Shannon Miles, PhD, James A. Haley VAMC in Tampa
TAMPA, FL — Psychotherapy is never easy, especially for a veteran being treated for post-traumatic stress disorder (PTSD). Being asked to recall and dissect the most traumatic moments in your life can be an arduous task for anyone.
But what if you never learned to accurately identify and process emotions—a skill that many men have been culturally discouraged from learning? The emotions raised by therapy can be overwhelming and incomprehensible, and the tasks being asked of them during treatment can feel so much more daunting.
Shannon Miles, PhD,, said she believes that this inability to process emotions accounts for many veterans’ failure to complete therapy—or not beginning it in the first place—and that veterans need to be prepped with those processing skills before beginning in order to achieve the best outcome.
“PTSD is hard to treat because treatments are unpleasant,” Miles explained. “We ask people to talk about the worst events they’ve been through, something they’ve been avoiding for a long time. There are different types of skill sets you’re asking them to do. Consequently, treatment initiation is kind of low. And rates of treatment completion are low compared to civilians.”
Miles is a psychologist working in the PTSD clinic at the James A. Haley VAMC in Tampa. Prior to that, she worked at the Houston VAMC, which is where she first began to focus on unregulated emotions in veterans struggling with trauma.
Miles noticed that a lot of the patients were struggling with aggressive behavior, which was making it difficult to complete treatment. For some, even after successful PTSD treatment, the aggression remained.
“Aggression isn’t just about anger,” Miles explained. “It’s about a variety of emotions. It’s sadness, and it’s fear and the lack of joy that also comes with PTSD. It’s disgust for other people and your own actions.”
Miles helped create a three-session treatment program for veterans planning to seek psychotherapy that teaches them how to identify and respond to their emotions and hopefully puts them in a better place to receive the more intensive psychotherapy for PTSD.
“The treatment has been around forever, but we hopefully packaged it in a way that was more appropriate for veterans with PTSD,” Miles said. “If veterans are going to drop out [of treatment], they usually drop out after session three, so we made it three sessions. And it only targets the aggressive behavior. We don’t target the trauma.”
During those three sessions, Miles teaches veterans to identify the mental and physical signs of the emotions they’re feeling.
“That sounds very basic, but most of my patients cannot identify what they’re feeling outside of anger,” Miles explained. “These are fully capable adults, usually men, but they cannot say, ‘Yes, I’m feeling sad.’ They don’t know what it feels like in their body. [We teach them] those triggers, so they can start recognizing those emotions earlier. If you go from 0 to 60, and you don’t know how you got there, it’s because you don’t recognize the physiological sensations and what your mind is doing.”
After that, Miles teaches her patients skills to help cope with those emotions. Those include diaphragmatic breathing, which calms the sympathetic nervous system; focusing on the concrete things around them; and remembering things they value.
“That can mean putting a picture of their kids somewhere they can see it,” Miles said. “If they have a split second to see it before they go off on their boss, they could recognize their higher values.”
She also encourages them to schedule positive events, because joy isn’t just a symptom of a better life, it can help create one.
Better Outcomes
“One of the cool things about happiness or joy is that it predicts better outcomes in life across the board,” Miles declared. “Happiness actually predicts that better outcome, not vice versa. We teach them to recognize joy, which sounds so simple, but often they’re so stressed out and numb that it’s not even a consideration.”
The same treatment has been shown to work on patients also suffering from mild traumatic brain injury (TBI).
“We see a lot of emotional dysregulation in that group, a lot of PTSD,” Miles noted. “But the long-term outcomes for mild TBI in terms of aggression and emotional regulation are generally pretty hopeful. The things that are really contributing to the dysregulation are treatable.”
Miles’ three-session emotional regulation course is now in the recruitment phase of a clinical trial designed to track its impact on veterans about to go through psychotherapy.
One of the frustrating realities of Miles’ work is that, if these lessons in processing emotions were learned young, they might have prevented the veteran from developing PTSD in the first place.
“We often blame PTSD for being kind of the catalyst, but we actually know that one’s inability to regulate emotions prior to trauma actually predicts you developing PTSD,” Miles explained. “But, on average, men in our culture aren’t taught to the level that women are how to regulate their emotions. They’re taught to suck it up, don’t cry, don’t act like a girl and deal with it. You’re allowed to be tough and allowed to be angry, but all those other vulnerable emotions are not allowed. It starts there.”
In the military, that anger can energize a soldier and allow them to complete obstacles. Servicemembers learn how to use that anger proactively. But it rarely translates to civilian life.
“The military does a beautiful job of training people to use that,” Miles explained. “The problem is you come home and, if you’ve developed PTSD, one of the symptoms of which is negative emotions about events, and there’s this inability to regulate your emotions overall, then it’s a perfect storm. It’s not just military service. It’s our culture and the inability to teach them more effective ways to deal with all those intense emotions they’re dealing with.”