Healing Combat Trauma

Another Hidden Cost to Veterans: Decades of Suicide Watch for Your Peers with PTSD

I had an interesting conversation with a treasured Vietnam veteran the other day -- interesting in the sense that the Chinese mean it.  I thought he was planning on being one place and then when his plans changed at the last minute, I found out why.  He was, in his words, "taking the loaded gun out of the mouth" of one of his dearest friends, a Silver Star winner who also served in Vietnam -- and not for the first time, either. I've heard some of the other stories, too, as they were happening.

Just out of curiosity I asked him, having recently heard that although he's usually "successful" at this particular task -- a combination of skill and luck, I am sure, and I've heard how he does it, it's really pretty cool -- he's also "gotten there too late," in about five people's cases -- how many people has he actually tried to "rescue" over the years in the same way?  Literally "taking a loaded gun out of their mouths" (although that really amounts to persuading the fellow vet to lay it down, not physically trying to take it.)

"About 100," he said, and wasn't too happy to have to say it, either.

Just think of that for a minute.  His odds are probably pretty good.  I'm sure some of the 100 were actually different tries by the same people, but even so...five dying, 95 successfully averting...but 100 attempts?  From your peer group?  That would seriously suck.  And I know he's made a few himself.

So when we as a country try to estimate and analyze the "hidden costs" and the "lifetime costs" of struggling with PTSD, let's remember the psychic costs as well.  I'm not sure any of us are particularly well-suited to be taking loaded guns out of each other's mouths...for decades.  And the irony to me of this whole situation is that of course, he does what he does out of love: because he can't let them do it.  And yet...he's often not much more than a few steps ahead of where the other person is, at that moment.  Granted, he's sharing everything he's got.  But really: is this a solution?  I'm sure if he hadn't been there for those guys, the suicide toll among Vietnam combat veterans would be that much higher.  Which would be a tremendous loss, and a continuing disgrace (that they have to, not that they did.)  But at the same time -- think about it from a mental health standpoint.  How great would yours be, if decades after a war, you could also look forward to THIS grim duty?  Good grief...The poets and the politicians both agree, sometimes: War is Hell.  But so can the aftermath be, sadly. Even for those who survive.

Editor's note: For veterans in crisis, call the National Veterans Foundation.  Staffed with crisis counselors -- other vets, just like you.  As their website says, "The NVF is standing by to provide you with personal assistance and advice. We are staffed by veterans with experiences from Vietnam to Iraq.  We are trained not only in Veterans issues but also in crisis management for PTSD and suicide prevention. If there is anything we can do for you, please ... simply call us at (888) 777-4443."

"It Was Loyalty to Your Buddies That Kept Men Going" -- The Wet Bond of Blood, Civil War Style

A few months ago we blogged about an interesting, little-known WWI-era poem, written by Robert Graves for Siegfried Sassoon, called "The Wet Bond of Blood," about the brotherhood men forge in combat. (That post is linked here.)

From the news this past week comes a related story in the L.A. Times, talking about the work of Dora Costa and Matthew Kahn, a husband-and-wife research team at UCLA, who have been delving into 41,000 Civil War records of the Union Army to find out what makes some soldiers "stay and fight on a brutal battlefield," and others "desert and flee." Their new book is called "Heroes and Cowards: The Social Face of War."

According to the L.A. Times,

"The book's thesis is that serving in a homogenous Army company, particularly one of volunteers recruited from the same region, reduced desertion rates in the 1860s. Patriotism played a role in keeping soldiers at the front lines, according to the book, but more important factors were sticking with buddies of similar backgrounds and avoiding a bad reputation back home.

"Loyalty to comrades trumped cause, morale and leadership. But loyalty to comrades extended only to men like themselves -- in ethnicity, social status and age," the authors wrote."

For example,

"Through statistical analysis, the authors developed a formula in which group loyalty in those Union regiments was found to have counted twice as much in preventing desertion as a soldier's ideology, and six times as much as their unit leaders' popularity. For example, Company D of the 36th Regiment contained neighbors and relatives from Worcester County, Mass. The men, mainly mechanics and artisans, saw heavy action and no desertions.

In contrast, Company B of the 47th Regiment from New York was a more diverse lot, including men from cities and farms, along with laborers who were paid to substitute for conscripts. Its desertion rate was 16 percent."

