Healing Combat Trauma

No Easy Answers: Guide for Survivors after a Loved One Commits Suicide

The Mayo Clinic has produced a short, readable, highly useful guide, available online, to how to handle a particularly painful topic: "Survivors of Suicide: After a Loved One's Suicide," which is linked here. As they write, "Bereavement after a loved one has taken his or her own life is often more complicated, intense and prolonged than it is with a death from natural causes. Although as a survivor of suicide you may never fully recover and always feel a loss, you can learn how to cope better and eventually move forward in a way that's healthy." The short, succinct guide encourages the reader to: "brace for powerful emotions after a suicide;" expect certain "physical reactions after a suicide;" as well as "emotions in the weeks after a suicide;" ways to "find support and treatment;" and "healthy coping strategies" after a suicide, finishing up with "the future after your loved one's suicide." Worthwhile guide to bookmark. 

Recent Women Vets with PTSD Use Mental Health Services Differently, Not Enough -- Study Says

According to a recent item published by Boston University's School of Public Health, younger women combat veterans with PTSD under-utilize specialized mental health treatment programs provided by the VA. Just why this is the case hasn't been determined yet, but the study highlights some interesting results  -- and in any case it's progress that the needs of this special population (women combat veterans) are being studied. From the press release:

"Younger women veterans with substance abuse problems, post-traumatic stress disorder and other mental health diagnoses were significantly less likely to utilize specialized Veterans Health Administration (VHA) mental health services in 1999, after the first Gulf War, than their male counterparts, a study led by BUSPH researchers has found.

Veterans of recent conflicts have been shown to have significant mental health needs," says the study, published in the journal Women's Health Issues. "Examining the effects of gender on disease burden and health care utilization in this growing group of veterans is important."

The study found that younger women (under 35) were significantly less likely to use mental health services in comparison to men. However, middle-aged and older women were more likely to use the services than men."

In terms of specialty mental health services, women veterans under the age of 55 were significantly less likely to use PTSD or substance abuse services. The authors speculated that women with substance abuse problems "may be averse to using male-dominated therapeutic groups," may seek treatment in general medical settings or may not seek treatment at all, as described in prior literature on women and substance abuse.

If underutilization of [substance abuse] services continues in newer women veterans, a significant percentage...may remain untreated," the authors cautioned.

The researchers said the underutilization of specialized PTSD services by younger women could be due, in part, to the fact that a significant proportion of PTSD in female veterans is associated with a history of military sexual abuse: "Women with a history of military sexual trauma may not feel comfortable either in mixed-gender groups or using services in which treatment is oriented primarily toward combat-related PTSD.

Overall, a higher percentage of women veterans than men utilized outpatient mental health services, other than the specialized PTSD and substance abuse programs. The study also found that women veterans who used VHA services had a higher prevalence of mood/anxiety disorders and bipolar or psychotic disorders than their male counterparts.

The researchers said that, if the utilization trends found in the study persist, an increasing number of women veterans with significant mental illness and comorbidity could be expected to rely on the VHA for care.

They said their findings highlight the complexity involved in crafting mental health services for the new wave of women veterans."Further research is warranted as to how to address the complex needs for specialty mental health services in this newly emerging group of veterans," they said.

They noted that examining gender differences alone, without taking age, diagnosis and other factors into account, may not provide an adequate picture of women veterans' mental health service needs."

Source: "The Insider," from Boston University's School of Public Health, June 29, 2009. Submitted by Lisa Chedekel.  Link is here.

Feel Like Just a Number / War's Psychic Toll

The New York Times has a good op-ed piece today by Bob Herbert, entitled "War's Psychic Toll," linked here.

One point he makes, in the wake of the shooting deaths at Camp Liberty, is that:

"The fallout from the psychic stress of the wars in Iraq and Afghanistan has been vast, but there was no reason for its destructive effects to have surprised anyone. There was plenty of evidence that this would be an enormous problem. Speaking of Iraq back in 2004, Dr. Stephen C. Joseph, who had been an assistant secretary of defense during the Clinton administration, said, “I have a very strong sense that the mental health consequences are going to be the medical story of this war.”

He also further clarifies a point that a number of people have been making over the last several years, which is that an all-volunteer military concentrates the inevitable "psychic toll" of warfare into too few combatants on our side.  Herbert writes:

"Because we have chosen not to share the sacrifices of the wars in Iraq and Afghanistan, the terrible burden of these conflicts is being shouldered by an obscenely small portion of the population. Since this warrior class is so small, the same troops have to be sent into the war zones for tour after harrowing tour.

As the tours mount up, so do the mental health problems. Combat is crazy-making to start with. Multiple tours are recipes for complete meltdowns."

We've already seen, in previous blog posts, how more combat => more opportunities for PTSD. The relationship is direct.

At some point, with the same people serving multiple deployments, being injured becomes a numbers game.  And increasingly servicemembers who keep going back, if they've managed to avert injury so far, become concerned that their luck can't hold out forever.

A Recon Marine, with multiple deployments under his belt -- some would say, the toughest of the tough -- headed back to Afghanistan on Monday.  "I'm scared," he told his friends and family, unashamedly.  War is a dangerous game, and multiple deployments wreaks havoc on those who go, and those who stay behind and wait.

