Ethical Considerations in the Treatment of PTSD in Military Populations

More than half of all individuals will be exposed to a traumatic event over the course of their lives (1). Depending on the trauma type, the rates of developing posttraumatic stress disorder (PTSD) are as high as 17.4% (2). Traumatic experiences vary, but they include natural disasters, assaults, domestic violence, and combat. More recently, the Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-5) (3) further defined the criteria for traumatic events to include direct exposure to, witnessing, and learning of traumatic events to family members or loved ones or repeated or extreme exposure to aversive details of trauma. These traumatic events can result in difficult moral and ethical dilemmas for patients and providers. Research to date suggests that those who struggle with guilt associated with ethical dilemmas in the aftermath of a traumatic event may experience more severe posttraumatic symptoms (4). We present cases of PTSD in military personnel related to ethical dilemmas, potential secondary gain, potential for retraumatization during treatment, and early return to work.

These cases are intended to illustrate how PTSD involves exposure to events that sometimes involve moral and ethical dilemmas for the patient. There are specific ethical questions that arise in treating PTSD patients (5), such as how to benefit them while avoiding the risk of retraumatization—and how and when to inform them of these risks.

The goals of this column are to deepen readers’ understanding of ethical principles as they apply to situations in the treatment of PTSD, as well as to describe practical ways of approaching individualized decision making.

Case 1

During a combat deployment, a 47-year-old Army reservist engages in hostile fire while on patrol and fires back, only to learn afterward that one of the combatants who was shot and died appears to be a young boy. Upon return from the war zone several months later, the patient struggles when interacting with others, especially when being recognized by civilians as a “hero” for his military service. The patient now has guilt, shame, anger, irritability, intrusive thoughts, and nightmares. He is angry at his unit leadership for putting him in this position and presents to the clinic for your assistance.

Case 2

A 22-year-old Marine Corps bomb technician experienced a near miss while detonating an unexploded ordinance five weeks ago and has been unable to go back to work. He reports insomnia and problems concentrating secondary to worries about the serious accident that almost happened. Coworkers informed his supervisor that he was seen laughing and playing in the barracks on multiple occasions over the past week while off work. His supervisor shares this information with you.

Case 3

A 32-year-old female Air Force sergeant, who works as a mental health technician, experienced and reported an episode of military sexual trauma. At the beginning of treatment, she is assigned a male clinician but makes it clear that she would prefer working with a female clinician. The only female provider in the clinic has limited experience treating PTSD and is not trained in an evidence-based psychotherapy.

Case 4

A 25-year-old Marine infantryman was in an extended firefight one month ago and lost two buddies. He is experiencing insomnia, psychomotor agitation, and poor concentration and reports that he can’t stop remembering and thinking about what happened to his friends. He reports increased anxiety for his own safety, in addition to survivor’s guilt. His commanding officer insists that his skills are needed for an upcoming mission.

Answers

1.1. The answer is D. This case brings to light a very difficult issue: a moral conflict in the aftermath of traumatic stress. In treating patients with PTSD, providers sometimes face the question of the role of moral commentary or moral positions. There may be advantages as well as disadvantages to remaining “neutral” in your stance toward the patient’s expressed issues. Neutrality can allow further exploration of what his anger may mean, beyond the presenting complaint. The anger could represent, for instance, long-standing anger at his father or anger at a peer whom he believes let others down during the fighting. Maintaining neutrality may also allow the provider to appear and be nonjudgmental. This is important, because if the patient sees the clinician as biased in one context, he may conclude that the clinician is biased in other aspects affecting the treatment.

On the other hand, neutrality in the face of obvious moral dilemmas may be perceived as a lack of empathy and/or integrity. Being “neutral” about their account of a horrific event can be perceived as a form of bias. Neutrality is only one among many stances/positions that the provider may choose at given time points over the course of the treatment. The provider may choose to be neutral, support the patient’s perspective, and/or support the needs and values of the unit leadership/hierarchy, shifting as needed, even within one session. The provider may ultimately model and prioritize helping the patient to discover an accurate, balanced view of the traumatic event. The provider should maintain ongoing awareness of the range of different moral/interpretive positions and consider how he will perceive each of the different positions the provider might raise—or be perceived as taking. Nonalignment with the patient’s interpretation of the event may be perceived as opposition, and possibly threatening, to an individual with PTSD who may already be struggling with trusting others. Deferring exploration of these themes in favor of initiating medication may be perceived as a lack of awareness of the need to share and/or of concern for the moral dimensions of the trauma. Both may reinforce the experience of detachment and estrangement from the clinician and others.