"Cohesion" in military units is a topic even experts like Jonathan Shay, M.D., Ph.D. have spoken about as vital and essential for morale, and for the prospect of some form of healing taking place also in community.  As the article's author remarks, "Unlike the Civil War army, American units today are ethnically and geographically diverse. Yet the military has learned to reinforce the bonds gained in training, and usually rotates entire units in and out of war zones rather than fill in for casualties with new soldiers as it did during the Vietnam War, the professors said."

Interestingly, the book's authors are economists, not sociologists. The data they surveyed, and the ways they worked with the source material might also be useful for others to evaluate as well.  One of the recent, though debated, conclusions of PTSD research is that ethnic minorities are at risk for suffering from PTSD at greater rates than the general population.  There are various hypotheses proposed as to why, and no general agreement as yet about why this might be.  (See "PTSD among ethnic minority veterans," from the National Center for PTSD Research, linked here, for more on this subject. Also Professor Hedley Peach's research with the Australian Vietnam veterans studies as well, previously discussed on this blog.)

(Here's a look at the source material and their techniques for analyzing it, from the same L.A. Times article:)

"They used Internet databases as well as copies of antique paper documents written in the elegant penmanship of 19th-century government clerks. They applied the statistical tools of economic analysis to history, a cross-disciplinary technique increasingly popular in academia. Through those archives, the authors examined service records, ages, birthplaces, prewar occupations, battlefield deaths and prisoner-of-war interments among 35,000 white and 6,000 black Union soldiers. They also tracked census and pension information going back in some cases to 1850 and as far forward as 1910. Similar Confederate records were not available, they said. And to estimate pro-Union sentiment among the troops they studied, the researchers examined support for President Abraham Lincoln¹s elections in the soldiers' home counties."

Dora Costa, one of the book's authors called the source material they used, the Union Army's war records, "a fantastic laboratory for studying how do men behave under extreme stress." For that very reason, I hope other authors and scientists will mine this same trove of information.  The book's authors come up somewhat blank on one of the most fascinating themes of all.  During the Civil War, "the most ideological of U.S. wars," Costa remarked, "it was loyalty to your buddies that kept men going.id. "But we don't know why there was this loyalty."

Answering that question, we might want to turn to Graves' poem for Sassoon, mentioned above, or the thoughts of America's premier wartime journalist, Ernie Pyle, who we've also talked about at length on this blog.  From last summer -- the author of "Ernie Pyle's War," describing Pyle's authentic empathy for the soldier beside him, so well-conveyed in print:

"He knew, too, that it was neither God nor Flag nor Mother that impelled a pimply faced kid to risk, to lose his life in an obscene adventure.  He did it for the kid next to him; he couldn't let him down.  They needed one another so bad."

In "Heroes and Cowards," Costa and Kahn were surprised to learn that the average Union desertion rate was only about 10%, on average.  Says the L.A. Times, "Given the horrific conditions, it is surprising there was so little desertion," Costa said. That was especially true since fewer than one-half of those who deserted were caught, punishment often was not very harsh and execution extremely rare."

In the absence of any other, better sociological explanation, it just goes to underscore the "wet bond of blood" -- or what Pyle referred to as "the powerful fraternalism of the ghastly brotherhood of war."

PTSD in Antiquity -- the Apostle Paul

Those of us who've spent more time than we care to admit it around religi-anity are familiar with the story of the Apostle Paul.  Probably a Hellenic Jew, he had a strong background persecuting -- i.e., killing -- Christians -- which all the more shocked first century Christians when he converted and became one.  Christian churches often use the story of Paul, an aggressive non-believer, as an example of how "anyone can become a Christian," even one fervently opposed to Christians and their teaching, such as he was in his early years.

As he says about himself, in Acts 22: "⁴I persecuted the followers of this Way to their death, arresting both men and women and throwing them into prison..." And later in the same passage, "'Lord,' I replied, 'these men know that I went from one synagogue to another to imprison and beat those who believe in you. ²⁰And when the blood of your martyr Stephen was shed, I stood there giving my approval and guarding the clothes of those who were killing him.' "

For our purposes here, though, there's something more interesting about the Paul story.  How the frustrations he espouses in his later life are really textbook PTSD hallmarks: from killing Christians. 

¹⁵I do not understand what I do. For what I want to do I do not do, but what I hate I do. ¹⁶And if I do what I do not want to do, I agree that the law is good. ¹⁷As it is, it is no longer I myself who do it, but it is sin living in me. ¹⁸I know that nothing good lives in me, that is, in my sinful nature. For I have the desire to do what is good, but I cannot carry it out. ¹⁹For what I do is not the good I want to do; no, the evil I do not want to do—this I keep on doing. ²⁰"

(The foregoing passages are from Romans 7.) Paul pitches this as a battle between good and evil,   between sin and God; but we can just as easily see this as the characteristics of PTSD that Paul could not shake, even though he had left his former life as a killer of Christians, and reconciled himself to God.