---
In the old Bob Seger song about working on an assembly line, "Feel like just a number," he sang, "I feel like just another / Spoke in a great big wheel / Like a tiny blade of grass / In a great big field."  Seger insists he's gonna "cruise out of this city / Head down to the sea / Gonna shout out at the ocean / Hey its me!" "I feel like a stranger / A stranger in this land," he sings.  "I feel like a number / But I'm not a number / I'm not a number -- Dammit, I'm a man! / I said, I'm a man."

I recall a conversation with another Marine, who between tours of Vietnam, had a premonition that he wouldn't survive his second tour.  What worried him even more than the dream was that everyone he knew who'd had a dream like that, and shared it with his buddies, subsequently was killed.  This Marine talked it over with his dad, a heavily-decorated Army officer, who told him, in sort, to buck it up and suck it up and go back -- because if he didn't, he'd be running from every other experience like this in his life.  Well, the premonition had a lot of weight to it -- he was shot multiple times and almost died, and took years to recover from his injuries. So we know that the Recon Marine in today's story, headed back to Afghanistan, does have something to be worried about -- even if he hasn't had a dream like this.

Ultimately, whether he and servicemembers like him think of themselves as "just a number" in the larger war machine or not, their more pressing concern, with multiple deployments in harm's way, is whether this time their number is going to be up.  And let's hope it won't be.  But of course, for society at large -- who stays behind -- the broader public health worry is that even if these warriors come home relatively "unscathed" -- in body, more likely than in mind -- their struggle with dealing with the after-effects of combat will just have begun.

Editor's note: To listen to the Bob Seger song mentioned above, on YouTube, click here.

Wyoming Takes More Steps to "Guard" Mental Health

More good news from Wyoming.  NPR reports today in their show, All Things Considered, that Wyoming is "about to mobilize its largest deployment of National Guards in state history. Embedded with the troops will be a mental health professional who is a PTSD specialist. The commander of the Wyoming Guard believes treating the mental health needs of the National Guard troops is a priority and he has also worked to connect mental health resources in Wyoming communities to those in the military."

For a link to that story, entitled "Embedding Mental Health in the National Guard," and originally reported by Wyoming Public Radio, click here.

A Look in "The Mirror" -- Great Britain Seeing War Trauma Now in 3 Years, Not 13 As Before

Because Americans are notorious for paying little attention to things that happen elsewhere, even among other English language-speaking countries, here's some news from Great Britain's tabloid-esque "The Sunday Mirror" today about their soldiers' battles with PTSD on the homefront -- soldiers who served in Iraq and Afghanistan.  For the link to the article, called "War's Silent Victims," by Rupert Hamer, click here. (The tabloid nature of the newspaper explains the fairly breathless writing style, but let's hope the facts and the reporting are accurate nonetheless.)

Points worth mentioning from the article include:

"Alarmingly, the charity [Combat Stress, see below] say[s] the figures are just the "tip of the iceberg" and add that the rate at which soldiers are developing the condition has accelerated. Usually it takes 13 years for cases of post-traumatic stress disorder to develop in veterans.

But psychiatrists at Combat Stress's pioneering centre say the men and women now being treated have come forward after just THREE years.

Also:

Dr Walter Busuttil, a consultant psychiatrist at Combat Stress, said: "What we are seeing now is just the tip of the iceberg.

"Because there has been no proper study of post-traumatic stress disorder among troops in this country we have no idea of the true scale of the problem.

"The same thing happened in the US after Vietnam. The Government tried to dismiss the disorder as a myth - then the whole thing exploded. Now when I speak to my colleagues in America they tell me: 'You are going through your Vietnam'."

And finally:

Dr Busuttil, 49, a psychiatrist in the RAF for 16 years, says the Government has covered up the severity of the conflicts from the public.

"The worst thing for a serviceman or woman is to come back from a war and for people not to have any idea what they have been through.

Editor's note: For a link to Great Britain's charity, Combat Stress, click here.  To find them on Facebook, click here. We've written about them before on this blog, but according to their website, "Combat Stress is the leading charity specialising in the care of British Veterans who have been profoundly traumatised by harrowing experiences during their Service career and who are suffering from poor mental health as a result."

One Veteran's View - Dissociative PTSD, Criminality and the Combat Veteran

You've heard of Bruce Lee -- warrior, philosopher, actor -- now hear about Scott Lee -- Gulf War combat veteran, social work student, blogger.  Scott writes an excellent blog, PTSD: A Soldier's Perspective, linked here, which has been a finalist for the MilBlog award (given to military bloggers). 

Of particular interest to us, though, is this paper he just completed for a class in social work law, about PTSD, criminality and veterans.  Scott's background as a veteran and a student gives him a unique perspective not shared by most, and what he writes could serve to open many people's eyes to the problems faced by returning combat veterans. 

Scott has kindly given us permission to reprint his paper in full on this blog, so we're going to do that in two parts, because of length.  First up, the section that follows; a subsequent post will include his guide for returning combat veterans and their loved ones, if the veteran has been charged with a crime.  Scott isn't giving legal advice here (nor are we); he's sensitizing us all to the problem at hand.

--- 

Scott Lee writes:

The following is a paper that I have completed for my Social Work Law class, parts of the paper I have been writing about in my blog. The paper ties together the evolution in my train of thought concerning the veteran or soldier consumed by the ravages of full blown PTSD.

 

The paper is long, but relevant to the plight of our returning combat soldiers and veterans. If you want to understand more about why a veteran or soldier runs afoul with law and society then you should read this.

