Thank you very much for the invitation. I'm honoured to be here. I'm very aware that I have only 10 minutes, so I will fly through my text. My apologies to the interpreters.
My name is Céline Paris. I'm a psychologist. I've been working with soldiers and veterans since 1990. I started within the CF system. Since 2005 I have been in private practice. At first I did mainly diagnostics, and now I do mainly treatment.
I want you to know at the start that I was drafted to speak with you today. I was drafted by a brilliant young veteran. He said, “Céline, you have to tell them about hope.” I take hope very seriously, so here I am.
I like positive psychologist Rick Snyder's definition of hope. It's more than optimism or a general positive outlook on life. For Snyder, hope is made up of agency and pathways. You have hope when you believe you can achieve your goals through your own efforts, “agency”, and when you have a plan to achieve them, “pathways”. Hope is about being goal-oriented and staying that way through the highs and lows of life. I think hope has left the hearts of too many veterans, and as a society we're not doing all we can to stop the bleeding.
My message of hope will be in two parts. The first is fact and the second is opinion.
The fact is that therapy works. There is scientific research that shows objectively, repeatedly, that psychological treatments for PTSD work. Science is the solid foundation that every other strategy builds on. I hope you will listen to Dr. Hector Garcia's TED talk or read the transcript I've provided to you. The title of his talk says it all: “We train soldiers for war. Let's train them to come home, too.” His message is that today we know how to eliminate PTSD.
Yes, he uses the word “eliminate”. This is a very strong claim, so I came with proof. These are not scholarly articles, although I have some here, if you like. These are three graphs. I hope you have the graphs. I'm going with moins mais mieux.
SUDS, subjective units of distress, is a scale used to measure progress in therapy. A score of 10 means extremely distressed and a score of one means perfectly comfortable. When a person with PTSD is going through this active part of therapy, which means reliving their trauma story every day to finish processing it, their psychologist asks them to track their SUDS each day.
I'll turn now to my three graphs. Page 1 shows the progress over two weeks of a soldier still on active duty. I'll call her Marie. She was brutally assaulted by her partner and left for dead. Pages 2 and 3 show the progress of a young Afghanistan veteran who faced grave dangers and horrors. He lost friends to the Taliban and later to suicide. He stayed fully engaged in love and work, but, boy, was he suffering. Let's call him John. As it happens, both Marie and John completed their trauma therapy for their worst event just this month.
The third case, on page 4, is from 2013. He is a sailor in his seventies who was almost killed in a fire at sea in 1969. He left the navy as soon as he got off the ship. By the time he heard there was such a thing as PTSD, more than 40 years had passed. He came to therapy because his wife wanted to go on a cruise, and setting foot on a boat was unthinkable.
As you can see, their SUDS ratings start high and go down from day to day and week to week. Like Carlos, Dr. Garcia's Vietnam vet, after a few weeks of hard work their trauma was truly in the past. The whole idea behind prolonged exposure is that it will stay there.
Are these three individuals different from most? Maybe. You might guess that they had more courage, but I don't think that's it. Soldiers are brave. What they did have was hope. They refused to let a diagnosis determine how they were going to live their lives. Without hope, they would not have been willing to summon and confront their worst memories, any more than a cancer patient would sign up for the cruelties and indignities of chemo.
To explain to our patients why they need to face their traumas, we tell them that all emotions have a function. They are a signal, like hunger, pain, or cold, that something needs attention. Ignore them and they get worse. If we haven't eaten, it doesn't occur to us to label our hunger as the problem, because if we did, we could just take an appetite suppressant rather than eat.
With anxiety it is trickier. Unlike hunger, our first instinct is the wrong one. The first thing we all try is to push the bad memories out of our minds. Avoidance is addictive, because it works wonderfully in the short term. In the long term it makes the problem worse. The alternative is exposure.
What I flee follows me, and what I face is erased.
So, therapy works, and now for the opinion.
Hope is in crisis, and we have to do something soon. Why is PTSD portrayed as a chronic condition, necessarily, by default? Why are newly diagnosed soldiers like Marie, who is just starting out in life, being told by clinicians and peers that managing their symptoms is all that they can hope for? It looks to me like hope needs a lobby group.
For every new effort of support, I ask that we remind ourselves that a safety net can catch, but it can also entangle. The short answer to why soldiers and veterans choose suicide is not PTSD, it's not depression, and it's not lack of support. It's hopelessness. Support without hope creates victims, not survivors, and soldiers don't make good victims. They don't need their struggles to be glorified. The antidote to shame is not honour, anyway; it's self-compassion, remembering our common humanity, the idea that there but for the grace of God go I. When they understand what they need to do to get past PTSD, they just get on with it, but first they need to grasp that they do have agency, and there are pathways, well-worn pathways, in fact.
No societal change is all positive. PTSD has become a household word, but awareness has come at a price. A treatable psychological condition has somehow become equated with a chronic disability, a life sentence, and an identity. Yet, a diagnosis is something you have, not something you are.
I don't love the term “OSI”, operational stress injury, mainly because I haven't found the analogy of injury terribly useful. I know the idea is to combat stigma, but I'm just not convinced it's lived up to its promise. I like analogies that hint at agency—what you can do yourself to recover—analogies that contain the seeds of hope. My favourite for anxiety is a wave that you can't control, that could very well engulf you, but that you can learn to surf or ride. That's why I chose it for the cover of my book.
Besides, a diagnostic label is a useful thing. I was so excited to read that our government is opening new centres of excellence and using the term “PTSD” in their name. A precise diagnosis is crucial, like you were saying, because it dictates the treatment. Just as in medicine, everything starts with the right diagnosis and stalls with the wrong one. Sticking with medical analogies, we know that cancer is not one illness. Choosing the best treatment protocol depends on an exact diagnosis.
I do know the word “eliminate” is scary. We certainly don't want to give false hope or, heaven forbid, leave those who didn't respond to therapy feeling like they didn't try hard enough. Believe me, I share those fears. Then I wonder, if we were talking about cancer, wouldn't I be grateful for any hope I was given? In medicine, it's natural to treat hope as the precious gift that it is. Sure, the risk of relapse does exist, especially if there are more traumas in my future, but then I can be PTSD-free, like we say cancer-free.
Of course, the cancer metaphor is not perfect either. You don't need hope to recover from cancer. A great surgeon could be enough. With anxiety, passive won't work. Someone like me has to convince you to take the scalpel bravely in hand and show you how to use it.
To sum up, support has a crucial, vital role to play before, during, and after treatment. It's protective and it's healing, but it's not treatment any more than support is a treatment for leukemia, diabetes, or a broken leg. When it's coupled with the message that this is all you can hope for, a beautiful safety net becomes a trap.
There is a controversial book that has come out this year called Against Empathy. In it author Paul Bloom argues that empathy can be a bad strategy for caregivers because it can lead to burnout and neglect of evidence-based solutions to people's problems. This stance has been criticized as being too extreme, and I tend to agree. Empathy without reason is blind, but reason without empathy is empty.
Good therapy is based on reason, and support is based on empathy. Our soldiers and veterans need and deserve both—oh, and also, hope.