Healing Combat 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.

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.

Sarah Haley - Psychiatric Social Worker, PTSD Pioneer, Friend of Veterans

Gerald Nicosia's book Home to War: A History of the Vietnam Veterans' Movement, is fascinating reading, if only to keep in mind the wisdom of the George Santayana quote, "If we do not learn from the mistakes of history, we are doomed to repeat them."  Nicosia goes into much detail about how the PTSD diagnosis was first determined and included into the DSM, and along the way he paints the picture of many of the key participants, including Sarah Haley, in first treating Vietnam veterans for combat trauma and the resultant PTSD.

Whenever we look at history like this, it becomes apparent that whoever is impressive today in this work owes so much to pioneers like Haley (who Nicosia discusses) and Lawrence Kolb, M.D. (who Nicosia oddly does not).  "Standing on the shoulders of giants" is the semi-cliched expression about what present practitioners owe as a debt to the pioneers of the past, and it is certainly true about Haley's work: she was a true giant.

Here I'm going to excerpt, with Nicosia's permission, parts of the many passages about her work so you can see three important things: what her background was, which gave her a special compassion for the truth the veterans first presented with; the extent of her rapport with and trust established with the veterans themselves, which allowed her to help them; and some of her more intuitive leaps about what PTSD really meant from the lives of veterans with whom she consulted.  What a truly remarkable person; and what a shame she's no longer with us, so that we can continue to benefit from her truly outstanding work with veterans.  (Few of these quotes are continuous; most skip around from important part to important part, with the gap indicated by the ellipses)

Haley's background:

"It was a woman .. a psychiatric social worker named Sarah Haley, in the big VA outpatient clinic in Boston, whose research into veterans’ stress disorder literally blew the existing psychiatric definitions to pieces and began to put a whole new definition on the map.

"Sarah Haley [initially] seemed the least likely person in the world to make waves…

Her friends all warned her that the VA’s psychiatry program was “fifth-rate,” that she would find herself treating ‘chronic schizophrenia and passive-dependent men with bleeding ulcers,’ and that her career would surely go down the tubes.  But despite the fact that she entered upon her new VA job with the meagerest of expectations, she couldn’t help being ‘shocked at the low caliber of the general run-of-the-mill health person there.’  As she recalls, ‘These were not mental health people that you would want anybody in your family to get near.’"

 

Haley's first astounding discoveries:

"One day, a young man in a highly agitated state was brought into the clinic by his parents.  He had only been home from Vietnam for three days, and his parents had no idea what to do with him.  He was having total body tremors and exhibiting ‘startle response’ every few minutes.  If a car backfired or a door slammed, he would dive under the nearest table.  After much rambling, the young man told her he had been at a place called My Lai, that terrible things had happened there, but that it was difficult to piece it together.  He was confused and experiencing a lot of amnesia, but he did remember seeing the bodies of women and children and vomiting into the bushes.  He also remembered that he could not shoot anybody himself, that he had thrown his gun down.  The American soldiers who did the killing had sought to intimated him and the others who didn’t shoot: ‘If you ever tell anybody, we’ll come get you.  Or we may come get you anyway.’

 

…

"Indeed, any other intake worker might have dismissed [this recent Vietnam veteran] as delusional, but Haley had reason to believe him.

(Her father had been on special operations with the OSS in North Africa during World War II, a self-admitted ‘assassin for the government.’  He had told her about seeing a truckload of German prisoners who were led out and made to kneel in front of a ditch, where an American officer shot each one of them methodically in the back of the head.  Then the Americans dumped their bodies in the ditch and shoveled it over.  Thus Haley, as she puts it, had “no illusions about war.”)

 

How Haley worked with veterans and understood their particular trauma:

"Haley had nothing to go on but a big hunch, but she decided to follow it.  It seemed to hear that a lot of mental health professionals – especially those at the Boston VA clinic – had great difficulty in listening to the recital of trauma: as a defense, they either disbelieved it off the bat, turning it into the less threatening notion of “delusion,” or else withdrew from the patient as quickly as possible so as not to have to hear more about it. 