  

VETERANS, DISSOCIATIVE PTSD AND CRIMINALITY

  

Scott A. Lee

Kent School of Social Work, University of Louisville

November 3, 2008

The Modern Combat Veteran:

Dissociative Posttraumatic Stress Disorder & Influences

on Criminality

Statistics

 

As of August 27, 2008, according to the Congressional Research Service (2008) 4,726 soldiers have lost their lives in combat and 32,977 troops were wounded in action, with 8,089 suffering from Traumatic Brain Injury (TBI). The USA Today (2008) reported that 68% of all soldiers have been deployed to a combat zone, 31% have been deployed more than once and 2,358 have had more than five tours of duty.

 

The United States Department of Justice (2004) reports that, “[t]he majority of veterans in State (54%) and Federal (64%) prison served during a wartime period….[that] Vietnam War-era veterans were the most common wartime veterans in both State (36%) and Federal (39%) prison.” The 57% majority of State prisoners were serving time for a violent crime compared to less than half of non-veterans who were serving less time for similar crimes. The report indicates the Iraq-Afghanistan era veterans comprise 4% of both prison populations (U. S. Department of Justice [USDJ], 2004).

 

Posttraumatic Stress Disorder (PTSD), Dissociation and Other Considerations

PTSD is a life-long endeavor; there is no cure for it. The triggering traumatic event changes the landscape of the mind, it no longer works in the same fashion that it did before. The mind has been rewired; the neuropathways have been altered into a continuous loop. The PTSD triggering incident converts the fight or flight response in the primitive portion of our brain. Imagine having that scared feeling you get without the fear while keeping the bodily reactions; the tenseness, the adrenalin rush, the mind racing, heightened senses, and the hyper response reflex to react without thinking.

 

The incident that solidifies the mental wound of PTSD results in a mind numbing, or psychic shift. In response to the trauma of combat, the person needs to make a mental detachment to do what needs to be done. The survival mode of operation forgoes the higher levels of functioning and depends on the primitive reactionary portion of the brain. When this unconscious detachment has been activated to frequently or for extended amounts of time it becomes part of conscious processing and interferes with everyday interactions (Lee, 2006; & Cerone, 2006). According to Howell (2005), dissociation refers to the separation of mental and experiential contents that would normally be connected.

 

The word dissociation is laden with multiple meanings and refers to many kinds of phenomena, processes, and conditions. Dissociation is both adaptive and maladaptive, both verb and noun, both cause and effect….Dissociation is often psychologically defensive, protecting against painful affects and memories, but can also be an organismic an automatic response to immediate danger….Dissociation can be understood as taxonic or, varying in degrees….It is both occurent and dispositional….It refers to such psychical events as spacing out, psychic numbing, and even experiencing oneself as floating above one’s body. Dissociation has been thought of in spatial metaphor, as acts of ‘keeping things apart’ as well as ‘vertical splitting’ (p. 18).

 

The mind can develop into split affective regions where multiple self-states dissociate incompatible values systems and set up residence along with establishing a unified substructure within matching internal guidance systems. The dissociated subsystems run parallel to other self-states and emerge when a particular skill set needs asserting pertaining to situational interactions. Here trauma based disorders may lead the symptomology to further entrenchment and compartmentalization that may lead to personality disorders. “A war veteran with PTSD might have more significant structural dissociation, involving the sequestration of more and larger portions of experience” (p. 22).

 

A defined preconditioned set of beliefs and values, the combat schema enables the warrior to navigate efficiently through the adversity of combat without a detailed consideration of consequences. I propose a unique set of beliefs, Combat Values Theory (CVT), based on the survival of self in relation to the context of war and the “combat-othering”, for we must wholly demonize our adversary and in the process dehumanize ourselves. The combat veterans primitive fight or flight defensive mechanism has been repressed through the training in the military, conditioning the troop to take up the fight portion leaving a proclivity for violence without a concern for personal safety. To engage in a mortal fight with the enemy this schema spells out the actions in a given situation without becoming preoccupied with survivability in the moment which could get a soldier killed.

 

The warrior with PTSD has grown accustomed to the value and belief systems of war and feels threatened when they become faced with having to let go of this security in an attempt to reintegrate back into society. Howell describes animal defensive and posttraumatic biological states,

 

The human animal may have a repertoire of discrete behavioral states that are adaptive to conditions of predation….[t]hese animal defense states may underlie different dissociative parts of the personality….[t]his begins a neurophysiological alarm reaction…[and]…a tendency to over read cues as threatening, which can increase the probability for violence (p. 29).

 

The ambiguity inherent in social dynamics can lead to mixed feelings or even a lack of feelings depending on the degree of interpersonal relatedness to the returning combat veteran (RCV). We rely on our parental figures to shape healthy personality and values structures through attachments with significant others, the attachments become avenues of exchange, a distillation of proper interactions and expectations according to society norms. When this exchange becomes distorted to the point of the child becoming a repository of negative energy, instead a healthy exchange solidifying proper boundaries, then the nature of our attachments may become warped and disorganized further compounding the RCV’s reintegration.

 

The combat attachments born of blood do not leave us because we depart the battlefield; they become an empty feeling inside of us. The soldier develops a highly narrow functioning self-organization in conjunction with his or her other squad members. This organization, "troop-organism," becomes an extension of the combat-self, no different than an arm or leg. We do not will our arms or legs to move, we react from the expectations of intentional imagery based upon the combat values structure. It happens, such as the members of the "squad-herd" where each part of the troop-organism and acts in a homogeneous way, each troop becoming part of the others self-states.

