Exposure, Meds, Yoga (and Why You Should Reconsider Offering Unsolicited Medical Advice)

Most people cannot emerge from post-traumatic stress by simply gutting it out. Chronic PTSD is a life-threatening event and has to be treated and intensively managed by loved ones. During treatment, you must continue to fight, continue to seek insights into your experience, continue to read and to introspect, continue to seek out the company and advice of others. The community of survivors is a real thing.

Morris, The Evil Hours, p 211

One particularly damaging effect of the atrocity hierarchy, I think, is that if we believe that PTSD is only ever caused by the worst of the worst of existential harms, then we only recognize the most severe and chronic cases as legitimate. That can persuade us that a PTSD diagnosis is a life sentence. But it isn’t (always), and treatment can help. Though 23% of PTSD cases last 10 years or more, 50% of them resolve in less than two years.

There is a huge – and growing – number of psychological, pharmacological, somatic, and behavioral interventions that are effective, though everyone’s path to healing is unique.

In The Evil Hours, Morris writes with great subtlety and power about the VA’s controversial gold standard therapy for PTSD: prolonged exposure (PE). Morris acknowledges that the imaginals (repetitive retellings of the story of a specific trauma ) and in vivos (doing something in the real world that reminds you of your trauma) used in prolonged exposure therapy can help “extinguish fears arising from trauma and allow the patient to regain control of the environment.” And yet, one of the most harrowing scenes in the book is when he stabs his phone after a PE session.

Prolonged Exposure treatment can feel like punishment, even sadism, Morris writes.   

His critiques of the modality are trenchant. The structured process of PE is more effective at inoculating therapists against secondary trauma than healing their patients, he suggests. Being asked to simplify a complex physical, moral, and intellectual trauma to a single inciting incident feels like “an act of vandalism.” The repetition central to the therapy can feel like punishment, even sadism, Morris writes.   

In Chapter 7, he explores some of the medications that have been found useful in treating post-traumatic stress: propranolol, a beta-blocker that may arrest the neurological process by which a memory becomes traumatic; prazosin, which reduces nightmares and restores restful sleep; SSRIs, which raise serotonin levels in the brain.  

In Chapter 8, Morris acknowledges that medications often fail and that “for many people, Western talk therapies do not work for post-traumatic stress.” Yoga, he writes, “stands out as a uniquely effective treatment, precisely because it insists that people shut up and start listening to their bodies.” Personally, I found that more active forms of yoga, like Ashtanga, keyed up my nervous system too much and could make me anxious. But Yin yoga, which I discovered by reading Stephanie Foo’s extraordinary memoir What My Bones Know, has helped a little.

Morris talks about the weird and wonderful eye movement desensitization and reprocessing (EMDR) therapy, which has worked well for J He talks about writing and haka. Mixed martial arts. Meditation and mantras. He doesn’t discuss sensorimotor therapy, which has been crucial for J.’s healing, or somatic experiencing, which was so important to McClelland in Irritable Hearts.

“There are many remedies recommended for post-traumatic stress, a truly bewildering variety of choices,” he writes. “Very few of these alternatives seem genuinely harmful, except possibly to your bank account. The sheer number of them speaks to the magnitude of the problem, the inherent complexity of PTSD, and the extremes to which people will go to seek relief from their symptoms.”

This is perhaps why J. and I have received such an extraordinary amount of unsolicited medical advice from people who believe they are well-intentioned. We keep a list: bone broth, a dog, walks in nature, a gun (!!!), probiotics, yoga, reiki, fish oil, flooding (exposure to traumatic memories), MDMA, microdosing, pot, CBD, “sucking it up.”

The sheer number of [alternative therapies] speaks to the magnitude of the problem, the inherent complexity of PTSD, and the extremes to which people will go to seek relief from their symptoms.

When I published an essay about my experience as a PTSD caregiver, the advice – medical and otherwise – came especially fast and furious. Drink lots of water. Transcranial magnetic stimulation. Leave the relationship. Find God. Ketamine injections. Move. Go vegan. The admonitions came through the comments section, in personal emails, on Twitter, even on my home phone.

I’ve been thinking about that response a lot this week, and specifically about why being on the receiving end of unsolicited medical advice makes me so angry. I know that many people offering advice do in fact have good intentions – and even personal experience, strategies that worked for them that they are eager to share.

But I also find that acquaintances and strangers rarely understand our context and history well enough to make meaningful suggestions. They fail to understand that treatments that are common in major cities, for example, often aren’t available in non-metro areas. I have been trying to find a somatic experiencing practitioner for four years, but the closest one I found is in Northampton, MA, 90 miles away.

And there’s a class dimension, too. Those with adequate financial resources rarely think that money is a significant barrier to trying alternative therapies. But for us, if the treatment isn’t covered by Medicaid, J. can’t try it. If a treatment you’re excited about isn’t available near us, or it isn’t covered by Medicaid, it’s best not to mention it at all. Otherwise, you are effectively saying to us: “Here’s something that might help you. A lot. But you can’t have it.” It can be devastating.

To be clear: Before the NYT essay, most of the advice we received came from people we love deeply. But PTSD has taught me to ask permission before offering my input to others with chronic illness. Here are phrases to try out: “May I offer advice based on my own experience?” or “I read about xx. Can I send you information?”

If a treatment you’re excited about isn’t available near us, or it isn’t covered by Medicaid, it’s best not to mention it at all. Otherwise, you are effectively saying to us: “Here’s something that might help you. A lot. But you can’t have it.”

Morris writes, “One of the odd paradoxes of trauma is that it happens in a moment, but it can consume a lifetime. The choice as to how much time it is permitted to consume is usually in the hands of the survivor.” (p. 212)

So when you are tempted to give unsolicited medical advice to people with chronic disease or trauma, please remember that — the path to healing is in the hands of the survivor.