Healing Combat Trauma

The Poetry of War: This Time, from Afghanistan

The BBC has an article today called "Afghan Poets Tackle Scars of War," linked here.

The article writes, regarding the effect the war has had on the national literature:

"This theme of violence is playing out in other genres in ...[Afghanistan], such as short stories. But it is more visible in poetry.

"It is not the poets' choice to write about war and violence, they are compelled to do so - to express their reaction and hatred to bloodshed," says Darwesh Durrani, a popular [Afghan] poet and professor of literature in Quetta."

Additionally, 

"Poets are inspired by what is happening in the outside world. Their imagination absorbs it," says veteran [Afghan] poet in Peshawar, Rahmat Shah Sael.

"That is why [Afghan] poets are writing about violence in one way or another."

One of the poems in the article is evocative of the violence and grief Afghans are experiencing.  The lines are from Zarlasht Hafeez, "a female Pashto poet who has published a collection called 'Waiting for Peace'." Her lines read:

"The sorrow and grief, these black evenings,

Eyes full of tears and times full of sadness,

These burnt hearts, the killing of youths,

These unfulfilled expectations and unmet hopes of brides,

With a hatred for war, I call time and again,

I wait for peace for the grief-stricken [Afghans]."

It's unclear whether Afghan poets are publishing books of their poetry or reading individual poems aloud, according to local tradition.  However, the feelings about war, grief and loss that they're expressing through poetry are an essential communal reaction, and will take their place alongside similar expressions from others who have experienced the pain of war.  The right hand "sidebar" of this website includes a number of books of poetry, from this war and previous ones -- whether individual books of poetry, or anthologies of war poetry. For an index of material we've written on this blog about combat and poetry, click here.

Editor's note: The photograph, of an elderly man surrounded by villagers and Aghan National Army soldiers during search operation in rural Afghanistan, 2007, is by noted humanitarian photographer Zoriah.  Used with permission.  For more of Zoriah's work, click here. 

"The Hard Part Comes Later" - about PTSD, Grief and Letting Go

The Associated Press had a story on its wire tonight, called "Stream of horrific crimes takes toll on town cops," about the child murder in Tracy, CA. For our purposes, we're going to excerpt just a few lines from the story.  Because while we've talked before about the similarities in how police officers and combat veterans develop PTSD, here too is another similarity: how focus on the mission is paramount, and afterwards -- the grief sets in.

From the story:

"Police were especially stressed by the disappearance and murder last month
of 8-year-old Sandra Cantu. The department's sworn officers and staff pulled
2,966 hours of overtime on that case alone.

And tougher than the intense work is the lull that follows, when the mask of
professional composure comes down and doubts, sadness and anger come
through, said Tracy police chaplain Dan Higgins.

"When they're able to focus on their jobs and do their part, they have an
outlet," Higgins said. "The hard part comes later."

In other words, personal grief and coping with the horrors of the work (be it combat or in this case, police work) can be set aside effectively, sometimes, mostly, to get the job done.  The grief gets sublimated to or displaced by the job.  And that's effective -- as a coping mechanism -- only so long as it lasts.  Afterwards, when it's removed, the full feeling of the grief and the loss starts to creep back in, to the vacuum that's been created.

Again, from the story:

Detective Nate Cogburn worked 200 hours in two weeks in the search for Sandra and then for
her killer, the article said, adding:

"This meant little sleep, no breaks, a canceled second wedding
anniversary weekend in Napa with his cancer-stricken wife and less time with
his 10-year-old stepson.

[Even though police now have a suspect,] Cogburn remains haunted by the case.

"I feel nothing in terms of a sense of relief or solace. I feel nothing but
devastation. Nothing," he said. "It is a good thing that we've identified a
suspect ‹ a good thing for the investigation, for the D.A.'s office, for
being able to close this case, hopefully for the family. But emotionally
it's a vacuum."

Earlier I've written on this blog about a WWII combat veteran who only "noticed" his PTSD in his 80s, when he was finally retired. In other words, when work was no longer front and center in his life, and in the vacuum that removing his prior, sustaining focus on work created, the nightmares and the cold sweats from combat flooded back in.  Decades after his actual service.  This story was told to me by the local veterans service officer, who helped the man to realize that what he might be struggling with was PTSD, and to get some help.

We all know about how combat veterans can seek to numb their pain, whether successfully or unsuccessfully, and perhaps only for a time, with drugs and/or alcohol. We need to also realize how workaholism, Type A behavior, and focus on the job -- even though warranted -- can also be a way to "keep the demons at bay."  Unfortunately, when the focus changes, as it often will, in time, the vacuum that's been created when the main focus gets removed, can also exert a powerfully destructive pull on the individual.  Drugs, alcohol and work -- we can use them all as ways to keep PTSD at bay, however temporarily.  But ultimately, none will be completely successful, or produce thorough, functional results.  Always better to deal with the issues involved, however painful, and however incrementally we might need to do so.

Domestic Violence: Personal and Family Safety Pocket Guide

The Washington state Dept. of Social and Health Services puts out these excellent pocket cards, in English and other languages, called the "Safety Plan Pocket Guide" for victims of domestic violence.  It looks like they were produced over ten years ago now, but Seattle-area businesses and medical offices still have them available, and the suggestions look current and practical.  Here they are:

Domestic Violence National toll-free hotline: 1-800-799-SAFE (7233)

Within Washington state: Domestic Violence Hotline: V/TTY: 1(800) 562-6025.