 

The other horn of this troubling dilemma was that the traumatized person, especially if he was a Vietnam veteran, would almost never come in and spill his guts to a perfect stranger.  Trauma patients need to establish trust with a therapist, and the Vietnam veterans coming into the VA clinic were never being given the chance to do this.  It was by the merest lucky chance that the My Lai veteran had seen something in Sarah Haley that made him believe he could confide in her, thereby opening the door not only to his own dark secrets, but also to possible help for a whole generation of trauma victims.

Haley perceived correctly that the reason the My Lai vet could not remember all the details of his trauma was that much of the most painful material had been repressed.  In the coming years, she would encounter the same phenomenon in hundreds of Vietnam veterans, some of whom could only recall five or six months of their 12- or 13-month tours of duty.

 

More insights into how Haley worked with veterans, and uniquely modified the approach for dealing with combat trauma:

"She further realized that the stuff was eating away at them would have to be brought slowly and steadily to the surface – that there were no quick fixes, like ‘5 mg. Stelazine daily.’  Equally ineffective, she would soon discover, was ‘the sort of non-authentic treatment’ where the professional would talk about family issues or other daily matters that were troubling the patient, but never bother asking about the existence of trauma in his past; for if the professional didn’t ask, the trauma victim would seldom bring it up on his own. Haley was aghast to learn, for example, that an analyst friend of hers had “successfully” treated a Vietnam veteran solely on the basis of working through the rivalry with his father and never even asked the veteran about his [combat experience.]

"Most of the Vietnam veterans Haley found were coming in to see a VA psychiatrist merely so that they could get their next month’s supply of Valium.  Haley would go to the psychiatrists and inquire whether they had ever asked these veterans about their Vietnam experience; the usual reply from the shrinks was that they had stopped asking because the veterans didn’t want to talk about it.  Haley was flabbergasted that none of the VA psychiatrists – with the exception of two notable women, Lillian Rodriguez and Constance Hartwell – evinced any interest in learning the cause of the tremendous anxiety for which they were blithely prescribing shelves of medication.

Unique problems to Vietnam veterans that Haley noted:

"During those first few years at the VA, Haley encountered a great many vets who talked about participation in atrocities.  she found most of them to be ‘terribly guilty, feeling unclean, and not worthy to be back in the world.’

…

 

"… Instead of hearing, “Doc, I have a bellyache,’ or “Doc, I’m seeing visions,” or “Doc, I’m terribly depressed,” what Haley would hear time after time was, “Doc, I think I’m a murderer… I slaughtered innocent civilians.”

 

And finally, Haley's substantial impact:

"Working with these men and the material they brought up was so painful that it took Haley almost two years to complete her article…which was immediately recognized as a landmark work.  By precise delineation of the symptoms of several veterans she had treated, Haley established that the Vietnam veteran who had witnessed or taken part in atrocities could not be handled merely as a traditional case of traumatic war neurosis, but presented a completely new challenge to psychotherapy."

Sarah Haley was indeed a remarkable woman, and a great Friend to Veterans.  So much of the unique and compassionate approach to understanding PTSD's impact on veterans comes directly from this woman's work, and for that we are deeply appreciative and honor her in memoriam.

Accessing Your Built-In Healing Mechanisms after Combat

It's safe to say that Patience Mason is a one-woman, cottage industry of helpful materials about dealing with PTSD.  Married for umpteen years to a Vietnam veteran with PTSD (Robert Mason, author of Chickenhawk), Patience has learned many life lessons of tremendous value to veterans. Along with Kathie Costos, Aphrodite Matsakis, Ph.D., and a few others, Patience Mason is one of the women who've given the most to helping vets and their families to recover from "combat trauma."  Read her helpful suggestions, below, and notice the emphasis on mind-body medicine, and in particular, mindfulness meditation.

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Since PTSD can also be triggered by subsequent events throughout the rest of your life, it is wise to learn how to heal. Many older veterans have lost their friends and families because of the struggle to hide symptoms and seem fine. The current war has also re-triggered PTSD symptoms in many older veterans because they remember. They know what you’re facing. If this has happened to you, don’t think treatment didn’t work. It worked before and it will work again. Go back for more.

