PTSD,” she said. “With PTSD, the trauma often has affectively got the patient stuck, they’re responding to cues of the trauma even though the trauma isn’t occurring anymore.”

The purpose of prolonged exposure therapy is to expose an individual to those cues under safe conditions so he or she can relearn those cues and no longer connect them to the trauma, she said. The treatment allows people to go about their lives again without having a physiological or psychological response to cues that occurred during the traumatic event.

Keith said she wants to educate the Travis community about what exposure therapy is and how beneficial it can be.

The first step is to explain everything to the patient, she said.

“With exposure therapy, we create an in-vivo exposure hierarchy,” said Keith. “A situation that’s not distressing we label a zero. From there we identify what is the most distressing situation for someone and we’ll label that a 100. For many people their 100 is the trauma itself. From there we find out what would be a 50 on that distress scale. Going to the movies is often a 50 for people because it’s dark, you can’t see very well, but, you can see the exits so if something happens, you have a means to escape.”

This process continues until the patient identifies a complete hierarchy from zero to 100.

“Once we have that, we give patients assignments in-between sessions to go out and do some of those things,” said Keith. “We don’t start them at a 100 obviously, because that could be too distressing. PTSD treatment is going to make you uncomfortable, but we’re going to work through it. I start my patients typically at a 40. Going to the commissary at 5 p.m., may be a 40 for someone because it’s crowded and more difficult to exit quickly. I’ll have my patient go there and stay there for at least 45 minutes or until their distress level has decreased by half.”

While at the commissary, the patient documents how he or she feels. Did their heartrate increase? Did they feel anxious? What did they think in those moments and did their distress level go up or down? These are all questions Keith has the patient answer.

Patients slowly work themselves up their hierarchy until they hit their most distressing situation, which in most cases, is the trauma that person experienced. In the meantime, during their sessions, patients will begin imaginal exposure. Imaginal exposure is where the patients will disclose the trauma to the therapist.

“I ask you to repeat the trauma that happened over and over and over again,” said Keith. “You sit in my office for about 45 minutes and you just tell me over and over and over again what happened. We call this imaginal exposure. This traumatic memory often causes people to do all they can to not experience that memory again because it’s so distressing. What they don’t realize is, by doing that, they’ve given that memory so much power over them.”

They may feel disconnected from their spouse because of a sexual trauma and they may avoid kissing or touching because doing so reminds them of that incident, she said. A combat veteran who experienced a firefight may avoid going to concerts, fireworks shows or large gatherings because they may want to avoid the noise or they may become anxious in large crowds.

“By confronting the trauma head-on and having you tell me about it, we are not only processing the emotion that’s there, we are showing you that you’ve made it through the worst thing,” said Keith. “This is a memory, that’s all it is. It doesn’t have to be as terrifying as it was any more. This is all done to help patients experience that emotion and work through it. Through that discomfort they can begin to grow and move on.”

Over the past year, more than 204 patients were treated for PTSD at DGMC’s Mental Health Clinic. Staff Sgt. Jasmine Smith (Name changed to protect the privacy of the patient), a member of the 621st Contingency Response Wing, is one of them.

Smith joined the Air Force in April 2012 and arrived at Travis in February 2013. In August 2015, she deployed to Bagram Airfield, Afghanistan.

“Before the deployment life was great,” she said. “My husband and I were assigned to Travis together and had a baby, I made senior airman below the zone and shortly after, tested for staff sergeant. I learned a few days after arriving at my deployed location that I had made staff my first time testing. Things were going well.”

Shortly after arriving at Bagram, Smith met the members of her unit and learned about her job. One thing she didn’t feel prepared for though, was the frequent attacks launched at the base.

“It can get crazy,” she said. “I never saw an attack before and we were mortared nearly every week.”

Having to constantly be ready to take cover at any moment wore on Smith over time. So much so that she has difficulty dealing with crowds, which makes shopping quite an experience.

