Editor’s note: Craig Bryan, PsyD, ABPP, is a psychologist and director of the National Center for Veterans Studies at the University of Utah. His continuing education presentation for GoodTherapy.org, titled Brief Interventions for Suicidal Military Personnel and Veterans, is scheduled for 9 a.m. PDT on August 29, 2014. This event is available at no additional cost to GoodTherapy.org members and is good for two CE credits. For details, or to register, please click here.
I am often asked whether I think we need to make mental health care easier to access for military personnel and veterans, expand mental health services in the Department of Defense or the Department of Veterans Affairs (VA), or allow veterans to get more treatment from community providers outside of these systems. My answer to each of these questions is the same: “Not necessarily.” Many people are surprised at my response because I am a clinical psychologist and military veteran myself. Why wouldn’t I think that “easy-to-access treatment” or “more treatment” or even “free treatment” are good things? To answer this question, let’s take a brief moment to imagine a situation that many of us may confront one day or may have encountered already.
Comparing Options for Treatment
Think about someone you care about very much—perhaps your spouse, child, good friend, or family member—and imagine that he or she has an illness that significantly reduces quality of life and increases risk for early death. The illness not only negatively affects that person’s life, but it also negatively affects the lives of family and close friends. Imagine accompanying this person to a doctor’s appointment, during which the doctor runs some tests and procedures and arrives at a diagnosis. The doctor then presents and describes the following treatment options:
|Treatment A||Treatment B||Treatment C|
|How many studies have been conducted on this treatment?||Hundreds||Dozens||None|
|On average, how much do people’s symptoms decrease after this treatment?||50-75%||50-75%||Unknown, but some doctors claim close to 100%|
|On average, how long does it take people with the illness to recover with this treatment?||6-9 months||3-6 months||Unknown, but some doctors claim 1-2 days|
|On average, how likely are you to experience a life-threatening symptom within 2 years of treatment?||50%||15-25%||Unknown, but some doctors claim almost 0%|
|Do most people like this treatment?||Yes||Yes||Yes|
When comparing these three options side-by-side, you might notice that Treatment A and Treatment B are very similar to each other. In general, both offer a reduction in symptoms of 50-75% and are fairly comparable in terms of time to recovery (Treatment A offers a 6–9 month recovery period, and Treatment B, a 3-6 month recovery period). Furthermore, both treatments have been researched fairly extensively, although Treatment A has received relatively more scientific attention, and patients seem to like both Treatment A and Treatment B equally. The primary differences between these two options are that people who receive Treatment B are half as likely to experience a life-threatening symptom during the next two years.
Treatment C is sort of the “wild card” of the bunch. Because Treatment C is new and hasn’t yet been studied extensively, it’s not so easy to determine whether it is better or worse than Treatment A or Treatment B; we don’t know how well it works, or, even worse, if it makes people sicker. We also don’t know how many people get better, or how many people experience life-threatening symptoms. What we do know is that patients like Treatment C, and a few doctors who prescribe it say that it works very fast and is very effective at reducing symptoms. The claims made by some doctors of immediate improvement within 1–2 days and the very low risk for experiencing a life-threatening symptom are certainly tantalizing, but we don’t know how often that occurs or how long that improvement lasts. Overall, Treatment C is a huge gamble given the potentially life-threatening nature of this illness, especially when we have an option (Treatment B) that has a strong track record of reliable results. Most of us, therefore, would not recommend this option for our loved one.
The Importance of Selecting an Evidence-Based Treatment
Like anyone else, military personnel and veterans have options for care. Some of those options have been studied more than others, and some of those options are clearly better than others, as in the case of Treatment B. For example, when we consider treatment options for military personnel and veterans with suicide ideation, we know that brief cognitive behavioral therapy that focuses specifically on suicide risk (as opposed to focusing on a psychiatric concern) contributes to 50% reductions in suicide attempts within the first two years of treatment, even though this treatment is often no better at reducing suicide ideation and symptoms of depression, anxiety, and hopelessness than others. In other words, many treatments help suicidal individuals feel better, but some treatments are more effective at reducing the risk for suicide attempt (i.e., the life-threatening symptom). This has been demonstrated scientifically in a sample of non-military individuals, and more recently in a forthcoming study conducted in a sample of active duty military personnel.
If we want to prevent suicide among military personnel and veterans, we should be making brief cognitive behavioral therapy easily accessible and free to military personnel and veterans. Although brief cognitive behavioral therapy isn’t necessarily better at reducing depression or anxiety than other therapies such as supportive therapy, psychodynamic therapy, person-centered therapy, or stand-alone medication therapy, it is better at reducing the likelihood of a life-threatening outcome. We should offer easy access to brief-cognitive behavioral therapy, and ensure that mental health professionals are familiar with this treatment approach and capable of providing it.
And what about Treatment C? Unfortunately, there are a lot of Treatment Cs around these days, including “energy” therapies, thought field therapy, therapeutic touch, animal-assisted therapies, outdoor or wilderness-based therapies, and others. None of these treatments have been studied with actively suicidal patients using rigorous scientific methods, so although they might be helpful for some suicidal military personnel and veterans, it’s also possible that they are harmful. Therefore, we probably shouldn’t recommend that military personnel and veterans receive them as first-line treatments when there are “safer bets” available.
This is not to suggest that brief cognitive behavioral therapy will prevent suicide attempts in all military personnel and veterans. Indeed, 15–25% of patients who receive this therapy make suicide attempts despite receiving the treatment as designed. Although we don’t yet have 100% efficacy, these treatments nonetheless have the greatest chance of working. That’s what clinical scientists mean when they talk about “empirically supported” or “evidence-based” treatments: They’re the ones to put your money on because they’re the safest bets.
Psychological injuries can be fatal, and many of us have lost friends, family members, and patients to these “invisible wounds.” The good news is that highly effective treatments do exist for many of these psychological injuries, and we’re continually improving them to make them work even better. The bad news is that these treatments are not yet widely available to military personnel and veterans. We as mental health professionals must therefore commit ourselves to learning and providing as many empirically supported treatments as possible. Our patients deserve no less.
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