Safety Plan Pocket Guide:

PLAN AHEAD:

• Develop a plan with your children;
• Arrange to have a place to go;
• Make copies of important papers and hide them;
• Have available important phone numbers;
• Pack and hide an overnight bag;
• Put aside money and spare keys;

DURING AN INCIDENT:

• Call for help (9-1-1);
  Get out if you can;
  Bring important items listed above;

IF YOU CAN'T LEAVE THE SITUATION:

• Avoid rooms with only one exit;
• Avoid the kitchen, bathroom and garage;
• Call for help;

IN YOUR HOUSE:

• Change lock, secure doors and windows;
• Arrange to have someone come stay with you;
• Change your phone number(s);
• Obtain a protection order;
• Notify trusted friends and family;

AT THE WORKPLACE, SCHOOL AND PUBLIC AREAS:

• Inform your work, daycare and schools;
• Change your daily routine;
• Plan ahead for unexpected contact with the abuser.

Editor's note: For previous coverage of domestic violence, PTSD and combat veterans, look to this blog post, linked here, or the index of blog posts on the topic, linked here.

"Love Shouldn't Hurt": Combat Veterans, PTSD, and the Deadly Serious Topic of Domestic Violence

Domestic violence is an enormous public health problem in our society today. Domestic violence among families of combat veterans is also a significant problem -- if you take "significant" to mean, "important to those it affects." According to a fact sheet produced by the National Center for PTSD (NCPTSD), part of the VA, domestic violence is "the most frequent cause of serious injury to women, more than car accidents, muggings, and stranger rapes combined."

Among veterans, studies show that "domestic violence rates among veterans with post-traumatic stress disorder (PTSD) are higher than those of the general population. Additionally, according to studies, domestic violence rates among "active-duty military men (Heyman & Neidig, 1999), couples seeking relationship therapy (O'Leary, Vivian, & Malone, 1992), and Vietnam veterans with and without post-traumatic stress disorder (PTSD; Jordan et al., 1992) have been found to be higher than those from the general population." 

One academic paper adds, making a crucial point, "Research has yet to study couples seeking relationship therapy in which the veteran has PTSD to explore how these relationships compare with other couples. Given the elevated risk for violence among these couples due to the PTSD, the treatment-seeking behavior, and the relationship distress, couples seeking relationship therapy are an especially vulnerable population." (And of course, couples not seeking relationship therapy might be even more under-served -- it's just they can't be as easily surveyed.)

---

Casey Taft, M.D., an associate professor of psychiatry at Boston University, has recently been awarded a $1.5 million grant from the Department of Defense to study this topic. From an article published by BU, announcing the grant, quoting Taft, and linked here:

"People who are exposed to trauma, and in particular those who develop PTSD, are at very high risk for aggressive behavior,” says Taft, who also works at the Boston Veterans Affairs Medical Center and the National Center for PTSD. “In one Vietnam war study, they found that among vets with PTSD, one third had engaged in physical violence against their partner in the past year. This rate was almost three time the rates they found among vets without PTSD. Since we know that current vets in Iraq and Afghanistan have been exposed to significant trauma and many of them have been on multiple deployments and they’re coming back with high rates of PTSD and other mental health issues, it would stand to reason that they would also engage in high levels of aggression and partner violence, though we don’t have the specific data to back that up.”

(Hence the study).

In the meantime, know that domestic violence can be "deadly serious."

Domestic violence is serious. Risks include death, serious physical injury, and psychological injury as well -- including PTSD and secondary PTSD. Just some of the psychological effects (often less obvious initially than the physical effects) are: depression and being at greater risk for subsequent suicide.

Again, according to the NCPTSD, "60% of battered women report depression," and "25% of suicide attempts by Caucasian women and 50% of suicide attempts by African American women" have been "preceded by abuse."

Some more sobering statistics about the magnitude of the problem:

• 20-30% of American women will be physically abused by a partner at least once in their lifetimes; 
• 30-40% of women's emergency room visits are for injuries due to domestic violence;
  
• 30% of women killed in the U.S. are killed by their husbands or boyfriends;
  
• 50% of men who assaulted their female partners also assaulted their children;
  
• 3.3 million children witness domestic violence each year.
• 1.3 million women and 834,732 men are physically assaulted by an intimate partner annually;
• 201,394 women are forcibly raped by an intimate partner annually;
• 11% of women in homosexual relationships and 23% of men in homosexual relationships report being raped, physically assaulted, and/or stalked by an intimate partner;
• 503,485 women and 185,496 men are stalked by an intimate partner annually;
• 1-25% of all pregnant women are battered during pregnancy;

What to do if you're in crisis?  There's a

National toll-free Domestic Violence hotline: 1-800-799-SAFE (7233)

There's an excellent "Fact Sheet" put out by the NCPTSD, linked here; and

There's a "safety plan pocket guide," linked here.

The NCPTSD's fact sheet, they say, provides "information regarding the definition of domestic violence, the prevalence of domestic violence, the dynamics of abusive relationships, the effects of domestic violence, treatment for victims and perpetrators, and resources offering assistance."

There are also some good resources at other websites, including FamilyOfAVet.com, linked here.

With PTSD, Naming It Turns Out to Not Even Be Half the Battle...

From a friend and Gulf War vet's blog. I'm glad he finally wrote about this (his own PTSD diagnosis):

"I thought with finally learning what I had, or what was wrong with me (PTSD), it would be more helpful than it actually was.In the back of my mind I believed I was literally crazy until I learned about my malady. I had the thought that by knowing what was "wrong" with me, that in someway I would get better. I assumed this knowledge would somehow cause a shift in my thinking. I had expectations of my enlightenment to be more profound than it was; but nothing changed except that I now knew more than I did before. My mind at this time could not fathom that I had become a member of the walking wounded.

