An Interview with Victoria Lemle Beckner, Ph.D. on Treatments for Post-Traumatic Stress Disorder (PTSD)
David Van Nuys, Ph.D. Updated: Jan 1st 2009
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Victoria Lemle Beckner, Ph.D. on Treatments for Post-Traumatic Stress Disorder. Dr. Beckner was raised in Southern California and spent the early part of her career in Washington D.C. working in public and legislative affairs and doing lobbying work. By the time she was in her early thirties, she found her interest in this work waning, and decided to pursue an interest in psychology. She attended night classes to complete a second undergraduate degree in psychology (the first was in philosophy), graduated from the Doctoral Clinical Psychology program at the University of Texas at Austin, and completed a clinical internship at the San Francisco Veterans Affairs Medical Center. Throughout this educational process she pursued her interest in the psychology of anxiety and stress, first generally, and then later, at the VA, working with combat veterans, more specifically on the topic of post-traumatic stress disorder (PTSD).
Dr. Van Nuys asks Dr. Beckner to define PTSD. PTSD arises from the manner in which memories are formed in the brain during traumatic experiences. In response to trauma, the brain and body flood with stress hormones such as cortisol which affect the hippocampus, a structure in the midbrain which functions as the filter through which short term memories are consolidated into long term memories. The hormone-influenced hippocampus then creates memories that are highly emotionally charged, and also highly disorganized in comparison to normal memories. Stress hormones also alter the brain's functioning to enhance the anxiety alarm system, basically by lowering the threshold for recognizing danger. The fragmented way that trauma memories were stored leads towards fragmented recall of the event. The heightened anxiety alarm system gives rise to ongoing arousal symptoms. Stuff in the environment that reminds people of their trauma, by being similar to something that was experienced with the trauma, provokes unwanted recall of disturbing memory fragments, which in turn are frightening and frequently cause people to start avoiding that stuff, in turn causing social relationships and work to suffer as the person withdraws. Finally, traumatized people experience an emotional numbing which is the flip side of the extreme emotion associated with the memories.
Dr. Beckner's new book, Conquering Post-Traumatic Stress Disorder, focuses on educating people about the nature of PTSD and the treatments that are available for helping people with that disorder. It has a self-help focus, and helps people to understand how they can apply the same techniques that a therapist would use in treating their condition to help themselves. Unlike many self-help books on the topic of PTSD, Dr. Beckner's book does not shy away from recommending exposure therapy techniques which require confronting traumatic memories and avoided situations. The book is also interesting in that she devotes a chapter to "post-traumatic growth strategies"; ways that people can grow and improve the quality and focus of their lives in response to trauma. It is often the case, in her experience that trauma becomes a focusing event that helps people take inventory of their values and goals and focuses them on what is truly important. She became motivated to write the book upon learning that only 10% of people who have been traumatized and who develop PTSD are ever professionally treated for the condition. Her hope is to help those untreated people understand how PTSD is best treated, so that they can best help themselves, and to motivate them to get professional treatment for themselves. While she believes that much good can be done in a self-help modality, self-help is not generally as effective as professional PTSD treatment.
A variety of treatments and techniques for managing different aspects of PTSD symptoms are described in detail in Dr. Beckner's book.
Cognitive Behavioral Therapy techniques are described that help people to become aware of and work through beliefs about the meaning of their trauma that may be impacting them in a negative way. For example, people may carry an unacknowledged belief that bad things only happen to bad people; that only "sluts" get raped. The fact that they were traumatized may imply, according to this belief, that they are a bad person; that they are a slut. This is not true, of course, but until the belief is ferreted out and examined in the light of day and debunked if necessary, that person is going to be walking around feeling like damaged goods.
Behavioral exposure techniques are described that help people to break out of their avoidance and to break down the intensity of their fear reactions. A person with PTSD who is avoiding going out for fear of encountering some threatening thing that has become associated with their trauma is helped to encounter that feared thing so that they can re-learn that the thing is not actually dangerous. Such exposure can be done imaginally (in vitro exposure), through the use of imagery, or by actually going out and putting one's self in front of that thing (in vivo exposure). More generally, a person with PTSD may not need to confront any specific thing, but just force themselves to get out and do something social on a regular basis so as to combat a general tendency to withdraw socially.
