Healing Combat Trauma

What the VA Needs Is "The Odwalla Effect"

[If this blog were a newspaper, which it isn't, this particular blog post would be an editorial -- found in the opinion section, separate from the rest of the paper.  The editorial section is where the editor "puts together" what the news means to him or her, and sets out a point of view, about what we should do or feel, think or believe about something, based on what else has been in the news lately, that they've been keeping people up to speed on.  It's the opinion section, essentially -- but from the editorial management's point of view.]

Here's ours:

Kathie Costos has a great series of posts over at her blog, linked here, but there's one in particular we'd like to talk about - and we'll leave you the link to it in a minute, so you can read it for yourself.  First, the discussion.  Kathie is conducting a question and answer session with Paul Sullivan, head of Veterans for Common Sense, clearing up "rumors" about the veterans' lawsuit against the VA.  Sullivan's answers are clear and to the point, and contain some fairly galvanizing statements, pro or con.

[I should insert the caveat here, in an effort to be balanced, that I DON'T believe the VA is "all bad," nor do I imagine Costos or Sullivan does.  Every once in a while you DO read about people who are extremely thankful and grateful for the care they're received through the VA - I read an item the other day where a veteran was reminding us that they have one of the best healthcare systems in the world.  True.  But that also brings up a question of which metric you're using, since while they are succeeding in some areas, they are clearly failing in others (and those are the areas which are making the news, frustrating veterans and families, and where they're being sued.)  Highly competent, concerned and caring individuals DO work for the VA -- many of the leading lights of care in the PTSD segment in particular have come from, or worked with, or still do work with, the VA.  People who are tremendously significant in the history of caring for veterans in an extremely high quality, enlightened, empathic way -- so people like that DO work for the VA, and always have.  Look through the "Experts" section on this blog, and see how many people have an affiliation with the VA, past or present: Ray Scurfield, Shad Meshad, Jonathan Shay, as well as others, all come to mind. (For the record, these people were probably "born" (wonderful) not "made" (wonderful) by their association with the VA as caregivers, but still -- they worked there and in some cases, still do.  And God knows, the VA heavily reads this website -- even at odd hours -- including very late at night, on weekends, on national holidays -- times when the rest of America is out grilling a hotdog with their family, throwing a ball in a park, or just snoozing the night away -- so clearly there are some very dedicated individuals there, trying to learn all they can in order to deliver better care to those who are suffering.  (Though they may also be reading to keep up with public opinion, to see which way the wind blows...)

I do sometimes wonder when I see what the VA is searching for, on this site, because it either seems kinda elementary (like they should know about it already), or a little "weak" in the efficacy of treatment department (like things that are waaaaaaaaaaay down the totem pole or triage pile of things to actually try with a demographic of patients who are suffering greatly). To give you an idea of what I'm talking about, frequent searches -- and the topics change regularly -- by the VA include such things as "spirituality for PTSD," "does recreation help?" and things like that, where, really, yes, even if they do -- they're only adjuncts and pretty far down the list at that, compared to more likely things that seem worth trying or are known to have some benefit.  But maybe I should just be patient, and it's more a case of "if you build it, they will come."  Maybe there's a huge lag time afoot, where if the information is laid out there, eventually the searches will catch up -- on the VA's part, that is.]

(Huge digression -- but the point is, the VA's not all bad, and that's NOT the point of suggesting they change, which it certainly seems like they should.)

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Deep in the Q&A between Costos and Sullivan is this exchange, with the comment of importance highlighted:

Do you know about the Freedom of Information request to the VA by CREW and VoteVets?(Which we blogged about earlier here, by the way.)

Yes. It is too bad that VA still plays games with FOIA. VA should be forced to turn over the information. Embarrassing information is never a reason to deny a FOIA, as VA frequently does.

