Healing Combat Trauma

Kind Words from a Mentor and Friend about "Healing Combat Trauma"

Unsolicited feedback can be encouraging, especially when it's positive. Had a very nice surprise of that kind this past this past week when I received a lovely and unexpected email from Arthur Egendorf, Ph.D., a dear mentor and friend, whose own work with war veterans recovering from trauma gave me practical hope that good, heartfelt work could be done in this area.

(Egendorf is a Vietnam veteran [Army intelligence] with a Ph.D. in psychology from Harvard, and a lifelong interest in therapeutic healing modalities, beginning with talk therapy and branching out from there. He was one of the originators, in the 1970s, of the "rap groups," that allowed returning Vietnam veterans to have someplace to go and peers to talk with, when they weren't willing to take part in the services offered by the V.A. In any history of the Vietnam era that focuses on PTSD and veterans, such as Gerard Nicosia's encyclopedic "Home to War: A History of the Vietnam Veterans' Movement," Egendorf is one of a handful of experts from the time whose name keeps coming up.) 

I'll write more later in the month, as a certain anniversary date rolls around, about how much his award-winning book "Healing from the War: Trauma and Transformation after Vietnam," (sadly, now out of print) was put to constructive use with one veteran, whose life it helped to change. It's fair to say that my copy of his book is fairly well completely yellow from highlighting key passages, thoughts and inspirations, so it was especially gratifying to receive these unsolicited kind words from him.

Dear Lily,

In dedicating so much of yourself to the men and women who risk and give their lives for duty, honor, country you do all of us, this mostly sleep-walking America, a great service.  As tireless, fearless, noisy (when necessary) and deeply caring witness you give our soldiers and veterans what they deserve from this entire country but get from only very few.  As one who knows a bit of what it takes to love and care for bloodied and pained survivors who've fought for all of us and then have been mostly ignored, I salute and cheer you on to keep waking us up.  Keep shaking us, Lily.  Keeping making us see how much those who've served have given to us, and how much we owe our thanks, respect and unending care.  You go girl.  

Artie Egendorf 

Editor's note: For more of an introduction to Egendorf's work, here are a few posts that mention him, linked here, here, here (this one in particular, called "A Hand Across the Abyss: How Openness Helps Heal"), and here, among others.

More Praise for "Healing Combat Trauma"

Belleruth Naparstek, Ph.D. is a psychotherapist, author, and guided imagery pioneer who is also the author of Invisible Heroes : Survivors of Trauma and How They Heal, and Health Journeys: A Guided Meditation for Healing Trauma (PTSD), two items that have helped many veterans interested in healing to make definite forward progress.

This past year, Naparstek published an important and educational article in the Huffington Post in May called "Note to Colleagues: Please Stop Saying Post Traumatic Stress is Incurable," linked here, as well as one in February called "Returning Troops from Iraq and Afghanistan are Different From Our Vietnam Vets," linked here, both of which are "required reading" for those who want to understand what obstacles face veterans and clinicians alike in treating combat-based post-traumatic stress.

Just the other day I happened to read an article on Naparstek's own HealthJourneys site where she mentioned our very own Healing Combat Trauma as "an excellent site" and referred readers to it. Very gratifying praise indeed from a someone who's a true pioneer in thinking about and working with trauma survivors.

Praise for "Healing Combat Trauma"

Had a nice surprise at the week-long clinical training in PTSD at the National Center for PTSD. Picked up a copy of Ray Scurfield, Ph.D.'s comprehensive "War Trauma Resources," and in it read something very nice he said about this site: "Lily Casura’s very rich compendium -– she has over 100 categories of information! -- of books, article, commentaries, resources, other readings and information regarding military, veterans and their families. I am most impressed with Lily’s passion, dedication and abilities as an advocate for vets and their families." -- Ray Scurfield, Ph.D.

 Scurfield is and was one of my first heroes in this because of his longtime work with veterans healing from war trauma, so it's extra-nice to hear something like this from him. In addition to the resources he provides nationally, Scurfield is also the author of three key books about veterans and PTSD: A Vietnam Trilogy, Healing Journeys, and War Trauma.