As well, anger management techniques are described which help people to manage communications issues common to traumatized people, and mindfulness strategies are described, which help people to learn how to better tolerate their emotions by learning to watch them actively rather than just passively react to them. As Dr. Beckner summarizes the various techniques described in the book, she mentions that the overarching theme of PTSD treatment is to help people to learn to better tolerate their emotions; that there are a variety of ways and tools through which this goal is accomplished, but that they all boil down towards the same general goal. Fundamentally, all the techniques are about helping people to learn how to tolerate their feelings and get on with their life.
Dr. Van Nuys asks Dr. Beckner about two trauma therapies which she has not mentioned, Eye Movement Desensitization and Reprocessing (EMDR) and the Emotional Freedom Technique (EFT). Dr. Beckner notes that while she is aware that research has shown that EMDR is an effective therapy for PTSD, that there isn't any good evidence to suggest that the active ingredient of that therapy is anything different than the active ingredient in basis exposure therapy. In other words, the bilateral stimulation which is the hallmark of EMDR may simply be window dressing for the hidden active ingredient (exposure therapy), and not actually anything useful in itself. Dr. Beckner was not familiar with EFT, but recommends to proponents of that therapy that they do clinical research to establish that their therapy is useful. "I'm a girl who likes to see the evidence", she says. Testimonials as to the greatness of a given therapy are not adequate evidence that those therapies actually work.
Dr. Beckner talks about how exposure therapy, which has been shown via scientific study to be an effective treatment for PTSD, is able to help people. The basic format of exposure therapy for PTSD is to have patients tell their stories, in as much detail as possible, again and again. This is an imaginal form of exposure therapy. In the retelling process, the narrative of the trauma story is worked out, which helps to unify the fragmented memory of the actual event, and the intensity of the emotion associated with the memory fragments fades through a "getting used to" memory process known as habituation.
Dr. Van Nuys asks Dr. Beckner her opinion of how the country is handling the current PTSD crisis with veterans returning from the wars in Iraq and Afghanistan. She replies that it is indeed a PTSD crisis, with some 25% of returning veterans experiencing a diagnosable mental illness, many of them with PTSD. In her experience, the military has done a fairly good job of communicating the idea that PTSD exists, what the symptoms are, and to encourage soldiers to utilize the VA health care system upon their return to civilian life. Her impression is that the VA has aggressively ramped up their PTSD treatment capacity in preparation for the returning soldiers. From what she has seen at the San Francisco VAMC, the quality of PTSD care there is good.
Dr. Beckner closes the interview by making an appeal to people who have been traumatized to educate themselves about what constitutes effective treatment strategies, and to get themselves professional PTSD treatment if that is possible.
Dr. Victoria Lemle Beckner is a licensed psychologist with eleven years of research and clinical experience in the areas of stress, anxiety disorders and depression. She received her doctorate in clinical psychology from the University of Texas at Austin, and was then awarded a postdoctoral research fellowship in the Department of Psychiatry at the University of California at San Francisco (UCSF), where she is now a professor. Dr. Beckner has provided PTSD treatment to military veterans at the San Francisco VA Medical Center and civilians through UCSF and her private practice, the San Francisco Group for Evidence-Based Psychotherapy. Her research investigates how the stress neuroendocrine system affects memory and physical illness, as well as testing new treatments for acute trauma, combat PTSD and depression. She recently completed a 3-year grant-funded study on how a stress-management treatment may reduce the negative effects of stress on brain lesions and symptoms in Multiple Sclerosis. Dr. Beckner teaches courses and workshops on psychiatric disorders, vicarious trauma, the role of stress in illness, and cognitive behavioral therapy for anxiety disorders. She was also invited to co-teach a course at the University of Rwanda in 2006 on multicultural treatment approaches to trauma in the context of genocide. Conquering Post-Traumatic Stress Disorder is her first book.
Dr. Beckner has been a strong advocate for expanding access to mental healthcare through legislative efforts and finding creative solutions to overcoming barriers to care. She conducts her advocacy work as a member of the Board of the California Psychological Association and its Government Affairs Steering Committee, and as the Federal Advocacy Coordinator representing California for the American Psychological Association. She is also the former President of the San Francisco Psychological Association, and co-Chair of their Disaster Response Network, which provides pro-bono mental health services to citizens and during local and national disasters.