Alrighty now.  That was the warmup (the foregoing).  Here's the pitch:

If the VA wants to control the flow of embarrassing information about it -- such as the Katz and Perez emails have provided us with -- there's one extremely simple way to do it.  It's NOT hiring a PR firm that specializes in crisis management and controlling the spin.  That's morally and ethically disgusting -- when contrasted with the concept of just changing -- and, it's ridiculously expensive -- a true waste of money that could be better spent on taking care of veterans and their families, with the needs the VA already knows about. And by promoting good works, like those of combat veteran Jay White, at the VA Center in Hartford, Connecticut, which we blogged about here.  Those ALSO make the news and contribute to public opinion, though everyone knows, and it's unfortunate that it's true, bad news travels first.  (And bad news here is definitely the Katz and the Perez emails, and the lack of putting patients first they describe, not to mention the rash of veterans suicides, etc.) Denying patients adequate care?  There's just no way to put a positive enough spin on that.  And the extent of the media coverage has been such, yup, we pretty much all know about it by now, if we even remotely care to.  Game over.  What needs to happen next is what happened with the Odwalla juice company -- what the VA desperately needs is the Odwalla effect.

Years ago, Odwalla was a new company with a great product: fresh juice, delivered nationally.  I knew someone whose three college friends had started it, and because of that, I guess I paid attention to what it was, and when I had the chance, tried the juice.  It was great, and for a while, everybody I saw who wasn't carrying some bottled water, seemed to be carrying a container of their juice.  They had, and still have, a number of blended juices, as well as the straight-up orange and apple.  And they had a novel, and in hindsight quite unwise, approach.  Their juice was unpasteurized, which they felt was needed to keep the juice as fresh-tasting and delicious as possible, but which also carried some known health risks, because pasteurization kills bacteria.  Children (particularly babies) and the elderly, as well as a few other groups (those recovering from illness and surgery, etc.) have weaker immunities -- in other words, are more susceptible to bacteria.  And I don't remember that Odwalla plastered their juice labels with big warnings about: "Warning! Our lack of pasteurization makes this juice likely unsafe for children and the elderly!".  They probably just made their juice, concentrated on getting it to market, and hoped people toasted each other with its deliciousness.  But over time, the inevitable happened: a few people who tasted their fresh, delicious (and unpasteurized) juices got sick - and, horribly - died.  And some of the affected were children, which the American public finds of course especially heartbreaking, and worthy of media attention.

In an instant, it seemed -- everyone turned on Odwalla, the juice and the company.  It went from being a media darling, to an object of abhorrence and fear.  How could they have let their juice kill people -- young children, even?  Horrifying...  Based on the immediate and complete backlash in the press and public opinion, I easily imagined Odwalla going under, and my friend's three college friends being put of work, and skulking away in public disgrace.

What happened next was amazing, though: and it shows you the power of good, and of doing the right thing.  (There's a conflicting story on the Web, but if you read the date on it, it's from 1999, which is ridiculously old news -- before the Odwalla success story of managing its PR happened, and before the company was later sold to Coca Cola - another evidence of its success. Plus, the guy who wrote it is by no means is a PR specialist, nor does he even seem to understand how PR works. I did work in PR, though I'm no expert on crisis management - I do get how it works.)  Odwalla didn't go bankrupt, didn't go out of business, didn't leave the marketplace in shame and disgrace.  What DID they do?  Simple as could be, and oh so powerful:

They accepted responsibility.  They apologized and paid the families' bills.  And they changed their process, so more people wouldn't be hurt by it.  They were wrong; they admitted it; they did what it took to make it right; and they changed.

In other words -- EXACTLY what the VA needs to do.

By now, we all know what the problems are, if we've cared at all to listen and learn.  They're kinda obvious.  And no amount of re-spinning the truth is going to make the problem go away.  All the media attention and lawsuit has done is show us the gaps in the system, the problems with care.  And because most caring, compassionate, fair-minded Americans care MORE about their veterans - we "get" the price they've paid -- than we do about hearing excuses and spin -- there's only one real solution here.  Admit the problem(s), apologize to those you've affected (veterans, their families, and the rest of us, who while less directly involved, are nevertheless put off by what we've learned), and fix the process.  Let tomorrow be vastly different from today, because you're starting to work -- really work -- on the problem, now.  The problem that we -- you, me, veterans, their families, the media, Veterans for Common Sense, the IAVA, the Disability Rights Project, Paul Sullivan, Kathie Costos -- all know exists.

Lack of pasteurization, denying veterans care -- and, if you'll allow me -- O.J. Simpson have all have been linked to killing people.  But in a contest between two kinds of OJ -- Odwalla and Simpson -- please, VA, we beg of you: show yourselves to be more like Odwalla, and less like Simpson. Fess up, come clean, do what's right by veterans and their families, make it right.  Now more than ever, what the VA seriously needs to re-create good public opinion is not denial, spin and blocking legitimate FOIA requests, in case something embarrassing gets revealed -- it's a simple thing called "the Odwalla Effect."  Also known as, doing the right thing, for the right reason, makes public opinion bounce right back.

