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While cognitive-behavioral therapy remains the most well-researched treatment for post-traumatic stress disorder, it doesn't help all patients. That's especially true for service members who have been perpetrators as well as victims of violence, says Russell B. Carr, MD, an Army psychiatrist.

"It's a much more complicated experience, and they often feel a lot of shame in addition to the usual PTSD symptoms," he says.

For the past six years, Carr has been working with soldiers who haven't responded to cognitive-behavioral therapy, and he's developed a new treatment rooted in intersubjective systems theory. This modern take on psychoanalysis pioneered by Robert Stolorow, PhD, posits that the heart of trauma is shame and isolation.

Carr's therapy, described in the October 2011 issue of Psychoanalytic Psychology, has shown promise helping soldiers who haven't responded to CBT by addressing the existential dread dredged up by trauma, and the feeling that their entire world has lost meaning. Though Carr's goals are ambitious, his intervention is relatively short—requiring twice-weekly sessions for up to three months. As a result, the therapist must clearly define goals, keep conversations on track and quickly establish rapport with clients, Carr found.

Short-term therapy—which is typical of CBT, but less common with psychoanalytic approaches—is often the only option in military settings, he says.

"In the military, there is frequently the situation where a patient or therapist is leaving soon," says Carr. "It's a transient population, and it limits the length of time we have to work together."

A key part of intersubjective therapy is helping clients put their feelings around traumatic experiences into words. These feelings aren't always negative. One patient described in the article found he enjoyed the smell of burning human flesh, and was later horrified and ashamed of his initial reaction. By expressing empathy and not rejecting the soldier, Carr helped the soldier process the experience and reconnect with the civilian world.

Convincing soldiers that a therapist—as well as friends and family—can understand a little of what they are going through lessens their PTSD symptoms, Carr found. In some cases, soldiers even learn from the experience, he says. "Recognizing the fragility of life, you can refocus on what's important to you, and not waste time on things that aren't."

—S. Dingfelder