The clinician’s role involves putting the patient’s perspective first, particularly during the initial phase of establishing a therapeutic alliance. Validation of suffering is an important priority, particularly in the context of moral distress. This approach does not require agreeing with their interpretation of the situation. In a series of steps or phases, the clinician may carefully revisit other positions or interpretations, helping him to consider alternative explanations or interpretations of his experience. Over the course of time and with the patient’s willingness, understanding, and sometimes explicit consent to delve further, an additional therapeutic consideration may be whether to ask him to think about potential reasons why the boy was fighting. For example, was it culturally normative to fight at a young age? Was it a response to military action or the death of a family member during hostilities? Does a child have autonomy to choose to fight? Also, one may consider making a comment or presenting a thought experiment to the patient, asking him what he would think of the situation if the young boy had been his own child. Does it matter whether the patient himself has a child?

1.2. The answer is B. Neutral words don’t exist—all have connotations. There are pros and cons of each that involve potentially distorting or putting emphasis on certain aspects of the event rather than others. Trauma, by definition, involves a distressing event, one that may evoke a powerful emotional response in both the clinician and patient as they speak of an extreme circumstance, sometimes including moral dilemmas. Speaking of the event may itself pose challenges regarding word choice for the clinician. Describing emotional responses to the event can present greater ethical dilemmas; for example, how to express empathy while respecting that the event is extreme and difficult to express. Under some circumstances, extreme language (e.g., expletives) could be considered judiciously and serve to capture the seriousness of the trauma. Depending on whether you have only recently met him or have been treating him for some time, your assessment of what words are tolerable will include your considering whether the words and meaning will retraumatize or serve to help him.

In treating individuals with these types of issues, it is common to feel a sense of uncertainty with regard to therapeutic direction. The clinician may struggle with how to work with the patient’s narrative. In addition to examining the meaning of the experience, the clinician could consider exploring the use of ceremony and other symbolic ways of helping the patient process the experience (e.g., narrating or imagining a scene of the deceased child’s funeral). The clinician’s experience of uncertainty may reflect feelings and perceptions that the patient also has and thus serve as an opportunity to model tolerance of uncertainty. The provider’s judgment as to whether to share his or her own uncertainty will involve assessing whether doing so is in the patient’s best interest and whether the patient may experience distress or guilt about the impact of the trauma on the provider. Last, clinicians must also attend to the possibility of becoming traumatized themselves through working with trauma patients, carefully observe their own reactions, and seek assistance when needed.

2.1. The answer is A. A critical need at the patient’s workplace should not be used to justify accelerating treatment and return to work. The ethical principles of beneficence and nonmaleficence lead the clinician to an approach centered on the patient’s best interest. Selecting optimal treatments, monitoring symptom response, and exploring psychosocial factors that might affect the treatment are core considerations for clinicians. Conversely, accelerating treatment and return to duty may present a significant risk to the patient, his coworkers, and others. The negative impact of psychiatric symptoms on work performance is problematic for any patient but is even more undesirable in jobs that pose significant risk to patients and their coworkers from accidents. Being distracted or having an otherwise impaired capacity for work in this bomb technician could result in retraumatization to the patient as well as potential injury to the patient or others.

While premature acceleration of return to duty is an inappropriate consideration, it is optimal to consider the effects that treatment may have on the patient’s ability to work. One such consideration would be to choose medications that are less likely to be sedating. A sedated individual working in a high-risk environment (e.g., bomb technician, pilot) or in a job that requires particular vigilance (e.g., bus driver, heavy machine operator, surgeon) would prompt this specific concern. Although reducing side effects of medication is an important general principle of treatment planning, such considerations are amplified if the patient continues to serve in a role associated with occupational exposure to trauma.