Occupational Therapy and PTSD -- It Had Its Origins in WWI, with Shell Shock

April is "Occupational Therapy" month, and come to find out -- Occupational Therapy has an interesting past! It was founded in World War I as a way to deal with shell shock -- what PTSD was called at the time -- because it was thought that "doing" was therapeutic for injured veterans, not just "talking." I've been fascinated with this ever since I learned it from an OT with a specialty in mental health, who has practiced in and around the military for decades.

(If you know any veterans who have been injured, you've probably heard about occupational therapy for traumatic brain injuries (TBIs), amputations from IED blasts, etc. But PTSD? Wow. Who knew that it was founded as a discipline to address that!

On the hunt for more information about this topic, I uncovered the following. Carolyn M. Baum, Ph.D., the immediate past president of the American Occupational Therapy Association ("AOTA") presented testimony on post-traumatic stress disorder to the House Veterans’ Affairs Subcommittee on Health on April 1, 2008. Her testimony, "Post-traumatic Stress Disorder (PTSD) Treatment and Research: Moving Toward Recovery, "explained the unique contributions of occupational therapy in the treatment of PTSD and other mental health issues."

"Occupational therapy brings a third dimension to the system of care for PTSD. Medication and counseling, supported by occupational therapy and performance, is the approach that we recommend the VA adopt, she said."

Dr. Baum also promoted the role of occupational therapy broadly with the Veteran's Administration (VA).

(Inquiring minds want to know what happened with that...)

Here are her remarks in full:

Statements of Carolyn M. Baum, Ph.D., OTR/L, FAOTA, Immediate Past President, American Occupational Therapy Association, and Professor, Occupational Therapy and Neurology, Elias Mitchell Director of the Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO; David Matchar, M.D., Member, Committee on Treatment of Post-Traumatic Stress Disorder, Board on Population Health and Public Health Practice, Institute o Medicine, the National Academies, and Director and Professor of Medicine, Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC; and Mark D. Wiederhold, M.D., Ph.D., FACP, President, Virtual Reality Medical Center, San Diego, CA; Accompanied by Gerald M. Haase, M.D., Founder and Chief Medical Officer, Premier Micronutrient Corporation, Nashville, TN.

Statement of Carolyn M. Baun, Ph.D., OTR/L, FAOTA:

Dr. Baum. Thank you, Mr. Chairman, Members of the Subcommittee, for giving me the opportunity on behalf of the American Occupational Therapy Association to discuss issues regarding post traumatic stress disorders.

You introduced me, so I will bypass that. I also am the Professor of both Occupational Therapy and Neurology at Washington University School of Medicine.

Occupational Therapy (OT) has had a rich history providing services to veterans dating back to World War I. Occupational therapists help wounded warriors return to their military responsibilities or transition into civilian life. We do this by helping them set goals, develop strategies to accomplish their goals, and gain the skills that allow them to achieve the maximum level of participation and independence.Occupational therapy perhaps is best known for its work in rehabilitation services after stroke, loss of vision, physical injury, including amputations, and traumatic brain injury, but occupational therapists also treat individuals with stress-related disorders that result in mental and cognitive impairments as well.

OT plays a unique role in helping veterans recover from PTSD as they serve as key members of the team, that along with physicians and psychologists who use medication and counseling, the occupational therapist employs performance strategies that support the veterans in achieving success in their performance in daily activities.

Actually, it is in these daily activities that it is possible to observe the problems veterans are having with multi-tasking, with sequencing of tasks, with their safety, with their judgment, and actually identifying the cognitive fatigue which has a very important need for consideration.

These are all problems that require strategies for individuals to overcome.

The effective treatment of PTSD and the return of veterans back into their work, their family, and community lives really requires an integrated system of care that includes assessment, goal setting, treatment, and learning to self-manage life with PTSD.

Rehabilitation does not stop when veterans are discharged from hospitals or medical care. It must be provided along a continuum addressing community reintegration, social reconnections, and work accommodations. All these are areas in which occupational therapists play an important role.

Veterans with PTSD often have difficulty in their daily lives and avoid activities because they result in anxiety or fear or even anger. Consider, for example, a soldier who is driving on routine patrol when a road-side bomb explodes. Upon returning home, the veteran might experience flashbacks of that event triggered simply by driving.

The therapist might use simulated or virtual reality driving experiences or even actual driving experience in a controlled environment to help the veteran extinguish or reframe the negative stress reactions.