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Editor's note: Kathie Costos' Q&A with Paul Sullivan of Veterans for Common Sense about the veterans' lawsuit is linked here. Kathie Costos' blog, "Wounded Times," is linked here. Veterans for Common Sense is linked here.

NPR Local Affiliate KQED's Story about VA Being Sued over Veterans' Healthcare

According to a story aired today on KQED -- a San Francisco public radio and television station, and NPR affiliate -- Berkeley, California's Disability Rights Advocates recently filed a lawsuit "that could affect thousands of veterans returning from Iraq and Afghanistan. They allege that the Department of Veterans Affairs is unable to provide timely mental health treatment for returning veterans. It describes a backlog of 600,000 claims for vets seeking care — some dating all the way back to the Vietnam War." To listen to the approximately five minute story, click here.  (And yes, this is the lawsuit that's produced the incendiary emails that have lately been in the news, including the infamous "shhh..." one about veterans suicides, which we blogged about earlier, here.)

Editor's Note: For more information about the veterans access to healthcare lawsuit in Federal court, as provided by the Disability Rights Advocates website, click here.

NYC's Urban Justice Center Offers Returning Veterans Legal Aid and Advocacy

The Veterans and Servicemembers Project of New York City's Urban Justice Center, linked here, offers, in their own words, "legal services and advocacy to a population often abandoned by the very system of government they defend in battle. Drawn increasingly from the poorest and most vulnerable communities in the country, past and present military personnel contend with poorly regulated recruiting tactics, unsafe working conditions, and an antiquated and overloaded disability benefits process. Often unaware of their rights and wary of challenging authority, they face especially daunting barriers to necessary assistance."

Furthermore, "At an individual level, the Veterans and Servicemembers Project provides legal training and representation on matters ranging from veterans disability claims to service discharge applications. The project also pursues systemic reform through litigation and advocacy in such areas as recruiting irregularities, workplace harassment, and inefficiency and abuse in the benefits application process. With the active collaboration of existing service organizations, it aims to provide comprehensive education and support for a population that, in a time of mounting war, promises only increase in size and collective need." 

Editor's Note: To learn more about this program, read the excellent article by Thomas Adcock, called, "Returning from War," originally published in the New York Law Journal, on February 22, and linked here.  If you're a lawyer who'd like to participate pro bono in helping veterans, click this link. 

Finding a Qualified Attorney to Represent You

In the coming months and years, more OIF/OEF veterans will need attorneys' help in getting disability payments they're entitled to, and representing them in the occasional criminal matter.  It's important for veterans and their families to find experienced attorneys who are knowledgeable about veterans' issues, and ideally are also compassionately disposed towards veterans and their families, and the particular struggles they might undergo, including PTSD.  We can think of several cases from the past few years, where returning veterans with PTSD committed crimes and needed representation that could effectively convey their side to a judge or jury: Daniel Cotnoir, Eric Acevedo, and, had he lived, Travis Twiggs (for the carjacking and resisting arrest in the ensuing police chase).  Thrown back on their own or their families' limited resources, veterans who have been charged with a crime may end up a) looking through the phone book or b) getting a public defender appointed by the court to represent them.  While there's nothing wrong with these approaches, they're also pretty subject to chance. What we'd like to see, over time, is a network develop of attorneys across the country who have a special expertise and concern for representing veterans in healthcare and criminal matters (not many attorneys will do both, but some undoubtedly will.)

To find a qualified attorney, consult your local state or county bar assocation's lawyer referral line, or learn how to use Martindale-Hubbell, the directory of lawyers across the United States.  "AV" is the highest rating that lawyers receive in Martindale-Hubbell, conferred by their legal peers; so finding an "AV" rated lawyer to represent you would be a best-case scenario; although the lack of this rating does not imply substandard service or qualifcations. If you choose an attorney on your own (i.e., through the phone book), be sure to also check the lawyer's background with the local bar association to see whether he or she has ever been sanctioned or disbarred in the past (better safe than sorry!).  Use this tool, provided by the American Bar Association, to find the state or local bar association in your area.