“When I’m in a store I have to immediately locate each exit, know how many exits are in the store and know if something went down and an aisle was blocked, how I would get out,” she said. “Knowing my plan to get out is important.”

Going to the ‘Happiest Place on Earth’ can also be quite a struggle, said Smith.

“The day after I got home my family surprised me with a trip to Disneyland, which is my favorite place in the world; I was excited until we got there,” she said. “I had a panic attack because I was constantly on guard looking at the ground, people’s expressions, wondering if someone was reaching in their pockets and if they were, why? There were so many noises, lights and so many people. That never used to get to me. Now, that was all I could think about. I don’t remember half the time I was there because I was so paranoid the entire time.”

Smith was also struggling with something tragic, the loss of Airmen she knew.

Four aircrew members of her deployed unit joined Smith for dinner before flying a supply delivery mission to a forward operating base in Afghanistan. After dinner, the crew left for their mission and Smith went to bed.

At 3 a.m., Smith learned the Airmen wouldn’t be coming back.

“I was woken up to come down to one of the tents for a commander’s call because something happened,” she said. “We knew something was up because the people in there were supposed to be on crew rest and you usually don’t disturb that for anything that’s not serious. We also noticed empty chairs.”

Smith’s commander informed her that her friends were killed in a crash after the pilot lost control of the plane shortly after take-off.

“It felt like an out of body experience,” said Smith. “You don’t expect that to happen to you or the people that are around you. We didn’t know what caused the crash until months later and the Islamic State of Iraq and Syria was claiming it. Being on edge for so long just gets to you. At first I felt shock, I became physically sick and I was unable to eat. I had extreme anxiety and I thought the worst case scenario for everything from then on.”

Then, Smith was struck by serious sadness during a moment when she realized her friends were gone.

“When we loaded their caskets into a C-5M Super Galaxy it really hit me,” she said. “That’s when it really sunk in. I felt so much sadness for the families and I felt guilty, because I was going to get to go home and they weren’t.”

Smith wrestled with this guilt, extreme anxiety and nightmares for several months after returning from her deployment. In August 2015, she contacted the Mental Health Clinic at Travis to get help and has made a great deal of progress.

“I meet with Capt. Keith on a near weekly basis and I take a behavioral health assessment before each appointment so she can see how I’m feeling,” said Smith.

“Keith helped me understand that beating myself up isn’t helping,” she said. “It’s not doing me any good to stall on one piece of negative information and allow that to control me.”

After many months of treatment, Smith’s nightmares have stopped and her anxiety has been reduced. She’s even been able to conquer her ‘Level 100,’ flying in an airplane on trips to Michigan, Hawaii and Mississippi.

“It’s about small rewards for me,” said Smith. “I’m getting there. Every single time I’m in an airplane, it’s like being zip tied in a bag and being suffocated. Still to this day, every single time I’m in the air I wonder why am I doing this? Why didn’t I just drive, does the pilot know what he or she is doing, is that noise normal, is this turbulence normal and are the air traffic controllers in control of the situation?”

“I’m still learning how to control my breathing when I’m having a moment,” she said. “It is a continuous struggle. I still get anxious but not nearly as bad as what I did before. I have to say to myself, ‘You’re safe.’ ‘Nothing is going to happen, just go.’”

Smith encourages people who are suffering from distress to get help.

“I know that sometimes you can feel so alone especially when you’re grappling with something,” she said. “You’re not alone. Someone you know is struggling with something and nobody is perfect. There’s nothing wrong with seeking help or talking to someone. It’s such a great display of strength to seek help. I encourage everyone to seek help if they need it.”

Keith said seeing the positive change in Smith’s life and the impact she has on her patients is the best part of her job.

“I love working with patients and seeing them improve over time,” she said. “It’s amazing seeing the positive change they can make and being there for people who may be in an immense amount of pain, to listen to them and use my training to help them; that’s the best thing about my job.”

Air Force Medicine