Healing Combat Trauma

Social Support a "Powerfully Protective Factor" Often Not Available to PTSD Sufferers

A quote about PTSD and its impact on the individual sufferer's ability to receive support from those around him or her:

"Social support is a powerful protective factor (Brewin, Andrews & Valentine, 2000) that includes the capacity of an individual to accept or utilize social support when it is made available (Benight & Bandura, 2004). This may be especially problematic in PTSD where symptoms such as avoidance, alienation and detachment impair affected individuals from benefiting from available marital, family, and social support."

Source: Oxford Handbook of Anxiety and Related Disorders, by Martin M. Antony, Murray B. Stein, linked here.

Upcoming Seminar on Warrior Health: PTSD, Depression and TBI

The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., presents:

A Center for Deployment Psychology Training Program:

"Addressing the Psychological Health of Warriors and Their Families: PTSD, Depression and TBI."

When: Mon 22 Jun 2009 through Fri 26 Jun 2009.

Where: The Cheyenne Mountain Resort, Colorado Springs, Colorado.

What: This intensive course, which is comprised of 4 modules, will train civilian mental health providers to better address the behavioral health needs of military personnel and their family members throughout the deployment cycle.

Who: The intended audience is civilian mental health providers who provide behavioral health care to the military population or military family members, including veterans and their loved ones.  This training is NOT intended for active duty military providers, but rather for civilian or private practice/community providers.

Supported by: Fort Carson Soldier Readiness Center, National Organization on Disability, Operation TBI Freedom and Regis University.

For more information about this upcoming seminar or to register online, click here.

Travis Twiggs: The Un-Happy One Year Anniversary of Combat PTSD's Perhaps Most Visible Death

Just a brief note to mention, it was one year ago today that Travis Twiggs passed from this earth, by his own hand, the veritable poster boy of combat-based PTSD.  It also marks his brother Willard's passing, who left this earth with Travis, apparently by Travis' hand.  It's an absolute tragedy, for any number of reasons -- from the family members and friends the Twiggs brothers leave behind -- to the fact that Travis, personally, was making an impact as a Marine who broke the code of silence, so to speak, and spoke openly about his PTSD.  Twiggs wrote about his ordeal in the January, 2008 issue of the Marine Corps Gazette, in an article that has been widely circulated, and is still available on the Web.

Travis Twiggs' suffering was something that really stood out to me -- perhaps because of his very willingness to speak openly about his struggles, something Marines.Just.Don't.Do.  We actually broke the news of his death on this blog, before the mainstream media had reported on it -- and in fact, the early reports were wrong on the facts but widely repeated, making the damage that much more painful.  (He and his brother were reputed to be hardened criminals, for example, which they were not, although they had been -- at the last -- involved in a carjacking, as part of their initially ill-fated but ultimately successful desire to end their lives.  In fact, Twiggs was a much-decorated Marine with multiple combat tours behind him, who had recently met the president, and whose Marines (and his family) deeply loved him.  His brother, Willard, was well-loved as well.  A year later, not a day goes by that people don't find this site out of a search they're doing for Travis or Willard; and in the days after their death, searches for Willard were almost as popular as those for Travis, though Willard was obviously shyer and less well known. And these tragedies were not the only ones the Twiggs family suffered in a very short amount of time: their beloved grandmother also passed away within days of the Twiggs' brothers' deaths. Hard, hard times for the Twiggs' family, and for all those who loved Travis and Willard.

It's hard to explain my own involvement in this saga except to say, I had a bad feeling about how Travis was really doing, without even knowing him, just based on reading what he wrote, and how it didn't seem to add up.  So the month before, without realizing he'd already been confined to an inpatient PTSD program at Bethesda Naval Hospital, and was therefore unable to answer, I repeatedly tried to get ahold of him and/or the Marine Corps Gazette, which had published his somewhat optimistic article months before.  When neither would reply, I started to really worry that something was amiss.  Then when the first news reports came out of the National Park Service about the "armed, tattooed and dangerous" Twiggs brothers, involved in a carjacking, I just knew it had to be Travis, and that things had somehow gone terribly wrong. Hoping to offset the "bad news" (and mistaken news" about who Twiggs really was -- not a lifelong criminal, but a decorated Marine, who everyone loved, who'd struggled mightily with PTSD -- I went out on a limb, and wrote, as I realized he was dying, what became a "PTSD obituary" to this at the time unknown Marine, who'd undoubtedly died from the consequences of his uncured, but not untreated PTSD.