Periodically we learn of a lawyer who seems to have a special expertise or affinity for representing veterans.  When we learn of such a lawyer, we'd like to include their information here, so it will be readily available to more potential clients.  Mentioning the name here does not imply an endorsement, but is an attempt to make resources available to interested parties.  We have no way of knowing about the quality of legal representation offered.

In disability matters, we've learned about the Law Offices of Robert Franklin Howell, in Monterey, CA, linked here.  Howell is both a longtime practicing attorney, and a combat veteran. To learn about his disability law practice, click here.  To contact him directly, click here.

In criminal matters, we've learned about attorney Jim Lane, whose Fort Worth, TX firm is linked here.  Lane, who has practiced law for approximately 40 years, was a captain in the U.S. Army as well as a military JAG officer.  His specialties including personal injury, criminal defense (felonies and misdemeanors), and court martials.  To contact him directly, click here.

Just a word of wisdom here, based on common sense: when you do go to consult an attorney, make the most of both of your time by having written down the facts of your case in advance, and, as much as possible, keep your initial contact short and sweet.  Be aware that the first point of contact in many lawyers' offices is a receptionist or a legal assistant, who is not empowered to handle your case.  Do not overwhelm that person with your needs and desires, nor the attorney, when you are able to speak with him or her. Keep it to the facts, take notes on what's discussed and what the game plan is, and bring someone along with you to your first meeting, if you feel that you are likely to be too emotionally involved in your own case to listen well or take good notes.  Learn how to be a good client, and you'll go farther with a good lawyer.  Clients do occasionally wear out their attorneys or get fired by them for being too difficult, which is very unfortunate, and will not help your getting closure.  Here is a good article about how to be a good client.  It's directed to family law, but the tips it suggest apply to other areas as well. Read it and consider what it says (linked here.)

Links for Lawyers Representing Veterans

It's been a while since we posted about legal issues concerning veterans.  Here are a few important links that orient as to the landscape.

This article, from the American Bar Association (ABA) website, is directed to lawyers, and talks about a few of the issues facing veterans.  It's a generic but comprehensive list of topics about which veterans might want to seek legal advice, written to lawyers who might find veterans contacting them for representation. The topics lightly covered include: veteran status; disabled veteran status; disability ratings; employment rights (including five-point preference, ten-point preference; and vocational rehabilitation); dependency and indemnity compensation; health care; home loans; insurance; education; the Montgomery GI Bill; the Veterans Educational Assistance Porogram; the Dependents' Educational Assistance Program; disability pension; death and burial benefits; correction of military records; and appeals.  The article, which goes back to 2005 but still serves as a good resource for what the key topics are, is linked here.  (The article's author is Captain Leslie C. Rogall (Ret.), who served in the U.S. Army Judge Advocate General's (JAG) Corps prior to her medical retirement from injuries sustained in a training accident.  She is an appellate attorney for the Disabled American Veterans in Washington, D.C.)

Other quick takes:

• Here's a short article from November of 2007, orienting lawyers to the fact they may now be representing veterans, linked here.
• For a little background on why several veterans rights groups were suing the Federal government recently, here's an article, also directed to lawyers, linked here.
• Here's the text of a letter lawyers wrote petitioning for the ability to represent veterans and get paid for doing so, linked here.
• And finally, an article from the well-regarded Nolo Press -- source of published self-help materials for non-lawyers, written by lawyers -- on "taking family leave for military employees," linked here.

Editor's Note: What would be really nice would if Berkeley, CA's Nolo Press would go ahead and publish a guide for veterans needing to get their claims approved, or appeal claims that have been denied.

Also, if you're a lawyer who's developed a specialty representing veterans, please contact us so that your information can be listed in a directory.  Thank you.

RIP Travis N. Twiggs, USMC PTSD Sufferer

Very sad just breaking news in the USMC Staff Sergeant Travis N. Twiggs story we blogged about yesterday.  See link for details.  It sounds like authorities who were searching for Twiggs and his brother, wanted in an armed carjacking in the Grand Canyon on Monday, learned that they just killed themselves as they were being surrounded by police in Arizona today, in a potential murder-suicide (though no one is speculating who killed whom at this point). The real tragedy that you won't necessarily learn about elsewhere, is that Twiggs, one of the few Marines to come forward and write both convincingly and publicly about his significant struggles with PTSD.  He was the the author of an article called "PTSD: The War Within, A Marine Reflects on His Struggles with PTSD," that was published in the January issue of the Marine Corps Gazette, and noted in an article by Washington Post correspondent and military historian, Tom Ricks. Click here to read a copy of that original article by Twiggs, whose recommendations must now of course be considered in light of his subsequently tragic, self-inflicted death.