 

These attachments to the other require a splitting within the interpersonal self-states where many such dissociated selves birth into existence, as each of the value system constructs do not match and out of necessity, develops into a complete compartmentalized persona while maintaining the "whole" sub-self organizations. Each of the self-states run parallel to one another and have the capacity of switching back and forth when the proper situation requires appropriate specialized skill sets. The interpersonal self of the civilian self becomes supplanted and filed away by the combat self due to the incompatibility of the value structures for survivability that requires a conforming from a civilian society to the norms of the combat environment.

 

Attachments can be considered the path to rigidity or vehicles of spontaneity; to become spontaneous the person must develop a mechanism for the free exchange of intimacy through beneficial interpersonal skill sets. Without a healthy development of attachments then disorganized attachments (d-attachments) form. The d-attachments become the mechanism to gauge interactions in the environment and in doing so they become rigid, an if this then that experiential existence. The d-attachment arraignment only allows for what can be controlled under a series of contingencies plans, or procedural knowledge, usually modeled after our parental attachments, an identification with the aggressor or other such negative role model. Becoming an identity of an exclusionary “personal culture” where the individual becomes estranged from regular society and defending their boundaries as they were national borders between two hostile countries (Howell, 2005; & Lee, 2006).

 

The cycle of procedural enactments play out in significant others that we allow in our lives, the reason why we keep having the same dramatizations and arguments while never finding a resolution. We enact our past roles and project them into our relationships cast from our childhood in an attempt to resolve the attachments constructively. Since we have not been shown healthy attachment enactments we reside in the cycle of d-attachments and further compound our disorders through retraumatization and or neglect, predisposing the person to develop trauma based disorders and or personality disorders (Howell, 2005).

 

Without a reintegration of the self and of attachments and d-attachments, a combat veteran can and will run afoul of friends, family and society. The returning combat veteran faces hurdles that they have not been trained to handle, the training and experiences they have navigated and survived will lead them to think a civilian life will be easy compared to the battle life. What they fail to realize is that they have replaced their civilian self with an operational combat value system and attachments, where in American society the individual has the utmost consideration further combining and compounding issues of integration. Little concentration on developing healthy attachment systems the untenable situation can lead the RCV with severely dysfunctional interpersonal skills and a mechanism of perpetual isolation.

 

Indoctrination

Combat alters and modifies the value system, a preconditioned set of beliefs, entailing a value-orientated constitute of definitions of situation in terms of direction of solutions and action dilemmas, formulating a culture of killing, stripping the combat vet of the niceties that lubricate society’s interactions, which in combat would result in death. In combat the fluidity of boundaries becomes awash in the relational adaptation to an integral cohesion with their battle buddies, a devolution of survival mindset develops and provides a sense of safety; the germination of base natural selection process by successful integration of the combat value system. With a disproportionate 56% of Army veterans incarcerated, the Army culture seems to generate people more prone to violence (USDJ, 2004).

 

The war zone recons the birthing of the “trooper organism,” where the firing squad becomes integrated with one other with a culture of survival. The individual boundary of the soldier submerges within the organismal boundaries of the trooper organism while shedding the individual identity. The troop organism allows for the diffusion of immense responsibility over all involved making the transition to an evolution of survival more manageable wherein the herd mentality brings forth the primitive instinctual remnants and the decentralization of obligation. Military culture portrays the combat arms military occupational specialty (MOS) as having more cultural capital and esteem. The infantry MOS with combat decorations increases the rate of promotion, rank and respectability while non-combat soldiers tend to be overlooked (Lee, 2006; & Howell, 2005).

 

Situational Imprisonment

Military enculturalization subsumes CVT into an identification born of survival and dependant on the assimilation of the “firing squad mind set”, where one troops thoughts relates to an extension of his battle buddies. The fluidity of boundaries births the “troop organism” and forever impairs the RCV to return home without his “other selves.” Now the RCV has to try and interrelate without his relational attachments and attempts to reintegrate back into the civilian world where nothing makes sense anymore, where boundaries cross without attachments as a normative experience triggering perceived threat-states. This leads RCV to become his own “isolated island organism,” or an identity incomplete without the other part of the firing squad, that thinks, feels and acts as they do. The RCV becomes unable to interrelate with family and community in a meaningful way, impeded by the fluidity of boundaries.

 

As their safety has been compromised, a feeling of abject detachment has arisen from the conditioned reality of the combat organism that depended upon the battle buddy “having his back.” Therein leading to a sense of safety, the combat vet needed only to worry about their own personal “line of sight” in a battle field environment requiring a 360 degree threat radius. On his own in society this burden becomes an impossibly overwhelming sense of danger engulfing the RCV, leading to a susceptibility to triggers. A culture of 360 degree radius in the battlefield and shackled intimately with the culture of combat values, hereinto relying on the troop attachments and the evolution of survival, the RCV becomes stuck on the troop-organism functionality.

 

The troop-organism capacity becomes problematic to the integration of the “civilian-self” as it now has become supplanted by the “combat-self.” An attachment of the self to the self that is the identity of one whom sufficiently succeeds in suffering, completing the veteran and familial rift. The fluidity of boundaries in an intimate relationship with a loved one becomes a threat to the RCV due to the misidentification of signals between the two, one having adapted an independent perspective and the other a dysfunctional dependent state. The crossed-signals of the significant others has complicated the adaptation from independent relational skills verses over dependence and the perceived threatening self states with both parties expectations of returning to “the way it was.”