Therapists also work with veterans to help them manage issues related to PTSD such as depression, mild head injury, or concussion, and substance abuse by helping them develop strategies to reengage in daily life that are meaningful for them and their families. Having the families involved is particularly important because we know the importance of social support to individuals recovering from PTSD.

The unique contribution of occupational therapy is highly valued by the Army for their combat stress control. The Army model deserves additional attention from the Veterans Administration and the Subcommittee because it fully recognizes occupational therapy's contribution as a member of the team by adding the performance component to the medication and counseling provided by other team members. We recommend the VA consider and adopt the Army model.

The Veterans Administration has made significant strides in preparing to meet the needs of veterans, but work remains to be done. There are only 750 occupational therapists in the entire VA system. While both the Veterans Administration and the Department of Defense guidelines for PTSD exist and include occupational therapy, it is the experience of our members that the inclusion of occupational therapist varies from site to site. This variation does not ensure full access to effective treatment.

The American Occupational Therapy Association encourages the Committee to look at this issue. From the consultation with AOTA's members within the VA, we have heard that they are struggling to maintain the quality of care for which they are known because of increased demand for rehabilitation services and gaps in staffing.

The most important issue is to ensure that veterans receive the services they need to recover and reenter community life, able to care for themselves and others, able to work and make contributions to their families and communities. If the VA has staffing problems, they should look for, and contract with, community programs to provide the services that the veterans need.

Just as you discussed earlier with Colonel Hoge, there is also a need to study the effectiveness of complex interventions, medications, counseling, and I would ask for consideration to add the third leg to the stool, the importance of daily life performance.

Research should seek to understand the relationship of quality of life to PTSD symptom severity, disability, treatment outcomes and cost. The problem begs for an interdisciplinary translational clinical study.

Mr. Chairman, I have made additional recommendations in my written testimony, but I want to highlight a couple of issues for your Subcommittee's consideration.

To increase the numbers of occupational therapists within the Veterans Administration, we would urge that the Subcommittee consider expanding the Student Loan Repayment Program to ensure that the VA remains an attractive employment option because there is a real supply and demand issue for OTs right now and that would draw people to the VA services.

Salaries in the VA appear to be lower than other healthcare settings. The Bureau of Labor Statistics estimated in 2006 that the average salary in California for occupational therapists was $73,000. Right now the Palo Alto Polytrauma Rehab Center is offering $50,000 for two new positions that have been vacant since last July.

New positions continue to be added across the country, but salary will continue to be an issue, and AOTA urges the Subcommittee and the VA to attend to salary, recruitment, and retention issues.

Mr. Chairman, in conclusion, I want to reiterate that occupational therapy has expertise in the treatment of functional impairments resulting from a broad range of conditions faced by veterans, including PTSD. Occupational therapy should be explicitly included on treatment teams to address the every-day life issues of veterans and their families through the phases of recovery and community reintegration.

Thank you very much for the opportunity to provide testimony to the Subcommittee. AOTA looks forward to working with Congress and the VA to meet the needs of our veterans. And I would be happy to answer any questions. Thank you.

[The prepared statement of Dr. Baum appears on p. 45.]

Mr. Michaud. Thank you very much, Dr. Baum.

Editor's note: The source for the testimony is linked, here.

Cast Adrift by Trauma in the Center of Your Own Universe...

I've been reading Belleruth Naparstek's book, "Invisible Heroes: Survivors of Trauma and How They Heal," and she makes an excellent point both about the safety and normalcy we unconsciously come to expect from life, and then the terrible way in which we find ourselves suddenly cut adrift from those same moorings through tragedy and trauma.

After first describing how the human toddler first takes sheer delight in realizing they are the center of their world and can "make things happen" -- by knocking over piles of blocks in play, again and again, or shouting and laughing at the sound of his or her own voice -- she the contrasts this with the sheer helplessness people feel because of a trauma-causing incident. Sagely, she describes the point:

"And because it is built into our human hard-wiring to love ourselves for being able to make things happen, the converse is also true: we lose self-regard when bad things happen that are beyond our control.  The essential insult of trauma is the helplessness it generates, and the inadequacy and powerlessness we feel in its grip.

Rational or not, we can't help but feel it's a reflection on our worthiness that, when confronted with a terrifying and terrible event, we didn't prevent it, escape it, or fix it.  So we somehow lose value to ourselves and, at a level we may not even be aware of, we feel guilty and ashamed."