When I had the realization of my condition, that a name could be assigned, I felt an immense relief. But then it hit me that nothing had changed at all! I expected this awareness would have a greater impact than it did.What I did find in this new perception, a deep profoundness and discernment which had escaped me before,I finally found myself to be no longer alone."

His warranted conclusion?

"It hit me just recently that information can lead to knowledge but without necessarily leading to wisdom."

Editor's note: Scott Lee's background, in his own words:

"I am a Army veteran of the first Gulf War, I was a driver of a Bradley Fighting Vehicle. My unit fought the Iraqi Republican Guard in three campaigns and my vehicle was point for the brigade. I drove for 172 hours straight, engaged in 100 hours of sustained combat and witnessed literally thousands of enemy combatants die in that short span of time. Since being honorably discharged from the service of my country I have struggled with PTSD, depression, substance use disorder, homelessness, social and health issues. It took me 7 tries and 15 years to go through the VA bureaucracy to get the help that I needed. Nothing has been given to me that I have not fought for with my life, either in the Gulf War or with the VA. I gave freely of my time and service, the same was not done for me."

For a link to Scott Lee's excellent blog, PTSD: A Soldier's Perspective, click here.

Who -- and What -- a Survivor Is

Quotable quotes:

"I define a survivor as one who has touched, witnessed, encountered or been immersed in death in a literal or symbolic way and has himself remained alive." -- Robert Jay Lifton.

LIfton, an American psychiatrist and pioneer in PTSD studies from the 1970s, is also the author of "Home from the War: Learning from Vietnam Veterans."

(Hat tip to Chris Lombardi, for pointing this one out.)

Let's Hope This Isn't More "Blame the Victim" Thinking on Combat Veterans with PTSD, But...

A recent medical study, published in the British Medical Journal and reported on Friday, suggests that "the risk of combat-related post-traumatic stress disorder (PTSD) increased by two- to threefold in military personnel who had significant mental or physical problems before deployment, according to a study of 5,400 veterans."  In other words, those who were vulnerable beforehand, were even more susceptible to PTSD than their peers.  Hmmmn.

It's always interesting, and is going to stay interesting, to contemplate what, if any, predictive or predisposing factors there are for who develops later develops combat-based PTSD and why.  At the very least, this study throws yet more analysis into the mix, in a story that will continue developing for years.

According to the BMJ, the conclusion of the study was that:

"Low mental or physical health status before combat exposure significantly increases the risk of symptoms or diagnosis of post-traumatic stress disorder after deployment. More vulnerable members of a population could be identified and benefit from interventions targeted to prevent new onset post-traumatic stress disorder."

The study, which was supported by the U.S. Department of Defense, reported that:

"More than half of post-combat PTSD diagnoses involved veterans who ranked below the 15th percentile in mental or physical health at baseline, Cynthia LeardMann, of the Naval Health Research Center in San Diego, and colleagues reported online in BMJ.

"We have identified an at-risk population whose functional health seems to predict vulnerability to PTSD after combat deployment," the authors said. "In theory, such a population could be targeted for PTSD prevention programs, early intervention after exposures to stress, or even protection from stressful exposures, when possible."

The findings came from the Millennium Cohort Study, which has accumulated data on military personnel since 2001, before the wars in Afghanistan and Iraq. Investigators collected follow-up data from June 2004 to February 2006.

A previous report based on the study suggested that combat exposure -- as opposed to deployment -- significantly increased the risk of new-onset PTSD. Building on that observation, the authors examined the association between baseline mental and physical health and the risk of new symptoms or a diagnosis of PTSD.

The current analysis involved 5,410 combat veterans who completed baseline and follow-up questionnaires. The questionnaire includes a 17-item self-report measure of PTSD symptoms.

Baseline health status was determined by participants' scores on the mental and physical summaries of the SF-36V (veterans) health survey. A new PTSD diagnosis was based on DSM-IV criteria (derived from the questionnaires) or self-reported physician diagnosis.

The analysis showed that 7.3% of the participants had new-onset symptoms or a diagnosis of PTSD at follow-up by DSM-IV criteria. When self-reported physician diagnosis was included, the rate increased to 8.6%.

The authors stratified the participants into three groups according to mental and health status scores: below the 15th percentile, 15th to 85th percentile, and above the 85th percentile.

Combat veterans who scored below the 15th percentile of the mental summary had a relative risk of PTSD of 3.51 compared with those in the 15th to 85th percentile.

A score below the 15th percentile of the physical summary more than doubled the risk of PTSD (RR 2.22).

Overall, 58% of new PTSD diagnoses involved combat veterans who were below the 15th percentile for either summary.

Subgroups at increased risk for new PTSD symptoms or diagnosis included:

• ≥3 combat exposures during deployment, 2.60
• Women, 2.33
• Current smokers, 1.56
• Non-officers, 1.77
• Reserve/National Guard members, 1.85
• Army veterans, 2.04"

Editor's Note: The full reference is: LeardMann CA, et al "Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective U.S. military cohort study."  The full citation is: BMJ 2009; 339: DOI:10.1136/bmj.b1273. For the link to the full article, click here.