 

Compounding the issue, the RCV has now been conditioned to the “culture of killing” and the relational fluidity of boundaries between the two have become incompatible, further given rise to the RCV’s sense of threat as he where in combat. In combat a registering between non-compatible boundaries would be reconciled by a reflexive reactionary exercise of survival, triggering the culture of killing (Kirmayer, Rousseau, and Lashly, 2007). “Those supporting the use of culture as a defense argue that is it intrinsically unfair to judge someone exclusively by the rules and values of a society that he or she does not know” (p. 98). The above goes to the creation of a Veterans Court, where culture competency would require a special understanding of combat vets cultural “shaping.”

 

Criminal Behavior, Context and Responsibility

“[T]rauma exposure and symptoms of PTSD are prevalent among incarcerated veterans….[e]xposure to combat was the trauma most likely to lead to PTSD among males in a general population survey of 5, 877 individuals, [totaling] 19 percent” (Saxon, A. J., Davis, T. M., Sloan, K. L., McKnight, K. M., McFall, M. E. & Kivlahan, D. R., p. 962, 2001). Saxon et al. indicated a higher prevalence for PTSD in incarcerated veterans than the general population. Additionally veterans who screened positive for PTSD had significantly higher numbers of childhood trauma, indicating a possible correlation between peritraumas, military culture and past traumatization.

 

Taking culture into account means that the purposes of the criminal justice system—which include prevention and rehabilitation—can be achieved more effectively. Cultural awareness must be coupled with an equally astute political awareness that traces the consequences of clinical or forensic consultations out into the larger society (Kirmayer et al., 2001, p. 101).

 

Before the Insanity Defense Reform Act of 1984, questions of the “ultimate issue” when a defendant pled insanity in federal court was whether he lacked “the substantial capacity either to appreciate the wrongfulness of his conduct or to conform his conduct to the requirements of the law” (As cited in Buchanan, 2006, p. 14). After the bill was enacted, the question now goes to whether he “appreciated the nature and quality or the wrongfulness of his acts” (p. 14). “Case law and the Rules’ legislative history suggest also that in less clear cases an issue’s ‘ultimate’ status hinges on who has the authority to decide it….because it amounted to an ‘ultimate opinion’” (pp. 14-15). Psychiatric expertise falls under the Civil Procedure Rules (CPR), Part 35, whereby the duty of the assessor, in an expert capacity, is to help the court. A mental defense with the question of competency will rely on the weight of cognitive capacities.

 

With our modern soldiers averaging two to three tours of combat, we will begin to see an increasing epidemic of incarcerated veterans. In the next 10 to 15 years the American public will see a sharp rise in veterans suffering from Post-Traumatic-Stress-Disorder, to the point of epidemic proportions. You see, never before in war have our troops been subjected to such prolonged exposure to combat and life threatening situations. In World War II our troops were fighting a defined enemy while engaging real objectives with sufficient downtime in between engagements. Most of the troops to see combat were infantry soldiers fighting on a distinct front, not the ones "in the rear with the gear". With a real threat to our sovereignty and way of life soldiers of this era were less affected by the trauma of war.

 

The significant political interference of the Vietnam War generated little to no tangible objectives for our soldiers solidifying and branding their levels of anxiety and forever troubling their minds. Guerrilla warfare, an inherently cognitively damaging military action compounded the neuropathic damage experienced by our troops in Vietnam. Even with the troops having regular downtime in between engagements the cognitive fractures of these veterans were enhanced by more intense combat and the rejection of our returning soldiers.

 

The soldiers in the Iraqi war have been sent on multiple deployments with an average of two or three tours of duty with little time in between. While in Iraq, there are no friendly countries or areas to spend leave time to relieve stress while residing on constant alert and most, even non-combat soldiers, see combat or threats on a daily basis. Now combine this with the most intensive warfare possible, guerrilla warfare in an urban environment. We get troops that are overextended and overexposed to life threatening situations within unprecedented levels of combat. Our troops in Iraq have no respite from danger, further entrenching the effects of PTSD through the hyper levels of neurotransmitters (Lee, 2008).

 

Dissociated attachments reenact combat trauma somatically and between interstates within the RCV resulting in a “civil war” amongst oneself. A seemingly supra-intelligent guidance of the unconscious, this device of PTSD that engages in the survival defensive mechanisms that has sustained the combat veterans life on a persistent basis. Thus becoming the protector and a “conceptualization of hostile self-states in ‘personified narcissistic and sociopathic defenses’ that defend against dependency, vulnerability, and guilt…[and]…applies just as well to pathological narcissism” (Howell, 2005, p. 224). The ‘diminished capacity’ rule would apply when dissociative episodes result in a “psychotic” break, whereby a thought disorder could be ascribed.

 

Diminished capacity resulting in a thought disorder would be split between two categories; one being “disturbances in the content of thinking and perceiving (hallucinations and delusions), and… [the second would be]…disturbances in the form of thinking (formal thought disorder)” (Young, 2003, para. 7). Procedural memory becomes disengaged from experiential memories where reactionary encoding enables the maladaptive somatic response encoded reactions needed during survival in the moment situations. Multiple self-states dissociate and boundaries within boundaries abound.