Notable in this case is the report of laughing and playing by coworkers (communicated through a workplace supervisor to the treating clinician). Such reports are more common in healthcare systems in which leaders/supervisors are part of the same organization as the healthcare provider (e.g., the military, some federal agencies, police). The clinician’s use of this type of information obtained from the employer is a complicated issue. Do you inform the patient about the information you received and risk embarrassing the patient when this may negatively affect his relationship with coworkers and/or the therapeutic alliance? Is it a potential avenue for exploration of the patient’s reluctance to return to work? Should the clinician ignore the report entirely? Although the answer depends on myriad factors specific to the individual, it would be wise to tend toward avoiding the risks related to directly revealing the outside information to the patient. Stigma is a significant struggle for many, and those with the most severe symptoms may experience an increased sense of stigma and barriers to care (6–8). Accentuating these problems is a considerable concern for the treatment of such patients.

2.2. The answer is E. Disability considerations in PTSD are potentially unique relative to such concerns in other mental health conditions. The majority of individuals who experience a trauma do not develop PTSD, and those who do often recover, in contrast to other serious mental illnesses, such as schizophrenia and bipolar disorder, which more consistently result in permanent disability. The patient, in conjunction with his or her treating clinician, would ideally take the time to carefully consider the various effects of moving forward with disability. These include the disruption to the individual’s career and longer-term goals and aspirations. However, there is a risk of retraumatization and potential negative effects on the treatment if a clinician pushes for a return to work. Disability might, on the other hand, cement the illness in the patient’s mind and create disincentives for returning to health due to financial incentives.

The one concern a clinician should not consider is the effect on the patient’s workplace and the potential that moving forward with disability could open a floodgate of others feigning symptoms to avoid work and/or seek financial gain. These risks are likely less pronounced in today’s all-volunteer military, but even when these risks exist, the ethical principle of beneficence would guide a clinician toward focusing primarily on the care of the patient.

3.1. The answer is C. An important issue to consider in this case is the fostering of a patient’s autonomy to the fullest extent possible to help the patient regain a sense of control. Too frequently, patients may feel forced into care and forced in their care. Systems also sometimes err in supporting a paternalistic stance. An example would be a military commander’s recommending counseling for a soldier who reports being raped, to ensure that the soldier receives care. What if the soldier is not ready or interested in treatment? Should she be allowed to exercise her autonomy? On the other hand, it is important that patients are afforded timely and appropriate care, which includes taking into account the evidence for the best type of care and the capabilities of the practitioner. Given these considerations, the primary ethical consideration is making sure the patient is sufficiently informed to make autonomous choices. Here, this includes discussing the risks and benefits of following her preference regarding the treatment provider’s gender.

3.2. The answer is D. In this question, autonomy versus beneficence (paternalism) are again the ethical principles that require balancing. In the first question, we discuss balancing the benefit of receiving evidence-based care versus respecting patient autonomy and increasing the patient’s sense of choice and control. In this question, the provider may consider using an element that is known to be essential in treating trauma (exposure) as part of the rationale for working with a male clinician. If the desired outcome of treatment is for the patient to be able to function socially, overcoming fear of a particular gender would potentially be a useful therapeutic goal. However, the evidence base for this approach does not exist (9). In this situation, a potential ethically defensible position is to discuss the reasoning with the patient. For example, a male provider might say the following:

“I certainly can understand your request for a female doctor; however, may I suggest that you may gain some benefit from working with a male doctor? Working with a male clinician who is trained to help patients with these exact types of difficulties may help you to overcome your feeling of being unsafe around men. For this reason, I wanted to discuss this idea with you for us to consider and suggest that maybe we try for a few sessions to see if we could work together. On the other hand, you may also find that working with a male evokes memories of the trauma too strongly, so we would have to be very mindful of that potential and adjust our plan if this begins to occur. I will ask you from time to time how you are experiencing the process of working with me and encourage you to be candid about whether our working together is helpful for you.”

Comments such as these may foster awareness and autonomy. The discussion may encourage a higher level of autonomy because it is also providing the patient with more information, thus enabling him or her to make a more informed choice, rather than her initial choice, which actually may have been an avoidance reaction to reminders of the trauma.