"Ding, Ding" -- Pavlov's Comment on PTSD

Famous Russian scientist (physician and psychiatrist) and Nobel Prize winner Ivan Pavlov -- famous for his experiments with ringing bells, feeding time and dogs that evoked the characteristic "Pavlovian response" -- also had some things to say about PTSD.  Bessel van der Kolk, M.D., a Harvard-trained psychiatrist, writing in his scientific paper, "The Body Keeps the Score: Memory and the Evolving Psychobiology of Post Traumatic Stress," mentions that Pavlov thought that "individual differences in temperament account for the diversity of long-term adaptations to trauma."  Interesting!

Editor's Note: The item van der Kolk appears to be citing is Pavlov IP.  Edited and translated by GV Anrep.  "Conditioned reflexes: An investigation of the physiological activity of the cerebral cortex."  New York: Dover Publications (1926).

Suicide Predictors in Young Men -- Combat Trauma Not Included

We've talked on the blog before about "suicide maps" and various predictors of suicide, however imperfect they may be.  Today there's an item from a medical journal that details a Finnish study -- aka, a medical study performed in Finland -- which essentially says, adolescent boys and young men who committed suicide frequently also showed some form of psychiatric illness at age 8 -- which happened to be the age where they were first evaluated, in the study.  Young women who killed themselves, didn't show this particular trend. Now, not to say that this study is in any way conclusive about PTSD -- since obviously it didn't even touch on that as a topic -- but it is interesting, since some of the research indicates that PTSD can be particularly difficult if it is "laid on top of" a previous, significant traumatic experience (often in childhood). In some ways, this study may not be all that germane to our topic, but it's interesting to note, in any case, since there are obviously a number of young men (and women) who commit suicide in the armed forces, and as veterans -- and it's always worthwhile to comb the scientific literature for any other reasons, or contributing factors into, why this might actually be.  Here's the info from the study:

Childhood Psychiatric Problems May Predict Suicide Attempts in Males

Most males who commit suicide or need hospital care for suicide attempts during their teen or early adult years appear to have high levels of psychiatric problems at the age of 8, according to a report in the Archives of General Psychiatry. However, later suicide attempts in females are not predicted by mental health issues at this age.
 
Andre Sourander, MD, of Turku University Hospital in Finland, and colleagues studied 5,302 Finnish individuals born in 1981. Eight years later, information about psychiatric conditions, school performance, and family demographics was gathered from children, parents, and teachers. Participants were then tracked through national registers through 2005.
 
Between the ages of 8 and 24, 40 participants died, including 24 males and 16 females. Of those, 13 males and two females died from suicide. A total of 54 males and females (1%) either completed suicide or made a suicide attempt serious enough to result in hospitalization.
 
Of the 27 males who either seriously attempted or completed suicide, 78% screened positive for psychiatric conditions at the age of 8, compared with 11% of 27 females who had serious or completed suicide attempts. In addition, males who would go on to make life-threatening or completed suicide attempts were more likely at the age of 8 to live in a family that did not consist of two biological parents, have psychological problems as reported by a teacher or have conduct, hyperactive, or emotional problems. However, none of these factors at 8 predicted later suicidal behavior in females, and depression at age 8 was not associated with suicide attempts for either sex.
 
Previous research has shown that in females, suicide is associated with depression and other affective disorders, which increase sharply after the beginning of puberty. This may explain why childhood psychiatric conditions do not predict later suicidal behavior in girls, the authors noted.
 

— Source: American Medical Association

Wyoming Takes More Steps to "Guard" Mental Health

More good news from Wyoming.  NPR reports today in their show, All Things Considered, that Wyoming is "about to mobilize its largest deployment of National Guards in state history. Embedded with the troops will be a mental health professional who is a PTSD specialist. The commander of the Wyoming Guard believes treating the mental health needs of the National Guard troops is a priority and he has also worked to connect mental health resources in Wyoming communities to those in the military."

For a link to that story, entitled "Embedding Mental Health in the National Guard," and originally reported by Wyoming Public Radio, click here.

Wyoming Plans Conference for Combat Veterans on PTSD, etc.

According to a recent press report, the Wyoming Department of Health and the state Military Department will hold the ''Wounded Warrior Wellness Conference'' in Casper next month to discuss the unique psychological needs of returning soldiers and their families. Unfortunately, no further information is forthcoming via either an in-depth Google search OR a search of the Wyoming Department of Health's main website.  The conference is not listed under May, 2009; nor does a search for "warrior" or PTSD reveal it. So if you're interested in finding out more, read the article about it here, or contact Regina Dodson, Housing and Veterans Service Coordinator, at the Wyoming Department of Health, (307) 777-8627. (And while you're at it, ask them to publish some material on their website ABOUT this conference, if they want people to actually...attend.)

On the plus side, it does look like the Wyoming Department of Health has a good page of veterans' resources, linked here. It has links to: Issues for Veterans; Resources for Veterans; Resources for Providers; and Resources for Families of Veterans.

A Look in "The Mirror" -- Great Britain Seeing War Trauma Now in 3 Years, Not 13 As Before

Because Americans are notorious for paying little attention to things that happen elsewhere, even among other English language-speaking countries, here's some news from Great Britain's tabloid-esque "The Sunday Mirror" today about their soldiers' battles with PTSD on the homefront -- soldiers who served in Iraq and Afghanistan.  For the link to the article, called "War's Silent Victims," by Rupert Hamer, click here. (The tabloid nature of the newspaper explains the fairly breathless writing style, but let's hope the facts and the reporting are accurate nonetheless.)