How many combat veterans with PTSD sit in the wreckage of ruined family celebrations, and wonder the same things? To have the intention to experience one thing with their loved ones, but end up being blindsided by feelings and reactions they can't control? And who end up feeling terribly ashamed for how things turned out, when they really meant for them to be so very different?

Many veterans with PTSD "solve" this dilemma by "taking themselves out of the mix," either figuratively or literally, by sequestering themselves "off in their bunkers" away from family and friends, mainly out of a desire to protect their loved ones from one more disaster at their hands, and to avoid the all-too-familiar triggers.  Unfortunately, quality of life is lost somewhere along the way, and trigger-avoidance only goes to behavior control, not finally lessening the symptoms or reducing the overall sum of what's there to be triggered.

Seems that current suffering veterans, with or without specifically religious leanings, may have an antecedent of their own in none other than the Apostle Paul.

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Editor's note: More than a hat tip to Pat, whose insight this really was...

What Would Hope Regained Do for Combat Veterans?

I was in a conversation the other day with a Vietnam era psychologist, who I respect and admire a great deal, but who was nonetheless giving me static for the way I talked about "hope" in a previous blog post, as it concerned combat veterans.  "You talk about it as though it's an abstract, but then immediately move into talking about its RESULTS," he said (I'm paraphrasing.)  Rrrright.  And that would be exactly the point.  Hope is a great and a necessary thing -- but our goal here is to find ways to get over combat trauma, to the extent possible -- at least to reduce its effects on veterans -- and in that regard, yes, we're all about the results.  Are there any?  And what can those be?  Because if they're legitimate at all, in the vacuum of hope-lessness and despair created by a complete lack of reasonable solutions, let's figure out what those are, and let's try them out.  Are combat veterans game?  Many are.

Here's something I ran across the other day, in the middle of a [draft] journal article.  The author was talking about a type of therapy he used -- a therapy he's famous for developing, and which has been around and in use for decades -- on combat veterans, mostly from the Vietnam era, and the results he was able to achieve with them.  I have some inside knowledge of his program, but this was the first time I'd read something in print about it.  In the middle of quite an extensive article, charting this result and that, he happened to mention the results of one of the tests he did on the 22 vets, both before and after the two weeks of treatment.  This is what he wrote:

"Scores on the Beck Hopelessness Scale fell from an average of 11 before treatment to 3 following treatment.  In clinical practice, scores of 9 or more are used to indicate serious hopelessness.  A score of 4 is expected in the general population.  The veterans went from having pre-test scores characteristic of hopelessness, suicidal ideation and predictive of suicide attempts, to having scores typical of the general population.  Thirteen veterans had scores above 9 before treatment, one had a score above 9 after treatment. (That individual's score had dropped from 17 to 10.)  Nineteen out of 22 scores dropped; two remained the same (scores of 1 and 2); and one score increased [negligibly] (from 4 5o 5).  Marked decreases in pessimism are indicated, and it seems safe to conclude that the treatment group felt considerably more hopeful at the program's conclusion."

Do you see what's embedded in that, if true?  In two weeks of treatment, combat veterans with PTSD that went back decades started feeling better to a degree, on average, better than the general population?  That's remarkable...

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So I ask you, what would HOPE do for veterans today, and their families?  It's pretty clear that when it comes to suicide, people are able to go forward with the act because they've given UP hope.  (That's why the Beck test, for example, is able to link the two: hopelessness and suicide, both ideation and attempts.)  We've seen in previous blog posts how the "focus" of a suicidal person becomes narrower -- it's not that they "don't love their family" or "aren't thinking about the consequences to others," they simply have narrowed their focus down to an either/or choice, and the rest of the considerations, no matter how otherwise dear, are simply "not in the picture." 

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Now it's entirely possible that the veterans in the above-mentioned program didn't functionally "stay" that perky and optimistic, and that's why more follow-up studies, such as retests at longer intervals, would have contributed more information worth knowing.  Many times, at the end of a program, irrespective of what type of program it is, participants feel most buoyed and optimistic about future performance, lighter about their burdens, and more likely to discount the negative effect of future obstacles they may encounter.  However, even so it's significant to note how good those scores seemed to be, given the great degree of difficulty the same participants had having hope beforehand.