4.1. The answer is D. All of the above are important when making a determination for return to duty except for the critical nature of the mission. If a million people would die if a certain task were not performed, and the patient was the only person available with the skill to do it, this scenario might, of course, be considered as a rare exception. However, sending back to duty a patient who is on temporary disability due to trauma-related symptoms could risk the success of the mission, because he may be unable to perform. This would also be contrary to the principle of beneficence for him, as it is not in the patient’s interest to attempt to work and to then not succeed because of his premature return to duty. We must always factor in the risk of retraumatizing the patient, especially if he is still experiencing symptoms that may affect function, when making this determination.

Motivation to return to duty may, however, be a key factor. Many people train for years in their professions, and the prospect of being “taken out of the game” is cataclysmic to their sense of identity, even if returning to the job may be perceived as potentially hazardous to others. On the other hand, some people become so overwhelmed by the situations they face that their motivation to return to duty becomes superseded by their personal needs, which, in a combat situation, may trigger a need for self-preservation. This is potentially modifiable over time, and it may be best to have a period of “time out” to determine whether a person who is originally not motivated to return to duty may be able to recover and want to return.

The level of dysfunction related to symptoms is very important. This is the core question that addresses immediate safety concerns for the patient and coworkers. Short-term safety concerns are an area in which a paternalistic approach frequently is rightfully ethically appealing. An example to illustrate this is a patient’s ability to concentrate. How important this is may depend on the task at hand and how poor the concentration is. For example, what level of concentration is required for the Marine infantryman in this example to go back to using his weapon in a battle? Would a soldier who disarms bombs require a different threshold for concentration before returning to duty? In the civilian world, what level of concentration should an air traffic controller who was on duty during a plane crash have before returning to duty? It is also important to consider how to measure the level of dysfunction. Is self-report adequate? Is a trial of supervised work adequate, or would a standardized test with a threshold be best required in making this determination? These are all issues that factor into making a determination, along with balancing autonomy versus paternalism in a situation in which the patient has acute, active trauma-related symptoms. How medications and their side effects factor into the level of acute or long-term dysfunction is also an important consideration.

Some may conclude that the risk of retraumatization is the most ethically concerning issue in this case. Trauma is an inherent risk in life. On the one hand, the level of exposure to trauma can affect the chances of long-term dysfunction in a patient. However, the risk of being exposed to additional trauma may or may not be a justifiable basis for exercising the principle of paternalism when managing patients. What if our patient desires to return to duty, informed of the risk? What if the loss of his career is more threatening than the potential for being traumatized again? We can advise patients of the risks of many things, including sugar intake in a diabetic, but the optimal ethical course may still be to allow them to choose how to manage the issue once we have provided them with adequate knowledge about the risks and benefits for their informed consent and autonomous decisions.

4.2. The answer is C. In addition to the challenge of making a determination about treatment disposition, there also is a question here of the clinician’s countertransference. Some may think that it is unethical to return a soldier to combat and risk having him or her traumatized again. Does this opinion change if the soldier wants to return to duty? Would this opinion change if those who leave combat after a traumatic event actually end up with worse outcomes than those who stay and complete their tour of duty? This theoretically may occur, but the empirical support is inconclusive (10, 11). If true, this phenomenon may be related to feelings of shame and guilt about having left their comrades behind, having not finished what others could, and guilt from having safely survived while others stayed. Providers have observed this phenomenon countless times, at least as far back as Vietnam, but it would be difficult to study through randomized prospective studies. In situations in which ethical dilemmas related to the patient’s potential shame or guilt are involved, countertransference may be heightened. Again, it may be optimal to have a discussion about all factors in play. These factors include motivation to return to duty, risk of being traumatized again, the level of symptoms that may impair ability to perform duties, and the pros and cons of being a person who stays with the unit and finishes his or her tour of duty versus being a person who leaves the combat zone and returns home. Having such a conversation may be an ethically preferable way to reach a decision, because this can ultimately provide the patient with the knowledge to make a more autonomous choice. It also allows a provider to acknowledge his or her own biases yet still allow a patient to have and exercise as much autonomy as is possible. As with any other situation, the one caveat is that a paternalistic approach becomes more defensible when the symptoms exhibited put the patient in potential immediate harm, as in this case, if he or she were to return to duty.