Points worth mentioning from the article include:

"Alarmingly, the charity [Combat Stress, see below] say[s] the figures are just the "tip of the iceberg" and add that the rate at which soldiers are developing the condition has accelerated. Usually it takes 13 years for cases of post-traumatic stress disorder to develop in veterans.

But psychiatrists at Combat Stress's pioneering centre say the men and women now being treated have come forward after just THREE years.

Also:

Dr Walter Busuttil, a consultant psychiatrist at Combat Stress, said: "What we are seeing now is just the tip of the iceberg.

"Because there has been no proper study of post-traumatic stress disorder among troops in this country we have no idea of the true scale of the problem.

"The same thing happened in the US after Vietnam. The Government tried to dismiss the disorder as a myth - then the whole thing exploded. Now when I speak to my colleagues in America they tell me: 'You are going through your Vietnam'."

And finally:

Dr Busuttil, 49, a psychiatrist in the RAF for 16 years, says the Government has covered up the severity of the conflicts from the public.

"The worst thing for a serviceman or woman is to come back from a war and for people not to have any idea what they have been through.

Editor's note: For a link to Great Britain's charity, Combat Stress, click here.  To find them on Facebook, click here. We've written about them before on this blog, but according to their website, "Combat Stress is the leading charity specialising in the care of British Veterans who have been profoundly traumatised by harrowing experiences during their Service career and who are suffering from poor mental health as a result."

A Combat Veteran Asks Himself, Who Am I, on the Inside?

The combat veteran, one with decades of severe PTSD, asks himself that question, and the answer that comes back isn't pretty.  "What's your biggest problem right now?" he was asked, and then handed some implements with which to draw his answer.  Describe what you've drawn, he was asked.  "My biggest problem?" he said, "It's that I'm 'an exploding ball of hate'...on the inside." (Comment and drawing, used with permission.)

Now, on the one hand, this doesn't tend to give you a lot of hope.  Forty years out, still thinking about life this way.  Ugh.  That's intense.  And so, so very tragic.

On the other hand, the story has a "happier" ending -- or at least, progress report.  The same person who said that is doing much better now (and has the drawings to prove it.)

But I was reminded of this story again today when I read of the terrible story of Marcus Luttrell, the former Navy SEAL, awarded a Navy Cross for his heroism, whose entire team was wiped out in a horrendous firefight in Afghanistan, and who suffered greatly because of that experience.  (Luttrell is also the author of "Lone Survivor," about that experience.) This past week, his lovely yellow Labrador retriever therapy dog -- who he named DASY, after a combination of the initials of his SEAL team buddies who were killed and himself,  who, parenthetically, says he also died on that mountain, with his team that day -- was shot in cold blood outside his house, apparently in a pointless thrill-killing by some heartless local punks.

From articles about the incident in the Houston Chronicle and on MSNBC, which described the 40 mile high-speed chase an injured (he was recently hospitalized) Luttrell went on to capture the perpetrators, assisted by the police:

"I did everything right; I didn’t do anything wrong," (Luttrell) said. "Make sure everyone knows they cold-bloodily murdered."

In other words, he was heavily provoked. (It's remarkable the self-control he exercised, just helping to capture, but not kill, the jerks who shot and killed his beloved therapy dog.)

The saddest part for me, after reading and hearing about this story, were these poignant lines from Luttrell, after the incident, no doubt disillusioned, despondent, as well as totally triggered.  Reportage said that Luttrell "said he had left his Huntsville home and [like Vietnam veterans before him, who took themselves out into the woods rather than deal with society that was hard for them to navigate anymore] was in "the middle of nowhere," adding that Dasy's killing -- of course! -- was a "huge setback" in his life. (A huge and completely unfair setback, too...cruel beyond cruel, and so completely pointless.)

Here are the heartbreaking lines of Luttrell's, as he's trying to come to terms with what just happened, not that he had any fault in the matter:

"I was trying to talk myself out of being who I am," he told the Chronicle. "Talking to myself about not doing the one thing I am good at."

Those are the words that should stick with people on this, who care about the topic of healing combat trauma, that is.  War -- and even training for war -- breaks people down and builds them back up in the mode of the warrior, in which they have a new, and very authentic skill set -- but one which they won't find much use for in civilian life, or are basically constrained by society from using.  Nobody wants to talk about it much, but the ability to kill, and the confidence and esteem that gets created by being "good at what you do," even if it's very much relegated to the combat experience, is a very hard thing to shake afterwards.

I can come back later and supplement this with references, but read the literature, watch the interviews with people who have combat-based PTSD.  There's a very uncomfortable relationship with killing: it's a high that's hard to deny, but also hard to live with, about yourself (no pun intended).  And that dilemma is at the basis of the combat veteran's, above, remark about what his biggest problem is: being "an exploding ball of hate," on the inside. 

It's very hard to get a grip on that, particularly when killing has become a significant skill set, and very hard to unwind from.  In many cases, veterans covertly mention, mostly to one another, it's become an addiction of its own.  Perhaps just the feeling of being amped up and in command of the situation, not necessarily the killing part, but whatever: it's a way they say they felt truly alive for the moment, and hard to replace in civilian life, which operates according to completely different rules, and is often ridiculously boring and unfair, by comparison.

No judgment intended: far from it.  It's the reality of the situation.  And it's part of why, as much as the military concentrates on breaking someone down to become the perfect warrior, there needs to be an equal and opposite side of the coin -- how to help someone reintegrate, so they can keep their skills, but become a whole person again who, most importantly, can look at himself or herself with appreciation and respect, for every aspect of their personalities.

