Can There be a Cure for PTSD?

by David Baldwin, PhD

This is my response to issues raised in another post (by Denis M. Donovan) on the traumatic-stress list, questioning whether there can be a "cure" for PTSD.

Since your comments reminded me of this, I'm going to start with a poem. Its actually a poem that I like, although below I'll mostly be arguing against the views expressed in the poem and also by you.

Reach for a star; and what will you find?
A stone, my boy, a stone.
Reach for a stone; will you find a star?
No, my boy, not one.
The sensible view is the view of the floor.
- Theodore Spencer (1941)

The other thing your post reminded me of was that one about how it can be proven that bumble-bees can not possibly fly...

To be clear, I will not be arguing here that there is a cure, but rather that it would be a foolish mistake not to look for one.

1. There can be no "cure" for PTSD because, unlike those conditions for which strikingly successful mono-cures do indeed exist (such as polio or smallpox), there is no uniquely identifiable causative agent in the trauma-response.

2. Indeed, given the right circumstances, almost anything can be traumatogenic.

Perhaps more clearly than most other mental disorders, PTSD by definition requires a uniquely identifiable causative agent. The fact that what exactly constitutes that causative agent for me might not cause a trauma-response in you is beside the point, and indeed consistent with much of what you argue below (some of which I even agree with). I believe the essential feature of a traumatic event is that it raises concerns about death, safety or security. Admittedly, this is largely a subjective experience (influenced by past experience and context). It's irrelevant to me that there may be error in this judgement: there is always error.

3. Just as traumatogenesis is a contextual phenomenon, so, too, is the enduring posttraumatic period. Traumatized individuals rarely exist in isolation. This is especially true of children, and anyone who has worked extensively with children knows that there is a very complex ecology of child treatment. [...] The most brilliant interventions can be stymied by what happens at home, in the community, or at school.

Yes, of course. It is clear that children, especially -- for example those living in abusive or neglectful homes (or without homes) -- may well remain in a state of trauma that prevents effective individual treatment (i.e., treatment not focused on that abusive context). In such cases, the child might best be removed from the traumatic situation and placed somewhere where they are safe and secure, before individual treatment on their trauma symptoms is begun.

But you (virtually) argue instead that there can not be a cure because there are children! An alternative position might be that no trauma treatment can be effective until after the patient is safe. Because my patient might be hit by a comet while walking out of my office does not mean that I don't do good clinical work. Does it follow that CPR is not effective treatment for drowning victims because they might slip back in the water again? These are different issues (although in the cases you describe they may be related).

4. Should we be surprised that certain simply described and easily recognizable (categorical) treatments for PTSD seem to work? No, not at all. There is a pattern to treatment-response that cuts across treatment domains. Even in the case of medicinal treatments, every new treatment enjoys an initial period of placebo-effect. [...] But it would be wise to learn from history.

I agree that placebo effects can be surprizingly powerful, and suspect you would enjoy reading this reference about the issue (re: several medical and surgical treatments once, but no longer, considered effective):

Roberts, Kewman, Mercier, Hovell (1993) The power of nonspecfic effects in healing: implications for psychosocial and biological treatments. Clinical Psychology Review, 13, 375-391.

But in this context I would prefer to learn from clinically relevant research, and my own experience, rather than from hypothetical extrapolations about Ponce de Leon....

For example, I think that in the case of PTSD, some considerable relief from, say, intrusive traumatic symptoms, can be perceived by a patient as enormously effective ("wow, I can sleep again"). I also suspect that these changes may begin an extended process of healing (or change a process of stagnation) that can continue long after termination (provided patient is not promptly re-traumatized, or hit by a comet). There are a few hints of such a possibility in the literature (well, as I read it), but more often there is a blinding absence of data. I see a failure to look for such extended change, or even something as basic as measuring the causal relationships among the primary PTSD clusters (as mentioned in an earlier post, looking for such SEM studies), that could give valuable clinical information about where best to exert leverage to effect change.

In the meantime, I'm trying to make things better for my patients; often this happens in small steps, but sometimes in large strides. It is a matter of looking for opportunites where I can help change for the better. Small steps can lead to big insights, and this process can repeat itself.

While it can be tempting to argue that something is so because there are no data saying its not (e.g., if it works it must be a placebo), in the area of clinically relevant research, I believe it is more often the case that research is largely not addressing issues of primary clinical importance. (This may very well have something to do with the fact that researchers have no idea what issues are of primary clinical importance, and clinicians, by and large, haven't a clue how to do research.) There's still an awful lot we don't know here.

For example, with regard to the possibility that trauma can cause permanent physical changes in the brain (i.e., Sapolsky/hippocampus; LeDoux/amygdala), there is no good way to measure the relative severity of stressors necessary to cause such an effect across species. That is, it is not clear if such change corresponds to a level of severity leading to a diagnosis such as DESNOS in humans, or is far more severe than that, or if it can be associated with briefer and relatively less complex traumata in humans -- or indeed if it depends more on individual factors (including subjective interpretations) than on the objective characteristics of the trauma. We just don't have the equivalent of a translator to understand the comparative equivalence of these manipulations across species.

And, since the baboons and rats and whatever (who were generous enough to demonstrate these physical consequences for us) were not given effective treatment for their traumas, we really haven't much of an idea whether these physical changes can be reversed or "worked-around" or not, in humans receiving effective therapy for trauma-related disorders. So it seems premature to be arguing from a research-based perspective that there _can't_ be a cure, when (first) we really don't know that, and (second) we surely won't find one if we "know" it doesn't exist -- and therefore don't bother to look.

5. [...] More important to the issue at hand, however, is the refinement of that [neuroplasticity] finding that meaningful experience, and learning in particular, drive neural reoganization. (4) The picture emerging from a dynamic and robust neuroplasticity research literature suggests that there are very good reasons, related to experience-induced gene-expression and experience-induced biological self-organization, why different individuals react in uniquely individual ways to the same experience...

I think here you are assuming that the "cures" Charles Figley reports having found are not individually-based. I suspect that any effective therapy or clinical procedure is going to be highly attuned (even synchronized) to the needs and issues and feelings of each patient. My own experience has been that, as a rule, clinicians are far more cognizant of the importance of such individuality than are researchers, who more often must subsume individual variation of their subjects into the error variance of group means. Perhaps we differ in our definitions of "cure" or "treatment".

Certainly there are individual variations on a theme of trauma-response. But the theme is recognizable within each patient's individuality (at least in those cases that I recognize as trauma-related :-)). While I can't speak from much experience with TFT or TIR or NLP, I am familiar with EMDR and have experienced it as being highly tailored to the needs and the direction of the patient, within a somewhat flexible framework that structures my options. Consequently, I suspect each of these treatments requires clinical skill to use.

What strikes me as most important about the research searching for a cure is its pragmatism. It offers the hope of discovering new ways of thinking about trauma and its resolution, and these new directions may lead us to research hypotheses that might eventually provide a rationale for such a new paradigm. If we "know" there can't be a cure, we'll never find out if we were wrong. That is the danger I see in arguing "Why there can be no cure for PTSD".

Ending as I began, here's a concluding quote:

Sometimes psychological laws are discovered... And sometimes they're enforced.
-- Ernest Hilgard (~1971)
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