It's not just veterans -- it's also their families.  How often do family members say things like, "But you were only in the war for two years...how can you let it affect you for the whole rest of your life?"

If combat veterans are able to access health care that adequately deals with their symptoms, and reduces their symptom load to a manageable extent, and gives them back HOPE -- they will have the ability to resume their lives with some degree of normality, and prevent any number of negative consequences that come from NOT having hope, from having given up.  The tremendous societal costs from combat trauma we have to start understanding not only affect the veterans involved -- they affect their families, the communities in which they live, future generations, etc.  Veterans with hope -- who get their hope back -- will be functional and integrated into all aspects of their lives, and actively participate in their various roles as spouses, parents, employees, citizens, etc.  Veterans who lose hope, and who we do not help to regain hope, will lose out.  And this loss will affect them first, and then like the ripple effect of a pebble thrown into a pond, concentric circles of effect will spread out from them to others in their lives: their immediate families, their workplaces, their schools, their communities, even future generations in their families.

Far from being an abstraction, I believe HOPE is pretty central to the whole concept of "healing combat trauma."  We've got to help combat veterans to hang on and have some, and they themselves have to believe it's possible to get better.  Then we have to make sure we're connecting them with the very resources that can deliver the results.

Chronic Life Stress as a Predictor of Illness: How Much is Too Much?

In the annals of stress management studies is a particular test called the Holmes and Rahe Social Readjustment Scale.  It assigns "points" to major and minor life stressors a person may have experienced over the past year, and then has you total up the points at the end of the test to get a "total score." That total score can be used to predict the likelihood of illness, whether mild or severe, because chronic stress is well known to reduce immune function.

(Of course, stress management skills, such as what we've been discussing on this blog for a while, in the "mind-body medicine" category, linked here, are very helpful in reducing symptoms of stress.  But conscious awareness and the willingness to make life changes are also crucial.)

Veterans may be under chronic stress; but their families -- partners, significant others, children -- may also be under chronic stress.  Partners and children of deployed servicemembers may also have very high scores.  And care-givers for injured veterans (combat trauma, TBI, PTSD, amputations -- veterans suffer any number of serious injuries) are also at increased risk for stress-related illness.

Ideally this is a case where "knowledge is power" -- being able to quantify the stress you're under could help you to ask for help, make better choices, and prioritize self care.  Let's hope so... In the meantime, here's the test:

In the past 12 months, which of the following major life events have taken place in your life?

1. Print out this form

2. Make a mark next to each event that you have experienced this year.

3. When you're done, add up the points for each event.

4. Check your score at the bottom.

_____ Death of Spouse 100
_____ Divorce 73
_____ Marital Separation 65
_____ Jail Term 63
_____ Death of close family member 63
_____ Personal injury or illness 53
_____ Marriage 50
_____ Fired from work 47
_____ Marital reconciliation 45
_____ Retirement 45
_____ Change in family member's health 44
_____ Pregnancy 40
_____ Sex difficulties 39
_____ Addition to family 39
_____ Business readjustment 39
_____ Change in financial status 38
_____ Death of close friend 37
_____ Change to a different line of work 36
_____ Change in number of marital arguments 35
_____ Mortgage or loan over $10,000 31
_____ Foreclosure of mortgage or loan 30
_____ Change in work responsibilities 29
_____ Trouble with in-laws 29
_____ Outstanding personal achievement 28
_____ Spouse begins or stops work 26
_____ Starting or finishing school 26
_____ Change in living conditions 25
_____ Revision of personal habits 24
_____ Trouble with boss 23
_____ Change in work hours, conditions 20
_____ Change in residence 20
_____ Change in schools 20
_____ Change in recreational habits 19
_____ Change in church activities 19
_____ Change in social activities 18
_____ Mortgage or loan under $10,000 17
_____ Change in sleeping habits 16
_____ Change in number of family gatherings 15
_____ Change in eating habits 15
_____ Vacation 13
_____ Christmas season 12
_____ Minor violations of the law 11

______ Your Total Score

Now, take the total score and look at the following key:

LIFE STRESS SCORES

0-149 Low susceptibility to stress-related illness.

150-299 Medium susceptibility to stress-related illness.

300 and over High susceptibility to stress-related illness.

Now is the time to look into techniques to reduce stress loads, and to practice better self-care (to the extent possible.)