Each symptom of PTSD develops from a bodily-based, God-or-evolution-given built-in survival mechanism, designed to keep you alive. We all have these survival mechanisms, and if we had been through what you have been through, we would also be affected. You learned these survival mechanisms under the hammer of war.

When you are ready to get better, you have to learn what they are, when and how they are useful, and new skills for when they are not. Each met a need, usually for survival, and finding other ways to meet your natural needs for safety and security is the job of recovery.

We also have built-in healing mechanisms. Attention (eye contact, being listened to, receiving empathy and respect), telling your story, safe touch, acceptance (bad things happen; they are painful), crying, making a contribution (working for the common good [altruism] and to support your family), justice, and spirituality are some of our built-in healing mechanisms. Our culture finds some of them awkward.

While avoidance strengthens and perpetuates PTSD symptoms, it is much less painful than the work of healing, especially if you have lost buddies, your sense of yourself as good or competent, and/or have shame or guilt or despair associated with the trauma as most people seem to. Somehow feeling like it is your fault, and if only you had done something, it wouldn’t have happened, makes you feel less powerless. The essential ingredient of trauma, however, is that it is overwhelming and you are powerless. No one can stop bombs or bullets with if-onlys. Many people spend their lives after trauma waiting and wishing for a better past, instead of working through the pain and anxiety for a better future.

Exposure is the basic task for healing PTSD. It teaches the parts of your brain that don’t speak English and can’t tell time that it is over. Exposure to what you are avoiding in small safe doses with a trained trauma therapist makes a huge difference. Often this is telling parts of your story again and again so that details come back and you can comprehend the whole experience. If you want to avoid these details because you think whatever happened was your fault, talking can help with that, too.

Most vets feel that if they ever let themselves feel, it would destroy them, but numbing bad feelings means the good ones are gone, too. Healing means you learn how to sit with a feeling and let it peak and fade, so you can process your memories. You went through hell. The feelings will hurt, but they will also pass eventually. Your therapist can teach you how to identify your feelings, that you are not your feelings, and that other people can have different feelings without either of you being wrong.

You can even learn to go in and out of numbing, since it can be handy, as can many of these survival skills. If you have developed an addiction to help you maintain numbness, you probably need to get clean, sober or abstinent from the substance or behavior.

The best way to deal with non-verbal memories is to move them from the non-verbal parts of the brain up to the frontal lobes and turn them into narrative memories, in other words: remember. Writing and rewriting something that happened to you is one way of doing it. Talk therapy is another. You get to tell your story. This is painful but you made it through the event, and you can make it through the memory.

For hyper-arousal, I always suggest basic un-training. Every soldier I’ve ever met thinks the military taught him to take care of himself. “Oh, really?” I often say, “So you used to say to your drill instructor, ‘Sorry Sergeant, I can’t do that. I need a nap.’” This usually gets a big laugh, but that is the kind of self-care you need to learn. After you have been to war, there are some things you simply can’t do. Sometimes it’s parties (don’t bunch up), cookouts (burning flesh), family fights. Sometimes it’s “Don’t ever come up behind me and grab me.” Whatever it is, learning to speak up is important. You have to learn self-soothing methods, so you’re not always yelling and angry.

You have to expose yourself to triggers in small safe doses, too, so they lose the power to trigger you. Learning that what triggers you is not necessarily dangerous here is also important, so your family doesn’t have to avoid your triggers.

Learning to meditate helps with these tasks and keeps you present in the present. The book Wherever You Go, There You Are, by Jon Kabat-Zinn helped Bob a lot. He also reads Thich Nhat Hanh. [Editor's note: Claude Anshin Thomas likes his work very much.] You may also find ways to heal your body’s constant state of tension through somatic therapies or yoga.

You may have to heal your beliefs. During extremely traumatic events, such as having a buddy die in your arms, or get killed when you weren’t there, people often decide “I will never love anyone again” or “I should never have left” or “It’s my fault.”