This is a powerful and accurate description of what so many people go through after trauma. Good for Naparstek for bringing it to light.

Triggered by Talking about Trauma

It seems a bit paradoxical that the very act of attempting to talk about trauma might actually trigger trauma, and turn out to be "too much" for the traumatized person to handle, but this can be the case, according to Belleruth Naparstek, in her well-regarded book, "Invisible Heroes: Survivors of Trauma and How They Heal." She writes:

"This is because with PTSD, language can be a trap. If a deeply traumatized person is prompted only to speak and think about the events that created his distress, without enlisting help from the imaginative, emotional, sensory and somatic capabilities of his right brain, his symptoms can actually get worse instead of better.  Encouragement to "talk about it" -- a therapist's and, for that matter, a good friend's stock-in-trade -- can catalyze a tailspin of flashbacks, nightmares and overwhelming anxiety."

Clearly, we're just scratching the surface here of a much larger topic.  But while the case can be made that listening to another deeply is often quite therapeutic, having to talk about (relive) something traumatizing might have adverse effects.

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.)

"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).

Upcoming Seminar: The Warrior's Journey: Healing PTSD (with Edward Tick)

The Warrior's Journey: Healing PTSD (6 CE hours)
Tuesday, April 28, 9 a.m. to 4 p.m.
Tuition: $150 general public; $130 Antioch alumni, faculty, staff

War's violence is so severe that it can cause the true self to become distorted or lost for life. Untold numbers of veterans from old and new wars suffer Post-traumatic Stress Disorder (PTSD). Newest estimates are that 20-40% of Iraq returnees come home with PTSD and its multitude of disabling symptoms. Countless more return with severe, disabling wounds to body and mind. Contemporary society and the institutions meant to serve veterans are in crisis and at a loss as to how to respond to this massive wounding.

In this workshop, gain insight into the psycho-spiritual approach to healing from war. Learn how PTSD is not just a stress and anxiety disorder. It is also an identity disorder, soul wound, interrupted initiation and social wound. Examine various forms of psycho-spiritual interventions and community activism that rebuild veterans' identities, shrink trauma and restore wounded dimensions of soul. Develop a deeper understanding of PTSD treatment philosophies and strategies that can bring hope and healing to veterans and their families. Explore the spirituality inherent in war and learn how to use it to heal veterans and society.

Instructor: Edward Tick, Ph.D., is a holistic psychotherapist, writer, educator, journey guide, activist and veterans' advocate. He has been working with veterans and survivors of war, violence and trauma since the late 1970s. He specializes in using psycho-spiritual, cross-cultural and international reconciliation practices to help veterans, communities and nations heal. He is founder and executive and clinical director of Sanctuary: A Center for Mentoring the Soul, and of Soldier's Heart: Veterans' Safe Return Programs. Tick is adjunct professor in both Communication and Global Studies at the Sage Colleges. Tick is the author of War and the Soul: Healing Our Nation's Veterans from Post-traumatic Stress Disorder.

Editor's note: for further information about the program, click here and scroll down until you see this particular seminar.

News from Hell before Breakfast: Journalists, War Trauma and PTSD

"I hate newspapermen. They come into camp and pick up their camp rumors and print them as facts. I regard them as spies, which, in truth, they are. If I killed them all there would be news from Hell before breakfast." -- attributed, perhaps erroneously, to Civil War General William Tecumseh Sherman.

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A different quote:

"On Thursday, June 26th, I witnessed the immediate aftermath of an Al-Qaeda suicide bomb attack.  Several dozen people lost their lives... children, old men, civilians, police, and military men.  The scene was horrific beyond words, even for someone like me who has a fairly high threshold for such things.

I found it nearly impossible to look through the viewfinder.  What I saw was abhorrently graphic, yet far too important for the world to ignore.  I present images that provide an uncensored view of a terrible event, and some small measure of dignity to those who lost their lives."

-- Zoriah, international humanitarian photographer, whose gripping images from that event were later censored by the U.S. military, and he was evicted from his embed assignment with the Marines. (The link to the post where he talks about those images, and shows them, is here.)

