Voice and Choice in Trauma Treatment: Thoughts from Me and My Friend Sharon Wise

As a current and a former member of the American Psychological Association’s panel to produce guidelines for treating posttraumatic stress disorder (PTSD), we had a lot to think about. That’s because although the evidence base strongly suggests there are several psychotherapies that can significantly reduce PTSD symptoms, there is a gaping lack of input--in research and in clinical inquiry--from trauma survivors themselves. We’re missing the patients’ perspective on what outcomes matter to them, what their goals and priorities for treatment are, and what they are willing and able to do to participate in these therapies. That’s a huge absence, although fortunately the situation may be gradually changing.

The good news is that despite the glaring omission of patients’ input we’re closing in on a few effective psychotherapies for PTSD. It’s important to develop several treatments because research consistently shows that there’s no one best treatment for PTSD, no one-size-fits all, no magic bullet. Treating PTSD isn’t easy, but it can be highly successful, and for a disorder which haunts up to 10% of Americans, that’s something remarkable to celebrate and news which needs to be spread.

The push to develop and disseminate effective PTSD treatments is great news for individuals who have experienced abuse in childhood and carried their psychic burden well into adulthood; for combat veterans who fought for their country but struggle decades later to find their way home; for women who served proudly in the military, only to be subjected to sexual assault by the men they served with; for victims of random acts of violence and horrific accidents; and for individuals who directly experienced acts of terror. Thousands of people can now benefit from the PTSD treatments that have been developed in the relatively calm centers of academia.

Still, we need to do better, and for that we need to talk with the people who are most affected. This lack of input from those who suffer is not unique to PTSD or mental health. Frankly, patient input is lacking from the entire health care system. Although there is talk in the health care arena about making patients partners in their own care, it seems to translate into merely helping patients have a better understanding of the currently available care options for their specific disorder. This approach feels a bit one-sided, unidirectional, and hierarchical. It ignores input from the largest expert cohort of all--those who are afflicted.

This may be one reason why so many trauma survivors wait decades before seeking help, and many more do not receive effective treatment. There are a host of other reasons for this as well, including denial or minimization of problems, avoidance of trauma memories and reminders, stigma, and wanting to solve problems on one’s own. Those barriers all need to be addressed. But perhaps an important way to improve mental health treatment seeking and engagement is by empowering survivors.

If we want trauma survivors to be active participants in their own mental health care, to help them make more informed decisions, we need to invite them to do more than listen to the options we presently have for them. We need to ask them important questions about those options and let them point out to us options we haven’t thought of. And we need to listen.

This is particularly important for trauma survivors, who don’t always realize they have a voice due to the perceived loss of control that often accompanies traumatic exposure. Survivors’ voices are often taken away or they have become unable to speak. Trauma survivors should be able to use their voices, however they talk, whatever dialect they use, community slang, Queen’s English, or Ebonics, to articulate what they need for themselves.

Many people are socialized to listen to their doctors, let them set the goals, and give the orders. Physicians and psychotherapists who buy into this treatment paradigm may be the same ones who wonder how articulating and including trauma survivors’ goals in treatment trials and services can improve outcomes. But patient preferences impact how engaged people are in their therapy and how much and well they benefit. If there is a mismatch between patients’ preferences and what they actually receive there is a greater chance for them to drop out, attend fewer sessions and receive less benefit from treatment.

Authorized by Congress as part of the Patient Protection and Affordable Care Act of 2010, the Patient-Centered Outcomes Research Institute (PCORI) may provide the remedy we are looking for. Through 2019 PCORI will receive $3.5 billion of federal dollars to sponsor research to determine the best ways to help patients and their providers collaborate in shared decision-making. As we wait for that research on patient-centered care, if our trauma patients tell us they don’t want to do the psychotherapies we have to offer, let’s honor them and build the treatments they do want.

Healthy Interpersonal Dynamics

This semester, my friend Professor Heidi Brooks asked me to co-teach an Interpersonal Dynamics class with her at Yale’s School of Management. Heidi has taught this highly coveted innovative course for over a decade and is a phenomenal speaker. I could audio-record her lectures and listen to them for days afterwards.

For me, it’s been a privilege and a challenge. Although I earned my PhD almost 20 years ago and have spent the majority of my professional life helping people with their internal selves as well as their relationships, the application of these skills to business and organizations is new to me.

Many of the required and suggested readings for the course are incredibly helpful. But one that I'm particularly soaking up is a New York Times business bestseller, Difficult Conversations: How to Discuss What Matters Most. Wow, I can’t help but think the world could benefit from this book. I know I am!

One of My Favorite Websites/Blogs


I met Dr. David Susman about four years ago when we were both serving as Council Representatives (the main governing body) for the American Psychological Association. I was impressed by his intellect and integrity then and I am in awe of it now. He started an award-winning popular website over two years ago to provide science-based information on mental health, wellness and recovery from mental health illness and addiction. His weekly blogs are insightful and his “Stories of Hope” (interviews with people who have experienced mental health challenges) are inspirational. I look forward to reading his Tweets every day and am thankful for his friendship.

On a personal note, I’m an only child. And, if I had a brother, David would be one of my top choices for adoption.

People's Impressions are Hard to Change

Great new article in The New Yorker. It’s a reminder that, once formed, people’s impressions are very hard to change. Thousands of research studies have found that even after people are presented “evidence” that contradicts their beliefs, they don’t make "appropriate" adjustments in their beliefs.

This piece also includes some fascinating new research and advice from cognitive scientists:

“If we—or our friends …spent less time pontificating and more trying to work through the implications of (our beliefs), we’d realize how clueless we are and moderate our views.” Although providing accurate information doesn’t seem to change people’s minds, appealing to their emotions may work better.

So essentially we all believe that we know more than we actually do. We all dig in at times and get stuck in our beliefs. Knowing that it is universal may help us all be willing to challenge ourselves when we feel like putting our roots deep in the earth and shouting, “I shall not be moved.”

When I’m feeling particularly entrenched in my own thinking, I try to remind myself of what the American psychologist Abraham Maslow once famously said, “If all you have is a hammer, everything looks like a nail.” May we all look for other instruments and strategies to put in our healthy life skills toolbox.