 

I am just now starting to sift through the sea of case law and journal articles on the considerations of PTSD and criminality; unfortunately I think that there will be an ever increasing need for individuals well versed in the pitfalls of combat trauma and difficulties in reintegration. I feel as you do that something needs to be done to address this issue head on, such as a Veterans Court much like the one just established in Minnesota. Additionally, we have only begun to see the tide of returning veterans with psychological troubles facing criminal charges.

 

Never before in the history of American warfare have we seen such high numbers of soldiers who have been under unimaginable stress. In WWII 18% of our soldiers actually engaged in combat, with Vietnam it was 30-40%, today 68% have actually engaged in combat (Veterans for common Sense & Veterans United For Truth, Inc v. Veterans Administration, item 54, & National Center For PTSD Fact Sheet, Aftermath of Violence section, paragraph 2). Not only have more soldiers engaged in combat, they have been in combat longer with an average of 2 to 3 tours of duty. Many have been on 5 tours and some as much as 6. As high as 80-90% of soldiers (Hoge, C. W., Auchterlonie, J. L., & Charles S. M., 2008, results section, paragraph 5) have seen someone get killed, or been in a combat zone, we have reached "Combat Saturation."

 

Today 15% (300,000; Rand Corporation, 2008) of our soldiers and veterans have been diagnosed with PTSD and this seems like it may be a smaller number compared to other wars. 30% PTSD rates in Vietnam, 15% estimated in WWII and 15-20% of Gulf War I vets reported to have PTSD. It took Vietnam veterans up to 10-20 years before their symptoms reached the point of becoming debilitating. The implications for our modern veterans will have monumental deleterious effects in the next 10 years, it has been projected that PTSD rates in today's wars will reach 50-60%. We will be inundated with mentally ill veterans who have few options and nowhere to turn and they will run afoul with the law (Lee, 2006).

 

Today we have become faced with a growing trend of soldiers and veterans becoming enmeshed in the court systems. In direct conflict with the perception in the media I propose the theory that our veterans and soldiers face an insufficient mental health care which has a major impact to their lives, families and communities. The problem is not individualistic but systemic requiring major changes in how we view and treat PTSD. The care of our soldiers and veterans is not being met and we have just begun to see the aftereffects of the mind shattering results of combat trauma. Untreated PTSD can destroy the lives of many, not only the soldier and veteran. We send our soldiers to war for our freedom and then lock them up when they are broken and of no use anymore (Lee, 2008).

 

---

References

Appelbaum, P. S., Jick, R. Z., Grisso, T., Givelber, D., Silver, E., & Steadman, H. J. (1993). Use of posttraumatic stress disorder to support an insanity defense [Electronic version]. American Journal of Psychiatry, 150(2), 229-234.

 

Brook, T. V. (2008, August 12). Report: 57% of troops sent on combat tours. USA Today. Retrieved October 12, 2008, from http://www.navytimes.com/news/2008/08/gns_deployments_081108/

Bourget, D., & Whitehurst, L. (2007). Amnesia and crime [Electronic version]. Journal of the American Academy of Psychiatry and the Law, 35(4), 469-480.

Buchanan, A. B. (2006). Psychiatric evidence on the ultimate issue [Electronic version]. Journal of the American Academy of Psychiatry and the Law, 34(1), 14-21.

Cercone, K. (2006). Brain based learning. In E. K. Sorensen (Ed.), Enhancing learning through technology (pp. 293-322). Hershey, PA: Information Science Publishing.

Congressional Research Services (2008). United States military casualty statistics: Operation Iraqi Freedom and Operation Enduring Freedom. CRS Report RS22452. Retrieved on October 29, 2008, from http://assets.opencrs.com/rpts/RS22452_20080909.pdf

Hoge, C. W., Auchterlonie, J. L., & Charles S. M. (2006). Mental health problems, Use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan [Electronic version]. Journal of the American Medical Association, 295, 1023-1032.

Howell, E. F. (2005). The dissociative mind. Hillsdale, NJ: The Analytic Press.

Kimayer, L. J., Rousseau, C. & Lasley M. (2007). The place of culture in forensic psychiatry [Electronic version]. Journal of the American Academy of Psychiatry and the Law, 35(1), 98-101.

Lee, S. A. (2006). Effects of combat on returning veterans. Unpublished manuscript, Jefferson Community and Technical College at Louisville Kentucky.

Lee, S. A. (2008). Combat veterans and institutions: A systems analysis. Unpublished manuscript, Kent School of Social Work at the University of Louisville.

National Center for PTSD. (n. d.). The unique circumstances and mental health impact of the wars in Afghanistan and Iraq. Retrieved December 23, 2008, from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_iraqafghanistan_wars.html

Mezey, G. (2006). Post-traumatic stress disorder and the law [Electronic version]. Psychiatry, 5(7), 243-247.

Poortinga, E., & Guyer, M. (2007). Criminal responsibility and intent [Electronic version]. Journal of the American Academy of Psychiatry and the Law, 35(1), 124-125.

Powers, R. (2005). Deployment rates, United States military. About.com. Retrieved on December 26, 2008, from http://usmilitary.about.com/od/terrorism/a/deploymentrates.htm

Rand Corporation (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Retrieved December 23, 2008, from http://www.rand.org/pubs/monographs/2008/RAND_MG720.pdf

Robinson, C. L. (1999). Observations on cognition and insanity [Electronic version]. American Journal of Forensic Psychology, 17(4) 63-75.

Saxon, A. J., Davis, T. M., Sloan, K. L., McKnight, K. M., McFall, M. E. & Kivlahan, D. R. (2001). Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans [Electronic version]. Psychiatric Services, 52(7), 959-964.

