Reintroducing patients with PTSD to whatever triggers their symptoms -- gradually, in a clinical setting -- can be effective. Veterans Chris Kyle and Eddie Ray Routh were not at a shooting range as part of exposure therapy on the day Routh killed Kyle.
Ron Paul set off a Twitter firestorm on February 4th when he said super sniper Chris Kyle's murder at the hand of fellow veteran Eddie Ray Routh during a target shooting session at a Dallas-area gun range "seems to confirm that 'he who lives by the sword dies by the sword.'" "Treating PTSD at a firing range doesn't make sense," he wrote.
The Internet meanwhile flew to Kyle's defense saying it makes perfect sense to treat war-induced trauma with target shooting. Early, confused law enforcement reports said that Kyle worked with veterans with PTSD and was engaged in "shooting therapy" with Routh at the time of the murder. The hive mind swiftly concluded that this must mean Kyle was providing "prolonged exposure therapy," a way to help scarred vets through "in vivo" immersion in real life settings that could trigger their PTSD, and showered Paul with contemptuous feedback saying he didn't know what he was talking about.
But Dr. Edna Foa, director of the University of Pennsylvania's Center for the Treatment and Study of Anxiety, says that what Chris Kyle was doing with Eddie Ray Routh was not only not prolonged exposure therapy, it wasn't any kind of therapy at all. Dr. Foa should know; she invented prolonged exposure therapy.
"The idea that Mr. Kyle was engaged in prolonged exposure therapy (with Mr. Routh) is completely uninformed about what prolonged exposure is. In prolonged exposure we encourage the patient with PTSD to gradually approach safe situations that they fear and avoid because they remind them of their trauma"
Prolonged exposure (PE) therapy seeks to overcome irrationally fearful and anxious reactions to situations that have become associated with a traumatic event in the mind of the patient that are actually not dangerous to them. For example, rape victims may come to fear all men, even those who love and support them, and may actively avoid encountering any men to avoid the fear and anxiety being near a man produces. Gradually reintroducing distressing stimulus in a safe environment allows the traumatized person to process "disconfirming information" that challenges their irrational fear and then process the emotional response to it. PE therapy may start in a therapists office, and after a number of sessions where progressively more potentially distressing encounters have been successfully processed, the therapy may if necessary move "in vivo," or into real life settings where the traumatized person can confront their feared thing in real time with the help of a professional.
Dr. Foa, who routinely works with battle scarred veterans and active duty soldiers, is the premier trainer of mental health professionals to perform PE therapy. Disregarding the fact that PE therapy is a highly specific system that should only be implemented by licensed professionals, she says that it makes no sense to say Chris Kyle was engaged in PE therapy with Eddie Routh because there's no indication that Routh was afraid of shooting weapons; in fact, all reports indicate that he was quite attached to them and became upset when people tried to take them away from him.
"In my experience with veterans and soldiers, most of them have not been afraid of holding weapons or shooting, that's not what they fear. So going shooting as a therapy would not help the patient getting over their problems. Veterans with PTSD are afraid of things like driving on highways, they're afraid of crowded places like a supermarket when it's crowded, of places like shopping malls." Oppositely, Dr. Foa says many veterans with PTSD go to these safe places they irrationally fear only if they have weapons on them, because weapons provide them a feeling of safety.
Dr. Foa says that an extensive evaluation precedes transitioning a patient to in vivo exposure to assure that the experience is safe and constructive for both patient and clinician. Routh is not a person Foa would consider treating with PE therapy; it was clear at the time of the incident that he was struggling with substance abuse, and twice in the weeks before he murdered Kyle he was in a full blown mental health crisis, threatening to end his life. He had left a VA psychiatric unit just days before the incident.
"I actually think that taking someone who is distressed, anxious and depressed to shoot is a grave mistake. This is contrary to what prolonged exposure would prescribe. This is not in vivo exposure at all." Foa says that when preparing to use in vivo exposure with a patient, "We carefully generate a list of situations or objects that the person is avoiding because he thinks that going into these situations is dangerous even though these situations are safe. The situations we encourage people to approach during in vivo exposure are safe. Also, in vivo exposure is done gradually and in a way that the patient will be able to tolerate. In this way the patient learns that the situations he is afraid of and avoids are actually not dangerous and that he can tolerate anxiety rather than falling apart. In prolonged exposure therapy the patient gradually go through the list of situations that each provoke a little more anxiety, but we always make sure the patient is safe and that the patient does not experience unbearable anxiety or flashbacks. None of this was done (by Chris Kyle for Eddie Routh)."
This isn't to say that a firing range could never be a constructive setting for actual in vivo exposure therapy. Foa has trained soldiers who have gained an irrational fear of guns to overcome it so that they can use their weapons and return to active duty.
"For the unusual case of a patient who is afraid of holding weapons, at the end of the treatment we would give him a weapon without ammunition. After he held the weapon many times without having anxiety and after the PTSD symptoms are substantially reduced, we would give him a gun with ammunition in a very controlled environment if he needs to use weapons in his work."
Foa isn't conflicted about re-training traumatized soldiers to shoot again, if that's the goal they want to achieve. The fundamental purpose of PE therapy is to return a traumatized person who is disabled by fear and anxiety to regain their ability to perform the necessary functions of their life; for a rape victim it could be to gain mastery over their fear of all men so they can hold a job in a coed office and regain financial independence, and for a soldier it might be gaining mastery over their fear of shooting so they can perform this duty which may be required to complete their tour in combat.
"I always say when people ask me if I don't feel bad when I do PET with a soldier who suffers from PTSD and then when he's getting better he get deployed again. My answer is that I'd rather a weapon be in the hands of a person who doesn't have PTSD than in the hands of one who does. If a person with PTSD has a flashback in a noncombat military setting, and think he is back in combat and the person standing in front of him is an enemy, they may shoot him. This can happen during flashbacks. I think it is unwise to give weapons to someone with severe PTSD; I don't recommend this."
Did the sound of gunfire trigger a flashback in Eddie Routh that caused him to murder Chris Kyle? It's possible, but it's not the only possibility to explain what happened on that tragic day in Texas. The only information we have even confirming that Routh has PTSD is his own self-report which may or may not be accurate. The Veterans Administration is refusing to release psychiatric information about Routh without his permission to protect his privacy, and law enforcement officials have reported that Routh has been uncooperative since being apprehended.
"I think it's unlikely that Mr. Routh was having a flashback when he killed Mr. Kyle. I think it was more likely a psychotic breakdown," Foa says.
And the most recent reports seem to corroborate Dr Foa's gut instinct. Routh is said to have felt like Kyle and his neighbor Chad Littlefield who were with him at the shooting range were out to get him, so he had to kill them first. He also said that he had "traded his soul" for Kyle's truck; it's possible that he was experiencing paranoid delusions.
This clinical information, like background about substance abuse history or mental health hospitalizations, is very critical in terms of deciding whether someone is appropriate for or will respond to PE therapy.
"PE should not be used with psychotic people," Dr Foa says, "The idea in PE and other CBT treatments for PTSD is that the individual with PTSD has wrong perceptions about what is dangerous and what is not dangerous and also wrong perceptions about himself. They think the world is entirely dangerous and that they are incompetent to deal with it. If the person is psychotic the distinction between reality and non-reality is weak or doesn't exist. People with PTSD will change these perceptions if you show them that what they think is dangerous is not. Psychotic people are unlikely to change their psychotic beliefs if they do not match reality."
It turns out that Ron Paul, regardless of whether he understood why, may have been right. "From any point of view," Dr. Foa concludes, "Mr. Kyle did not do exposure therapy."