Editor's note: For a video of Marcus Luttrell being interviewed by Matt Lauer, several years ago, about his book and the incident fighting the Taliban that inspired it, click here.

(Also, the second drawing, above, is done by the same combat vet mentioned in the first illustration, but it's not the one that shows improvement. It's another from the same day, where he answers the question about drawing himself "as I am now" -- in other words, with two very distinct sides to himself, darkness and light.

Getting Past the Blame Game...Especially Blaming Self

Two vignettes, both true, both involving combat veterans and PTSD:

A Marine with multiple tours of duty in Iraq and elsewhere, who can't allow himself to move after the death of two of his guys, for which he feels responsible -- even though objective third parties wouldn't see it his way at all.  It's clear from messages he left behind that he wasn't able to move on past the guilt, and eventually takes his life, and that of another person.

A former Marine with multiple combat tours in Vietnam, and one of his few buddies who survived from his platoon, who for decades spent their annual "Alive Day" getting together and staging a recreation of the battle that almost killed them with toy soldiers.  They laid out the toy soldiers in the positions of the battle they remembered from that day, and continually changed the way they arranged them, to see if there's any way the battle could have gone differently, and they could have saved any more of their men.  Was this replaying of the fatal battle at all therapeutic for them, despite how many times they did it?  Did it ever actually help?  "No," he answered, "all it did was make us mad."

I was lucky enough to have a conversation the other day with Dr. Farris Tuma, director of the Trauma Stress Research program at the National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH) in Washington, D.C.  As part of the conversation, he was telling me about what they've learned, over the years, in terms of resiliency -- who's likely to rebound after suffering a tragedy, and who is not.  Ironically?  Or maybe not so ironically -- those who hold onto blame (including self-blame) -- who need to find someone at fault -- "don't adjust as well, over the long term."  It's relatively easy to see why.  Blame, even self-blame, keeps you stuck in the terrible, tragic moment, while life -- with all its implied suffering, challenges and growth -- continues to move on.  It's very natural, Tuma said, for people to want to find someone to be at fault, at least initially.  That's hard-wired into us as humans, he said. When it becomes a problem is when that isn't just a phase we go through -- but one we're not able to leave.

The solution?  He says it's to connect with mental health professionals who are "capable and trained," and are able to address "issues like [misplaced or unhealthy] guilt," when the person is ready -- ideally, as soon as possible. What you want to overcome in situations like this is the innate cognitive bias -- the tendency to see things a certain way, different from the way they really happened, and believe that, rather than the truth, per se. Continuing to carry the baggage from the incident, continuing to blame yourself keeps you from getting past it.  What's important is to work with someone qualified who can help you see that "you didn't do something wrong."  Improved mental health can often be located on the other side of that particular statement; and unfortunately, there's lots of resistance to letting go, as though it disgraces the memory, or dishonors the deaths of those who died.  Big, thorny, difficult subject...the point of bringing it up is only to say, excessive guilt and self-blame where you can't seem to move on can be a distortion of reality, and there is a way to get help. 

The Good Work of Elmo: Sesame Street Special Supports Military Families

In celebration of April being "Military Family Month," the venerable public television institution Sesame Street rolled out a half-hour special called "Coming Home: Military Families Cope With Change," which they consider one of their most important efforts in a 40-year history.  The show features Queen Latifah,
who mentions on the show that she was raised by a Vietnam veteran with PTSD, who later got help; plus John Mayer and Elmo.

According to press material, "This half-hour special tells stories of service members who return home with injuries, visible and invisible, and explores the heroic struggles their families face in discovering a new way of finding a new normal. It salutes the extraordinary courage and strength of these military families and offers the general public a powerful glimpse into what they often must endure. The special will air on PBS on April 1, 2009 at 8PM (check local listings)." For more information about the program, click here.  To see videos about the behind the scenes making of the special, choose either one of the following links:Behind the Scenes, I and Behind the Scenes, II.

Kudos to Sesame Street for taking on this important issue, in such a positive and accessible way.

The Lure of the Partial or the Incomplete Cure

"I thought that finally learning what I had, what was wrong with me (PTSD) would be more helpful than it actually was." -- comment from a Gulf War vet, about his diagnosis.

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This post is going to be more oblique than most.  As people struggle both to find out a) what's wrong; and b) how to make it better, several problems arise -- not the least of which is the lure of the partial or the incomplete cure.

"I was so desperate at that point (in the past)," struggling with his PTSD, said one Vietnam vet, who'd experienced much combat trauma, "if someone told me that drinking bleach would help me, I'd drink it." Of course, he's exaggerating, but we understand the point that he's making.  Out of desperation, people become often ready to try anything, within reason (or even, unreasonably).

PTSD doesn't seem like it's going to produce the "silver bullet" cure.  There is no single silver bullet. But if so, why does it seem that people are still looking for one?  It's so unlikely that it will turn out to be "just one" treatment that helps, definitively.

I had an opportunity a few weeks ago to sit down to lunch with three psychotherapists, who immediately began talking shop.  One had just been to a psychological-consciousness raising group, and she was full of zealous enthusiasm for the experience, verging on proselytizing the rest of us at the table.  It turned me off immediately, and failed to interest the others at the table, but she didn't even appear to notice, as she forged on with more of the details about how great the experience was. Enthusiasm.  Hmmmn.  It sometimes borders on the frenetic, and the irrational.