Young, D. W. (2003). Varieties of thought disorder in the criminal context. Washington State Bar Association. Retrieved October 29, 2008, from http://www.wsba.org.media/publications/barnews/2003/mar-03-young.htm

United States Department of Justice. (2004). Veterans in state and federal prison system, 2004. Retrieved November 20, 2008, from http://www.ojp.usdoj.gov/bjs/pub/pdf/vsfp04.pdf

Veterans for America (n. d.). Talking points: The consequences of churning & weekend warriors to frontline soldiers. Retrieved October 29, 2008, from http://www.veteransforamerica.org/wp-content/uploads/2008/04/talking_points.pdf

Veterans for Common Sense & Veterans United For Truth, Inc v. Veterans Administration, C-07-3758-SC, 2007 U.S. Dist.

 

---

 

(To come...Scott's guide to dealing with PTSD and the law for veterans and their loved ones, linked here.) 

VA is On the Move with Mobile Counseling Centers

VA to Deploy Mobile Counseling Centers Across America

The first of a fleet of 50 new mobile counseling centers for the VA Vet Center program was recently put into service with the remainder activated over the next three months.

"Our widespread distribution of this fleet from coast to coast marks a new chapter in VA's innovation to reach rural and underserved veterans with high-quality readjustment counseling," says VA secretary James B. Peake, MD.

Each vehicle will be assigned to one of VA's existing Vet Centers, enabling the center to improve access to counseling by bringing services closer to veterans. The 38-foot motor coaches, which have spaces for confidential counseling, will carry Vet Center counselors and outreach workers to events and activities to reach veterans in broad geographic areas, supplementing VA's 232 current Vet Centers, which are scheduled to increase to 271 facilities by the end of 2009.

Vet Centers, operated by VA's Readjustment Counseling Service, provide nonmedical readjustment counseling in easily accessible, consumer-oriented facilities, addressing the social and economic dimensions of post-war needs. This includes psychological counseling for traumatic military-related experiences and family counseling when needed for the veteran's readjustment.

The team leader at each Vet Center will develop an outreach plan for use of the vehicle within that region, not being limited to the traditional area of a particular Vet Center. These vehicles will be used to provide outreach and direct readjustment counseling at active-duty, reserve and National Guard activities, including post-deployment health reassessments for returning combat service members.

— Source: Department of Veterans Affairs

Army General and PTSD: The Courage to Admit All is Not Well

In honor of Veterans' Day -- hey, every day should be Veterans Day, but we're not so lucky -- there's an important story to let people know about, because it so stands out from the crowd, in more ways than one.

In the wake of a recent apparent suicide by a top military officer, Air Force Brigadier General Thomas Tinsley, from unknown causes, this general's admission about his personal struggle with PTSD is all that much amazing. 

"Officers just don't get PTSD," one combat-hardened Vietnam-era veteran told me recently, knowing full well that it's not so much that they don't get PTSD, but that there's no real way to admit that they struggle with it.

---

An Associated Press report from the weekend talks about Army Maj. Gen. David Blackledge's courage to come forward, after returning from Iraq, and getting psychiatric help to deal with the trauma of war.  As the article says, by doing so, Blackledge is (fortunately) "defying the military's culture of silnece on the subject of mental health problems and treatment."

Says Blackledge, quoted in the article, "It's part of our profession ... nobody wants to admit that they've got a weakness in this area," Blackledge said of mental health problems among troops returning from America's two wars. "I have dealt with it. I'm dealing with it now," said Blackledge, who came home with post-traumatic stress. "We need to be able to talk about it."

The article focuses on the perceived "stigma" in the military culture about admitting there is a problem, seeking help and getting treated -- as well as indications that some positive change is afoot in this area.  Blackledge, who served in Civil Affairs in Iraq, and now works at the Pentagon, is clearly leading by example.  He was involved in several traumatic incidents in Iraq -- his convoy was ambushed, his driver was killed, and he was in a hotel that was bombed by suicide bombers -- and he's successfully sought help dealing with the incidents, help which he believes has strengthened him.

Given that we all pretty much know the statistics of how few people seek treatment vs. the ones who should, as well as how pervasive the culture of silence and fear of retribution is, it's GREAT to see Maj. Gen. Blackledge's openness -- and on this Veterans' Day, we can only hope it encourages many other servicemembers to go for help. The article is linked here. (Thanks to veteran John M. for the heads up!)

Editor's note: That's Maj. Gen. Blackledge 2nd from left in the photo, standing just to the right of Bob Dole, in this picture from a charity fundraiser for the Jericho Project.

A Hand across the Abyss - How Openness Helps Heal - A Therapist Talks with His Patient, both Vets

I've recently started reading a very interesting book from the Vietnam era, by Arthur Egendorf, a Ph.D. psychologist who was first a veteran - and later tried to piece together what he had experienced in a way that could also help others. Egendorf's in-depth work at the time with veterans, and his motivation behind it, really seem exceptional. 

Gerald Nicosia writes about him, too, in the excellent "Home to War: A History of the Vietnam Veterans Movement," because Egendorf was instrumental in establishing the veterans' "rap groups" which were an early feature of attempts made to cope with the combat trauma and PTSD Vietnam vets experienced. 