In the days that followed, as I waited for any national attention to be focused on his case -- none was -- the blog here received heavy, heavy traffic, as those who loved Travis and his brother came to essentially pay their respects, much as I had tried to myself, and also tried to come to terms with the brothers' passing.  Over time, various reporters kicked into gear and started covering the Twiggs' story in lengthy pieces. (I had to put the "use with attribution" notice up on this blog when one reporter spent, no joke, 40 hours mining this site, without acknowledging where he got his information.  Ugh.) Richard Ruelas wrote about the saga for the Arizona Republic (the brothers had died in Arizona), Bill Finnegan's at the New Yorker magazine, and there was a two-part series in the New Orleans-based Times Picayune. CNN, to its discredit, never once mentioned the brothers' passing.  I think once they missed the initial window, it was too embarrassing to catch up, but to this day, they never have, whereas pretty much everyone else has had something to say about it -- or them.

While many, many aspects of being the one to break this story -- on a blog, not in a newspaper or a wire service -- have been exceedingly frustrating, I'll spare you my angst on that one.  The blessings have also been there -- getting to "meet" online and sometimes in person, some of the key players in the brothers' lives, and have them express their appreciation for what I did to help to humanize their brothers, while the rest of the print world was essentially doing the opposite (at least initially). I'm still concerned for how Travis' wife, now his widow, Kellee, to whom the news of Travis' whereabouts and obviously his death, came about as a shock, as well as for the Twiggs' parents, whose loss of two sons at once is just incalculable.

In the New Age-y world, people do talk about being careful about what your intention is, and how your intention will carry the day.  Without going into what "intention" means, overmuch, it can be simplified to say, whatever the vision is of an outcome, that you carry in your heart, or that you express to the world.  In this case, it was very, very clear.  Back exactly a year ago today, as Travis Twiggs and his brother were in their last moments, and time was running out, I wanted the world to NEVER FORGET who Travis Twiggs was, and what the legacy of unresolved PTSD looks like.  If ever there were a poster child for PTSD, it was Travis Twiggs.  He took the first step when he told the world his secret in that powerful, much-read article in the Marine Corps Gazette, when he broke the silence for his Marines, and the rest of OEF/OIF veterans.  What I held in my heart that day -- despite the professional disappointments that may have followed -- was that when people thought of PTSD, they would think of Travis Twiggs.  And given that his legacy is still very much alive, one year later, I do believe that intention accomplished exactly what it was supposed to.

As Twiggs himself said, he was willing to come forward and talk about what he went through, because he wanted no other soldier, sailor, airman or Marine to suffer like he had -- in silence.  With his death, and that of his brother, unfortunately for the much-beloved Twiggs brothers, but mercifully for the rest of us -- it's a conversation we will all keep having.  RIP, Travis and Willard Twiggs. You are not forgotten.

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Editor's note: The original blog entries about Travis Twiggs from a year ago are: "One Marine Reflects on His Battle with PTSD," linked here (before his death); "PTSD -- "The War Within" -- Claims Another Victim," linked here; "RIP Travis N. Twiggs, USMC PTSD Sufferer," linked here; "The Ballad of Travis Twiggs," linked here; "Travis Twiggs' Suicide - Only Questions Remain," linked here; "The PTSD Obituary for Travis Twiggs," linked here; "Bleeding Green with PTSD," linked here; "Twiggs' Wife: 'The PTSD Drove Him Crazy'," linked here; "The Tragic Last Days of Travis 'T-Bo' Twiggs," linked here; "Travis Twiggs' Widow, Kellee, Puts a Human Face on the Suffering of PTSD," linked here;and, finally, "SSgt. Travis Twiggs - Well-Loved U.S. Marine and Hurting PTSD Hero - the Update," linked here.