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SYLLABICATION:	en·thu·si·asm
NOUN:	1. Great excitement for or interest in a subject or cause. 2. A source or cause of great excitement or interest. 3. Archaic a. Ecstasy arising from supposed possession by a god. b. Religious fanaticism.
ETYMOLOGY:	Late Latin enthusiasmus, from Greek enthousiasmos, from enthousiazein, to be inspired by a god, from entheos, possessed.

Overly enthusiastic?  It can border on the delusional :-)

It also just reminded me yet again of how able people are, with only "some" of the information, to advocate strongly for "their cure," sell tickets to others to jump on their bandwagon.  But to what avail?

There's also a strong tendency, when people are clutching at straws, to berate those who aren't willing to drink the same Kool-Aid.  Pardon the reference, but it fits. Scratch a zealot, and you easily find someone who believes "my way or the highway" about his or her cure du jour.  And unfortunately, oftentimes all that does is saddle the wary sufferer with yet more of a burden -- this time, from guilt -- over not jumping on the bandwagon.

I remember distinctly someone when I was growing up, someone very close to me, who was dying of cancer.  "It's bad enough that I'm dying of cancer," she said, "but people don't need to be maligning me that my 'faith' just isn't strong enough, or I'd be overcoming it..." Point well made.

There's an old Asian-esque expression that "when the student is ready, the teacher will appear."  That sounds very nice, and it's very consonant with offering the opportunity, but not binding the listener.  Not everyone can manage to do that.

I saw an item the other day on the Web, about a "cure" for PTSD.  It turned out to be a "juice drink" -- who knew?! And theorized that PTSD was from "organ damage" (really?). All you needed to cure the dis-ease was $400 and your appearance, in person, at an ashram, somewhere (necessarily) far removed from civilization.  Candid camera has long been off the air, but in some ways, it really might be a fit subject for that.  $400 and a juice drink, and PTSD be gone?!  Sounds highly overly simplistic.  My fear is, though, for every seemingly nutty cure out there, there's also a cadre of adherents who are browbeating those sufferers who aren't quite ready to drink the ... Kool-Aid.

And that's not even getting onto the topic of otherwise well-meaning friends and family members who think you should be "well past this" by now.  You were only in combat for how many months?  How can it possibly take over...the rest of your life?  Well...seems like it does.  It's the nature of the beast.  And while we might LIKE an easy solution...it's probably time to revisit that old adage..."the only way out of this...is through." And we'll pass on the $400 Kool-Aid.

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Another problem with the partial or incomplete cure, of course, is when it just doesn't work -- isn't able to sustain its success, over time.  This happens.  And this causes the excited convert to sink back down into a heap of disappointment, perhaps with chagrined, resentful family members gathered around as a backdrop.  The trouble with hoping "just one thing" can cure something as complex and involved as PTSD is that when it doesn't, hopes get dashed, and sufferers sometimes retreat even further into self-negative behaviors, as opposed to considering that it might have been an unrealistic hope in the beginning. 

When I wrote my book years ago about treating chronic fatigue syndrome successfully with natural medicine, I steered clear of the "single bullet" theories that so many others were espousing -- instead trying to focus on what amounts to a multidisciplinary approach to solving the problem.  Given how unique individuals are, and their biochemistry and their experiences, it's perfectly possible that what works for Person A doesn't work nearly so well for Person B.  Far better that people embrace a multitude of approaches -- anything sensible that shows any real potential for working -- and see what works best for them.  Otherwise, it becomes a war among the single-cure opponents, each of whom has the potential to be faced with crushing disappointment (including public shame, among their peer group) when whatever they've been touting so heavily turns out to be...limited in its eventual success.  The good thing about trying several reasonable approaches is that if you exhaust the potential of one, you can always move on...with no hard feelings. 

Common sense would say, beware of trumpeting from the rooftops that you're "all better now..." until you give it a while, to see if you really are.  The disappointment it breeds to have to backtrack from those premature pronouncements can be really destructive to people's own view of themselves.  And frankly, PTSD sufferers are suffering enough as it is.  Do the work...but beware the immediate, perfect cure. It may turn out to be incomplete. On the other hand, cobbling together solutions for each of the symptoms that vex you...can very much sound like progress.

Editor's note: Obviously, work with a doctor or a licensed health care professional to choose together the path that's right for you, since all these choices have consequences.  Be wise: It's your health.

Ethnic Disparities in Incidence of PTSD and Suicide among Combat Veterans

The topic of "culture, race, ethnicity and PTSD" is a complicated subject, with great potential to offend, so it has to be covered delicately, and slowly, over time.

There is a concern that ethnic minorities or non-white populations experience PTSD at greater rates than whites, but this concept is not without its detractors, who frankly disagree. 

It would be interesting to learn more about this phenomenon, and learn if the data really supports it, or if it's just an assumption.  If it turns out to be true, then it might be useful to map it against the prevalence of ethnic minorities who serve in the armed forces, in order to guesstimate more accurately future numbers of veterans who are likely to be affected by PTSD, and predict the resources that will be needed for their effective care in their home communities.  On the one hand, you would hope that these estimates were already being made; on the other hand, it doesn't seem that they are. Consequently, in this post we're unfortunately raising more questions than answers.

To narrow the focus here enough for discussion, let's take a look at just one ethnicity among many from which we could choose -- one that's on the rise in the United States (and in the U.S. military) -- Hispanics (aka Latinos). Observe how cultural issues may come into play with their incidence of PTSD, as the study indicates. (The same questions that are raised here could apply, in turn, to other ethnic minorities, and ideally, all should be studied.)