Other beliefs that can interfere with healing and with everyday life include ideas like “Don’t talk about it,” “Only weaklings and whiners ask for help,” “You can’t trust anyone who wasn’t there,” and its converse, “You can (and must) trust anyone who was there.”

PTSD can make you feel totally out of control. By choosing to take new actions which have worked for others, you can regain that sense that you are in charge of your life.

-- Home from War, by Patience Mason.

Mind Body Medicine: Healing the Wounds of War

When I started this blog over two years ago now, I was hoping that somehow James S. Gordon, M.D., and the Center for Mind-Body Medicine which he founded in Washington, DC, would somehow get involved in the prospect of bringing mind-body medicine to the troops.  Gordon is a Harvard-trained psychiatrist, with impeccable credentials, who has a lifetime interest in expanding patient care into new areas, particularly Complementary and Alternative Medicine (CAM), and mind-body medicine in particular.  (Mind-body medicine is a shorthand way of re-combining the two "halves" of medicine perhaps unjustly sundered in an arbitrary Cartesian mind-body split.  Much of Eastern thought, rather than Western, never saw them divided at all.)  In a previous lifetime, where I interviewed luminaries in the natural medicine field, Gordon was a favorite interviewee - smart, genial and with a very forward-thinking grasp of what mind-body medicine could accomplish.  Gordon, who was featured in the Bill Moyers series on PBS, Healing and the Mind, was a frequent lecturer at the Smithsonian Institution in Washington, DC, and for years had served as the head of the White House Commission on Complementary and Alternative Medicine.  He is also a Clinical Professor in the Departments of Psychiatry and Family Medicine at Georgetown University Medical School.

But more to our purposes, when war broke out in Kosovo, he and the Center for Mind-Body Medicine (CMBM) took their methods into the region, creating a program called "Healing the Wounds of War," to help war-torn schoolchildren and their caregivers manage the trauma they had undergone, through a sustained, devastating conflict.  What I was hoping -- and I kept checking the CMBM website periodically to find out -- was that they would leapfrog off their successes with PTSD in Bosnia and Kosovo, and Israel and the Middle East, and develop something geared to PTSD in servicemembers, and the conflicts in Afghanistan and Iraq.  For years, nothing was obvious (yet), but here's some of their success with children in Kosovo.  Notice what symptoms the program helped with, how impressive the statistics are, and make the conceptual leap to how this might help with combat veterans and/or their families:

The clinical efficacy of the CMBM program with traumatized children has been repeatedly demonstrated. In a pilot study in which high school teachers in the Suhareka region of Kosovo used the CMBM model, levels of posttraumatic stress disorder in high school students were reduced from an average of 88% to 38% in only six weeks (read the research, published in Journal of Traumatic Stress, April 2004, linked here). Participants have also reported the following documented effects of CMBM trainings, including: the alleviation of their own stress and trauma; decreases in anxiety and depression; increased optimism; decreased anger; and increased capacity to help others.

You can read more about the program's specific successes, here.  Or, you can read a general overview of the program and what's involved, here.  You can also read Dr. Gordon's bio, here.

Chaplain John Morris, Minnesota National Guard

Caveat gentle reader: We have no idea if Chaplain John Morris, oft-quoted chaplain of the Minnesota National Guard, is any sort of functional expert on PTSD.  What we do know is he's a straight-talking, reasonable proponent of caring for the troops, and as such, he totally has our vote of confidence.  Here's a little biographical information about him:

John Morris, an Army Reservist, has served in Norway; Kuwait; Qatar; Iraq; Cuba; Ft. Steward, Georgia; Ft. Benning, Georgia; Ft. McCoy, Wisconsin; Ft. Bragg, North Carolina; and Ft. Irwin, California. After serving as senior pastor at St. Croix Valley United Methodist Church for eight years, he was mobilized to serve with Army Special Operations Command in January 2004. In Iraq, he visited Psychological Operations teams in 17 different camps. Chaplain Major Morris is currently a full-time chaplain with the Minnesota National Guard. He is a 1986 graduate of Minnesota's Bethel Seminary.

