Healing Combat Trauma

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.)