Re: Hispanics/Latinos:

"Several studies have found that Hispanic Americans have higher rates of post-traumatic stress disorder (PTSD) than non-Hispanic Caucasian and Black Americans. The authors identified predictors of PTSD symptom severity that distinguished Hispanic police officers (n=189) from their non-Hispanic Caucasian (n=317) and Black (n=162) counterparts and modeled them to explain the elevated Hispanic risk for PTSD. The authors found that greater peri-traumatic dissociation, greater wishful thinking and self-blame coping, lower social support, and greater perceived racism were important variables in explaining the elevated PTSD symptoms among Hispanics. Results are discussed in the context of Hispanic culture and may be important for prevention of mental illness in the fastest growing ethnic group in the United States." (Source.)

Hispanics/Latinos in the military. Do figures exist for how many Hispanics/Latinos are currently serving in the military; and/or are veterans of the Vietnam war, the Gulf war, the Iraq war, or Afghanistan? Are more Hispanics/Latinos joining the military?

I've seen a copy of a report that the state of Massachusetts has for number of veterans by zip code across the state.  Not surprisingly, a quick glance through that report impresses the casual reader that numbers of veterans are highest in poorer communities than wealthier communities. (You'd have to know Massachusetts for the examples to make sense, but say, the difference between Brockton or Fall River, MA and Wellesley or Osterville, MA.) A similar trend may also exist for communities with higher concentrations of ethnic minorities.

Hispanic/Latinos military suicides. Similarly, do figures exist that break out the ethnicity of active duty servicemembers or veterans who have committed suicide? Seemingly, the data to this point has not been this specific, but it needs to be.

Ironically, an unrelated study (circa 2002) done at the VA showed that with regard to being misdiagnosed with a particular mental illness (in this case, schizophrenia), you were more likely to be misdiagnosed if you were black or Hispanic than if you were white.  Also, if you were single, male, and lived in a rural area.

A study published in the American Journal of Public Health, Dec. 2007, Vol. 97, No. 12 offered some conflicting findings.  Their study, done with the VA system in the Ann Arbor, Michigan area, suggested that suicide rates for Hispanic veterans were actually LOWER than those of whites.  According to the study's authors:

"When the researchers calculated suicide rates over the entire 5.5 year study period, they were much higher for men (89.5 per 100,000 person-years) than for women (28.9), and higher for whites (95 per 100,000 PY) than for African Americans (27) and veterans of other races (56.1). Veterans of Hispanic origin had a lower rate (46.28 per 100,000 PY) of suicide than those not of Hispanic origin (86.8)."

The study had other unusual findings, including that vets with service-connected disabilities committed suicide less frequently than those without, and, most interestingly, that veterans with PTSD diagnoses committed suicide less frequently than those without such diagnoses(!).

However, the study's methodology was such that "the researchers analyzed comprehensive data from 807,694 veterans of all ages diagnosed with depression and treated at any Veterans Affairs facility nationwide between 1999 and 2004." In other words, before any significant number of OEF/OIF vets could be included in the study, a group whose rate of suicide is markedly higher than expected. In fact, during the course of the study, only "1,683 of the [over 800,000] depressed veterans committed suicide," a figure which represents "0.21 percent of the depressed veterans studied." Clearly, suicide figures among veterans today are higher than this study indicated, and it would be worthwhile redoing the study with a more current population of veterans.

600 Blog Posts And Counting...

The other day marked the 600th blog post here at Healing Combat Trauma, all on the topic of exactly that, in just over three years' time.  That's an auspicious occasion, of sorts, but no way to mark that really comes to mind, except to maybe just mention it.

Tomorrow, the Veterans Home of California at Yountville marks its 125th year with some festivities.  The Veterans Home is an impressive location, which these days also houses The Pathway Home, an innovative residential treatment program for combat veterans with PTSD, one of the only ones of its kind in the United States, and very much a standalone program (meaning, not part of a series of them elsewhere).  The executive director of the Pathway Home is Fred Gusman, M.S.W., a name long familiar as a veterans advocate, even as far back as the Vietnam war.  The Pathway Home was recently featured in the "In These Boots" documentary film series, in the segment entitled "Broken Promise," about three Iraqi vets and their experience there, after feeling let down by the Department of Veterans Affairs. (We wrote about that in a blog post, linked here.)

I've been able to go to the Pathway Home and visit with some of the residents, and bring with me a Vietnam veteran and former Marine who spent time in a residential program for PTSD years ago, which, like the Pathway Home, was considered cutting edge at the time.  It was interesting watching him interact with the current veterans: They definitely could relate to one another. (Ironically, one of the vets we met was one of the three featured in the film, but we met him before knowing that.)

I'm still a little unclear on what the Pathway Home actually does to help its residents "get better"...perhaps over time that will become a little more obvious. They seem to be "trying" a lot of things, but as to why some choices and not others, that methodology seems unclear.  Either that, or they're just not broadcasting much about it.  Even the documentary film segment didn't shed any light on that.  The residents appeared reasonably pleased that it was meeting their needs, but as to what or how, again, nothing in particular was revealed.  I believe the Pathway Home is also in year one of a three year grant, so fundraising efforts to continue the program are undoubtedly underway or soon to become so.

In the meantime, Happy 125th Birthday to the Veterans Home of California at Yountville, and Happy 600th Blog Post on PTSD to us.

Editor's Note: On April 1, 1:30 p.m., at the Main Chapel, the public is invited to join in celebrating the 125th anniversary of the Veterans Home of California at Yountville. At 2 p.m., there will be a slide show followed by an ice cream social at 2:30 p.m.