He's frequently quoted by NPR, the Cloquet, Minn. Pine Journal, which did a fine series of articles on Minnesota's returning National Guard veterans, and the Christian Science Monitor.  We've blogged about hm in a series of posts, linked here.  He's immensely quotable, and he's a heartsy proponent of meeting the troops head on with the type of care they need, and he seems to have that rarest of all professional qualities -- a serious clue.  I'm a huge fan...

(References to Chaplain John Morris of the Minnesota National Guard on this blog are here, here, here, and possibly here, not to mention, most recently, here.)  In his wonderful essay, linked here, you can read his thoughts on "Beyond the Yellow Ribbon: How Churches Can Help Soldiers and Their Families Readjust after Combat."  (A podcast by Chaplain Morris is linked on another blog, here.)

One Great Book: "Home to War - A History of the Vietnam Veterans Movement," by Gerald Nicosia

"The Past Does Not Equal the Future" -- queue Tony Robbins -- well, unless we refuse to learn the copious lessons of the past, in which case it very well might -- or it might make the past look positively enlightened, by comparison.  Another take on the same thing, by the perennial, inveterate quotemeister himself, Ben Franklin: "Experience keeps a dear [expensive] school, but fools will learn in no other."  I'm reading the greatest book right now, recommended by another journalist who's interested in veterans issues -- "Home to War: A History of the Vietnam Veterans Movement," by Gerald Nicosia, linked here.  It's 2 lbs., 10 oz., 689 pages, and roughly 136 cubic inches of nowhere-else-to-be-found material on the actual history of what created the Vietnam veterans' movement, which informs the veterans' rights movement of today, including the efforts to destigmatize PTSD, figure out what it was, re-include it in the DSM manual for psychiatrists (where it had been removed), etc.  Just fascinating.  All the players are there -- dozens of politically important types, including John Kerry, Ron Kovic (if you've seen "Born on the Fourth of July," you know who he is) as well as therapeutically important ones -- Shad Meshad, Ray Scurfield, Arthur Blank, M.D., Sarah Haley, etc. 

As a late-model Child of the Sixties, I had completely forgotten how much sheer effort -- blood, sweat and tears -- it took to get certain things passed that we now take for granted: better care at the VA, better provisions in the GI Bill, etc.  I had totally forgotten about the armed protests, the hunger strikes and sit-ins at the VA, etc.  It made me wonder whether leaders of the current veteran rights movements actually KNOW this history, and know how far their predecessors had to go, to secure the rights veterans rely on today -- which still need to keep pace with the times, and haven't.  The book is just plain fascinating, and b/c it's relatively neutrally written (as opposed to written with partisanship), with a steadfast focus on the facts and the key participants -- and because it's based on 600 or so interviews with the actual players, it's both extremely well done (a PBS series in book form, but with more depth!) and should keep my interest for quite a while.  So fascinating to know, or begin to hazily recall, the all-important "backstory" of where we are today.  And the insights on the genesis of understanding PTSD are well worth revisiting, all on their own.  Great book - wish I'd known about it before. As more and more veterans send me (unsolicited, I might add) their life stories, or their experiences with PTSD, I have to say -- this book really puts an awful lot together, behind the scenes, as to why they suffered in silence for so long.  Wonderful effort, and a pleasure to read.

Too bad tomorrow is already "Father's Day," but if you're lacking a gift for a veteran dad, Vietnam era or later, and can find this in stock at a local bookstore, it's a superlative collection of everything that went before, and helps us to understand the issues of the present, through the highly informing prism of the past.