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.)

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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.

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.

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.

Sometimes a Photo Just Says It All...

Libraries Across America Offer Veterans Information Next Week for Veterans' Day

The American Library Association (ALA) is spearheading a series of activities during the week of Veteran's Day, November 11, 2008 at libraries across the country to make information available to help veterans and their families better understand the education benefits available under the new Post 9/11 GI Bill.

ALA's Office of Government Relations (OGR) is working with a group of four national organizations in this effort, including the American Legion National Headquarters, the American Council on Education, the National Association of Federally Impacted Schools, and the National Military Family Association.

(Realistically, knowledgeable reference librarians are always happy to help veterans and their families with information at their disposal; next week, however, appears to be a special push to get this information into the hands of veterans and their families, in honor of Veterans Day.)

For more about the services available, click this very Wikipedia-looking link, provided by the American Library Association.

Books Fall Open, We Fall In: Reading to Better Understand the Vietnam War and Its Veterans

The kindly and indulgent boyfriend, GuvBoy, left for the local library book sale with instructions to purchase anything that looked good about the Vietnam war and several other blog-related topics. As a former journalist and all-around smart person, he knows how to figure that out, so I knew I was in good hands.  As it turns out, he returned with some good ones, that seem to have been lost to history.  So I thought I would point them out here, in case they help anyone else who's interested in digging deeper into what went on and what the combatants experienced. 

(In case it's never been clear what orientation the categories of books in the various columns flanking this blog have, here's the breakdown:

The column to the right here on this blog lists various books of poetry about war, any war; followed by a section of all sorts of excellent first-person narratives about various wars, the better to give us an understanding of what veterans went through.  Those first-person narratives are organized by war, to make it more self-explanatory.  The column to the left here lists therapeutic resources for dealing with combat trauma up on top; and various miscellaneous things that get mentioned on the blog further down).

For Vietnam-era veterans who want their families (i.e., children and grandchildren) to better understand what the war was like, I'm still recommending "Home to War: A History of the Vietnam Veterans Movement," by Gerald Nicosia, because while he's talking about the veterans movement, in 700 pages, he's capturing all sorts of history of the era and feelings for and against.  The book is actually pretty neutrally, historically written, and it's a very good resource.  I've blogged about it earlier, here.  Except for its oversight of the extremely impressive (to me, anyway) Lawrence Kolb, M.D., I can't say enough good things about Nicosia's book.  There's a fascinating wealth of information about the legitimization of the PTSD diagnosis in the book as well.

Here are a few others:

Stanley Karnow's Vietnam: A History, is also good.  The cover calls it "The first complete account of Vietnam at war" -- maybe it should actually say, the first complete account of Americans at war in Vietnam -- so it has its place.  It was written as the companion to the long-ago PBS series of the same name.

Plus three new finds, though, thanks to the pleasantly-disposed boyfriend and his handful of small bills:

"Long Time Passing: Vietnam and the Haunted Generation," by Myra McPherson; "Healing from the War: Trauma and Transformation after Vietnam," by Arthur Egendorf; and "Vietnam: the Valor and the Sorrow" (from the home front to the front lines in words and pictures), by Thomas D. Boettcher.

Each of these books has a particular reason why it's good and worth perusing.  McPherson was a Washington Post and New York Times reporter who carried on 500 interviews with veterans and others to get her material; Egendorf, who Nicosia writes about in his history, was a Harvard graduate, Vietnam vet and psychologist who became one of the founders of the first rap groups to help veterans deal with the personal fallout from the war; and Boettcher was a graduate of the U.S. Air Force Academy who served in Vietnam in the press corps.  His book has more than 500 photographers, many never before published, which adds greatly to its interest (it's also very well-written and well-paced, not deadly.) 

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Additionally, we've already blogged about Lori Sekala's great bibliography on PTSD and war in the blog post entitled, "A Good Librarian is a Wonderful Resource," linked here.  (Sekala is the collection management librarian at the U.S. Army War College library).  But here's something we haven't talked about yet -- possibly THE definitive bibliography on books about the Vietnam war, to better understand the experience.  It's linked here.  Enjoy :-)