While several elements in Twiggs' realistic but optimistic story cast doubt to this writer on whether he'd actually overcome his demons, his words undoubtedly gave hope to many, and provided a flesh and blood example of a combat veteran who truly understood.  It's with great sadness that we note the literal "end" to the Travis Twiggs story.  We hope that the five(!) tours of duty he gave his country as a Marine, first in Afghanistan, and then four more in Iraq, are remembered more than his untimely and tragic end.   And we hope that much greater attention will be paid to the cumulative effects of back-to-back deployments and lifetime total load of triggering exposure to the things that cause PTSD.  RIP, Ssgt. Travis Twiggs.  You gave what you had to give, both before and after combat.  It's just a very sad tale that it had to end this way.

Mark Twain had a famous line about truth needing to be stranger than fiction, because fiction at least needed to observe some sort of structure in order to make sense.  In that light, there's a particularly, to me, poignant end to Twiggs' own article.  He tells his guys -- the ones he knew, and the ones he didn't yet -- "My e-mail is [omitted], and I will help anyone in need."  That's a great, kind statement, and particularly sad in light of the realization that Twiggs himself apparently wasn't able to get all the help he needed, either.

Editor's Note: If you want to learn more about who Travis Twiggs was, go to this longer entry, linked here. 

PTSD - "The War Within" - Claims Another Victim

How quickly, it would seem, one can go from badass to bad apple, when PTSD is involved.  USMC Staff Sergeant Travis N. Twiggs, please, say it ain't so.   I so want to believe this is a case of mistaken identity, or that somehow out there might be several Travis Twiggs, roaming America, with their country music star-sounding names.  But at this particular moment, that just seems more than a tad unlikely.

Some background.  On January 8th and then again last month, on April 23rd, we wrote about Travis Twiggs on this blog.  (See entries here and here.)  Twiggs is/was a USMC staff sergeant, from the 2nd battalion, 6th regiment, company G, who had served four(!) tours of duty, one in Afghanistan, and three in Iraq, including most recently in Fallujah.  That's a photo of him on the left, from about a year ago, touring a plant in North Carolina, and thanking them for sending his guys specialized socks in Iraq (Thor-Lo).  I've cropped the photo but he's talking with a seamstress at the plant, and he presented the company with a flag that was flown in Iraq to thank them for their support.  All good so far.

His story initially came to my attention because Washington Post columnist and well-known military author Tom Ricks wrote about Twiggs briefly in January.  Twiggs has been forthcoming about his battle with PTSD, and has told his story compellingly, most recently in the Marine Corps Gazette, in January of this year, in an article entitled, "PTSD: The War Within.  A Marine writes about his PTSD experience."  I wanted to secure Twiggs' permission to retell his story in full on this blog, in his words, but although he attached his email address to the article, and other email addresses have surfaced, no reply was forthcoming to my email requests.  Nor did the Marine Corps Gazette respond.  This, and some things he said in his article, both gave me pause, and made me wonder -- was his story really such a resounding success after all?

Fast forward to the tragedy part of this.  (If you do a people search for Travis Twiggs, you really only find one, nationally, who's his age, 36, so it seems pretty clear this is one and the same person.  From the photos, you can tell that there's also more than a slight resemblance.)  Today my blog statistics were spiking high and it made me curious to see what search was being run.  Cut to the chase: people were looking for news about Travis Twiggs.  And why?  Well, it turns out he's suspected of carjacking a couple's vehicle in the Grand Canyon, there's a manhunt underway for him and his brother, who's suspected in the same crime, and they're both considered armed and dangerous.  News coverage mentions that he's a ten year military veteran (they don't say he's a Marine), covered with tattoos, who suffers from PTSD and is known to behave erratically.