PTSD Experts - How to Find a PTSD Expert, Easily

One of the recent enhancements to this blog is the creation of an ongoing directory of PTSD experts, linked here.  These are known experts in the field of post-traumatic stress disorder (PTSD), who ideally are familiar with the ravages of combat trauma, and what it takes to heal.  This directory, which is not alphabetized, should serve as a one-stop directory for biographical information about these experts, which is of benefit to reporters, journalists, those planning conferences who need to find speakers, lawyers looking for experts to testify in court cases, etc.  If someone you think deserves inclusion isn't listed yet, it may just be that we haven't gotten a chance to post their information yet, so please feel free to submit it for possible inclusion.  Otherwise, it's guaranteed to be a continual work in progress, but already more informative than anything else that's out there -- because the information is extremely hit-or-miss on the Web -- hence the creation of this directory.  (Case in point: a U.S. government-sponsored trauma specialists directory, which shall be nameless because it was so embarrassingly bad, which listed only one(!) expert, worldwide -- seriously! why even bother? -- despite having been up for years.)

Another Expert's Quotable Quote on PTSD

A great quotable quote from PTSD expert, Frank M. Ochberg, M.D., who once said: "PTSD is a medical condition.  The most important thing we can do to help our loved ones with PTSD is to be the most informed person on your block about PTSD."

The Katz Email: Can We Just Call "Bullshh!it"?!

By far the most distressing revelation from the lawsuit by veterans against the VA, currently making its way through Federal court in San Francisco has to be the toxic email, disgracefully titled, "Shh!" and written by Ira Katz, M.D., the VA's top psychiatrist, about the not-exactly-light 'n humorous topic of veterans suicides.  The email essentially attempts to cover up the severity of the number of veteran suicides that are taking place by those who are undergoing treatment at the VA.  The contents of that email by now are fairly well known -- and the general reaction is to Katz's words, not surprisingly, is revulsion.  Senators Patty Murray (D-WA) and Tom Harkin (D-IA) are two legislators calling for Katz' removal.  There's been just enough stink about his ill-chosen words that Katz has been moved to make a very superficial apology for them, a la Roger Clemens.  An article in today's Seattle PI, linked here, quotes CBS News as saying Dr. Katz now calls his word choice "unfortunate."

Erm, well, can we just call "bullshit" on this?  Because, really, it's more than the choice of words people are reacting to -- they're sensing the specious and supercilious attitude behind them.  In the immortal lines from Oliver Wendell Holmes, "Even a dog knows the difference between being kicked, and being tripped over." 

The "Shh!" email brings to mind another bureaucratic bumbler of late, Michael Brown, head of FEMA during the Katrina crisis, who ostensibly fiddled while Rome burned, writing superficial emails to his colleagues preening about his choice in ties and lamely wondering if it was time for him to go home yet. "'Can I quit now?' FEMA chief wrote as Katrina raged," according to an article archived here on CNN.com.

Brown certainly seemed to be over his head (no Katrina puns intended) at FEMA; perhaps Katz, because of his psychiatry training is actually not.  However, they both have a world of learning to do in how to project empathic leadership.  There's nothing confidence-affirming about either one of their responses. Wounded warriors deserve a lot better from the top psychiatrist at the VA responsible for their care.  Those aren't just poorly-chosen words, there's an attitude of callous disregard for the patients behind them as well, that no thin veneer of apology really corrects.  Combat veterans struggling with alarmingly high and well-documented rates of PTSD and suicide need compassionate leaders with a vested interest in their care, not someone making light of the size and the severity of the problem.  In anyone but a psychiatrist, whose field after all is mental health, we might find this easier to understand or excuse.  But in a psychiatrist whose professional responsibility is the mental health of veterans?  Absolutely not.  That's a vote of no confidence, in someone who's sworn to uphold the Hippocratic oath to "first, do no harm."  The bumbling and apparent cluelessness of FEMA's Michael Brown in the face of a huge need for crisis management and control spurred calls for him to resign; perhaps outrage over Katz' email will do the same.  There's really no way to spin that into a positive.  The damage has already been done.

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Here's the content of the email Katz titled "Shh!" for those who haven't seen it.  According to the article in the Seattle PI, "Our suicide-prevention coordinators are identifying about 1,000 suicide attempts per month among the veterans we see in our medical facilities," Katz wrote in a Feb. 13 e-mail to Ev Chasen, the department's communication director. "Is this something we should [carefully] address ourselves in some sort of release before someone stumbles on it?"