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PTSD from being a combat journalist of photographer, embedded or otherwise:  Not everyone who's exposed to combat trauma develops PTSD, as we know.  Recently, Kimberly Dozier, CBS correspondent and author of Breathing the Fire, says she didn't develop it from her horrific near-death incident in Iraq in May of 2006, though ironically -- according to Dozier -- almost everyone she interacts with believes thatshe must have.  (See article to that effect by Dozier, linked here.)  However...many do; and for others, the signs and symptoms take time to manifest themselves. 

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Journalists bear witness, both to some of the most savage atrocities of wartime, though without the training and the mindset of combatants, and also to the suffering of the survivors, military and civilian.  Says one photographer who served in Vietnam:

It has been very difficult for me [to recount some of his memories from the past] as it has brought back many of the horrible nightmares that I had thought that I had finally put away. It did get them out in the open and off my chest so to speak and now my family now knows why I sometimes have to take those walks out into the woods alone to just get away. Hard to explain. I do have severe survival guilt as I have lost far to many friends in combat in up close and personal confrontations. I have many photos of me smiling and yes there were many good times. However; there were enough bad times to more than compensate for the good ones. I have learned to cope with this new world that I came home to only because I still feel a great need to help my fellow veterans. We 'Nam veterans are all but forgotten in my eyes.

Two significant resources: Dr. Anthony Feinstein's work, and the Dart Center for Journalism and Trauma.

Two excellent books:

Dangerous Lives: War, and the Men and Women Who Report It, by Anthony Feinstein (2002); and Journalists under Fire: The Psychological Hazards of Covering War, by Anthony Feinstein. (2006).  (Recommended by Jonathan Shay, M.D., Ph.D., noted PTSD expert.)  Shay wrote: "the first and only book about the occupational [psychological] hazards of being a war correspondent.  Published in Canada, will come out in the US next year from Johns Hopkins UP with a new chapter on embeds."

Dr. Anthony Feinstein is a professor of psychiatry at the University of Toronto and a neuropsychiatrist at Sunnybrook and Women's College Health Sciences Centre in Toronto. He is an expert on Post-Traumatic Stress Disorder in war journalists. Feinstein received a 2001 Guggenheim Fellowship to pursue his research. Dr. Anthony Feinstein's bio is linked here.  Much better bio, linked here.

For reporters: War, Journalism and Stress: The Self-Assessment Test, linked here. (General description of the test, linked here.)

What Feinstein has to say:

More than anything, says Feinstein, he’s learned that, “War is not good for journalists. They suffer from it.”

Specifically, they suffer post-traumatic stress disorder, substance abuse and anxiety disorders. One in five journalists, over the course of a long (15-plus-year) career, endures significant PTSD, says Feinstein. That means, among other things, bad dreams, flashbacks, numbness, an overly sensitive startle response and an inability to get close to others emotionally. One in four experiences depression. “And a number drink very heavily as well,” says Feinstein, “but I don’t know how many, because I never know for sure what they’re telling me.”

The most surprising revelation of the research for Feinstein? “I didn’t realize that the journalists were in such great danger. You see them when they report the news: cool, collected, with everything seemingly going on behind them. But these people are really right in the middle of it all.”

He is particularly sympathetic to still photographers. More than anyone, he says, these professionals have no choice but to get into the thick of things to do their jobs well.

The Dart Center for Journalism and Trauma, located on the campus of the University of Washington in Seattle, is a particularly good, targeted resource for journalists about reporting and trauma: both externally reporting, and internally experiencing trauma from reporting in war zones.  Click here to look through their extensive offerings, which are really superb.

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Who's the handsome young man in the photo? 

That's Robert W. "Grif" Griffin.  Griffin says, "I was a combat photographer with the 1st Cavalry Division Airmobile from 1966 to 1968 and 1970. I was in country [in Vietnam] as a photographer from 1966 to 1968, and back again in 1970."  (He was shot down near Quan Loi in 1970.)  He adds that he "spent 20 years in the Army mostly as a photojournalist/motion picture and still photographer."

According to Griffin, "the photographer who took the photo is Jere L. Smith, a fellow combat photographer and a Specialist E5 at the time. We were both assigned to the 13th Signal Battalion, which was part of the 1st Cavalry Division Airmobile."  At the time the photo was taken, Griffin was duplicating some slides for his Command for a Division briefing that was to take place in several locations at the same time: hence, the dupes.