It is heartbreaking to read this news.  What gave me pause about Twiggs' original story?  Two main things.  He attributed, somewhere I read, a signficant portion of his "cure" to spirituality.  Spirituality, while significant to those who believe in its importance, is really an adjunct to treatment, not the treatment itself.  Seriously.  The other reason was, he credited another significant portion of his improved mental health/recovery essentially to working out.  I left that out of the part I quoted, because it just rang so hollow.  Working out is great.  It's an effective, known way to disperse aggression, create feel-good hormones, and increase positive self-esteem.  But in no way, shape or form is it meant to be a cure for PTSD.  It is, again, a part of an effective personal coping strategy.  These two issues created doubts in my mind; the third doubt was planted by Twiggs and the Marine Corps' completely dead silence in response to requests to reprint his article.  On the off-chance he really was doing well, better than expected (and I very much wanted to believe that), his words could have helped many, many people.  However, the lack of response created an impression that perhaps the recovery was oversold, or somehow premature. If you rave up a cure, but you're really not there yet, you definitely want to distance yourself from those words in print when you later on turn out to be struggling.  Very understandable, if that's the case.

I'm so very sad to learn about this armed carjacking.  I very much hope it's not the same person at all.  And I hold out faint hope that even if it is, that it can still work out "well" -- but who knows what "well" would look like at this point.  Prison doesn't sound like fun OR a cure; or even an effective place to get treated for combat trauma.  Marines are in many ways, the best of the best.  (Marketers sometimes joke that the Marines have one of the strongest "brands" in America.  Truly they do.)  They're amazing warriors, but they also can have a habitual reluctance, borne in part by what they do for a living, so to speak, to admit weakness, when and where it exists.  Twiggs made a mighty attempt to admit the weakness he felt, by publishing that initial article, and by taking the rest of the steps he did, to try to get well.  As we have the opportunity to study the effects of combat on veterans, especially in light of combat trauma and PTSD, it's going to be increasingly important, I believe, to take a look at two things, among others, both of which affect Twiggs' own situation.  How many times you've served (which includes length of deployment and time off in between) -- in Twiggs' case that was four -- and what went on when you were there.  Twiggs was in Fallujah, at least on his last deployment.  What happened to him there, and did anything that happen there have bearing on what happened next?

Come to think of it, right at the beginning of Twiggs' own story, he talks about being sent back into combat after already experiencing too much.  That has shades of the Eric Acevedo story as well.  Heartbreaking.  When will the time come when we care as much for the warriors, like Twiggs, as they have cared for us -- by serving?  Sadly, that question is still rhetorical.  Wherever you are, Travis Twiggs, I hope it goes well with you, as much as it can, under the circumstances.  The responsibility for what you're going through is actually shared.

Marines and the Stigma of Mental Health Issues

If you haven't done so already, you owe it to yourself to read the excellent article published recently in The Nation, called "Denial in the Corps."  The author, Kathy Dobie, did another great piece for GQ recently, which we blogged about here.  (That entry was entitled, "Superb Writing about a Vietnam Vet's PTSD and Subsequent Nervous Breakdown.")  Kathy Dobie is a superb writer, who crafts an excellent narrative -- every sentence in the Nation piece is worth reading, and both informs and moves the story along.  Regrettably, the story is a painful one to tell, about how Marines haven't yet fully risen to the challenge of taking care of their own who have been used up, broken down, or shattered into pieces by their experience at war.  Three paragraphs are the sum of the story:

"According to civilian and military defense lawyers, mental health professionals and veterans' advocates, the trajectory of [one of the Marines profiled]'s postdeployment life, with untreated PTSD leading to misconduct and then punishment, is all too common in the Marine Corps. A marine endures one, two, even three tours in Iraq, serves honorably and well, but returns suffering from combat trauma and starts to drink or abuse drugs or becomes violent at home, and suddenly finds himself ostracized, punished and drummed out of the Corps with an other-than-honorable or bad-conduct discharge. A history of service is tarnished, and the marine is denied benefits--even the treatment necessary to recover from combat trauma--and left with only a bitter sense of betrayal. A Corps review in 2007 of 1,019 other-than-honorable discharges issued to combat veterans during the first four years of the Iraq War found that fully a third of the discharged marines had evidence of PTSD or another combat-related mental illness. Lt. Col. Colby Vokey, the Marine Corps's legal defense counsel for the western United States, estimates that of all the Iraq combat veterans his office defends, one-third have PTSD or another combat-stress mental heal