This passage, from Egendorf's book, is remarkable to me for several reasons: Egendorf's own intuitions about healing; his humility, openness and vulnerability with his patient (and friend); their nuanced dance together; and of course, best of all, the effects it actually had on the Marine he helped.  Egendorf's book is out of print, but here and there copies are available used, including on Amazon.  Here's what he wrote:

“If you look, it’s not hard to find veterans who are engaged in healing.  I met one of them eight years ago while visiting a VA hospital.  His name was Jim, an ex-Marine from the Bronx recovering from his latest breakdown, back for another of the hospital visits that began a year after he returned from Vietnam.  I introduced myself as a fellow vet, now a psychologist, who wanted to interview him for a study that would help Vietnam vets.

 
“You want to help me?” he asked.  “For six years I’ve been in and out of this hospital, and I’ve heard enough of shrink talk.  I want to know how you made it.  That’s how to help me.  Tell me how did you get it together?”

 
I responded by making him an offer.  If he would let me interview him, he could ask me anything he wanted.  He accepted and spent ten hours telling me his story.  Before the war he was the kind of youngster teachers like.  He behaved well in class and worked part-time after school.  During his teens he had seen a psychiatrist for “nerves,” but generally had held his own.  In 1969, when he was eighteen, Jim was drafted and goaded into “volunteering” for the Marines, then sent to combat duty in Vietnam.  He saw action in I Corps, in the north of South Vietnam.

 
Ever since he came back, his mother and his wife had been trying to tell him that something was wrong,  For the first year all he did was stay in the apartment, smoke dope, and listen to music.  Then one day while looking out the window he saw a junkie trying to steal the radio from his car.  Jim grabbed a baseball bat, ran after him, and started pounding the guy so fiercely it took three people to tear him away.  After that he knew he was out of control and went for help.

 
Seven years after coming back, Jim described his burdens this way: “Before I went, I worked for six years.  I was the best assistant manager Martin’s Bargain Store ever had.  I can’t work now.  They messed up my head.  How the hell are you supposed to concentrate after all I’ve been through?  Reality sucks.  It’s not what you know, it’s who you know.  That’s why a nineteen-year-old acidhead or college guy gets out of it.  Who do I know?  My shrink from before the war said I was fine.  Now the VA says I was always cuckoo and my problem’s got nothing to do with the war.  My wife is scared of me.  My family thinks I’m nuts.  We were supposed to be over there fighting for freedom, killing people who never did us any harm.  What are you supposed to do after that?

 
I listened, particularly to what was left unsaid.  He had just started to find some direction in life when the war crashed in.  Then it was “pussy,” as his drill instructors called him, and thirteen months of being constantly threatened with death, and seeing a dozen guys he knew pulverized into heaps of bloody flesh.  Others made fun of him, mocking a grunt from New York who resented the practice of calling Vietnamese “slopes” or “dinks” or “gooks.” When the time came to go home and he looked forward to leaving the mess behind, he found that things didn’t work as he expected.  After coming back he wasn’t anybody’s hero, the afterimages of shattering brutality stayed fixed in his mind, and the business-as-usual reality at home had no room for what he carried inside.

For Jim and many like him, it was not them but the world that was crazy.  What was keeping all of it from blowing up, just like the people and placed he had seen “wasted”?  Presidents give the orders and people die.  It’s like a primitive ritual with human sacrifices to bloodthirsty gods.  Jim was sure about only one thing: The people pulling the strings didn’t care what happened to him.

 
“How’d you get it together? That’s what I want to know,” he kept asking.  Our backgrounds were different, but the war gave us a common bond.  Jim was a ghetto kid who didn’t finish high school before entering the service, whereas I had gone to private school, Harvard, and then Europe for a year of postgraduate study before my draft board notified me.  Unlike him, I never saw a psychotherapist while growing up and was never seriously upset until after I came back, and then never so bad that I couldn’t go to school and hold a job, too.  All the same, he knew.  “Something got to you too, huh?”

 
He tested me to see if I’d open up with him. “People like you go into psychology to straighten themselves out, right?”  Yes, I told him, he was right about that.  After years of taking pills and hearing therapists interpret his past and try to modify his behavior, Jim wanted to “relate.”  It was the same hunger that led a dozen of us to form the veteran rap groups that began meeting in New York City in 1970.  In these groups we asked each other and the therapists who volunteered to assist us in gaining the same openness Jim now wanted.

 
After a few meetings Jim asked to be a regular client.  At the beginning he couldn’t take much – he would miss appointments and “forget” to return my phone calls. Eventually, though, we met more regularly, and he began to thrive on the questions I raised.

What had gotten to him?  What was so troubling?  What made him so vulnerable?  What was he going to do about it now?  How was he going to handle his life?  I didn’t intend for him to answer my questions the way elementary pupils answer their teacher’s drill.  Rather, the idea was for him to use the questions to orient himself, to direct his energies where the questioning pointed.  It was time for Jim to stop telling the same story over and over and to begin living out a new one.

 
The more we worked together, the more he saw opportunities to make himself useful – a gesture that would help his wife, an odd job to pick up some cash, a game he could play with his kids.  He studied enough to distinguish his sensitive reactions from his deluded flights of fancy.  And when he was ready, he acknowledged that his suffering would never make sense o its own.  It would only be valuable if he took it as a lesson, something he could use to remind himself that how he handles his life is up to him.

 
After a few months of groundwork, Jim was out of the VA for good.  Then he got off tranquilizers and stayed away from pot.  In the next year, he and his wife stopped fighting and started talking, and soon after that he was holding a job for the first time since he left the Marines.  Two years after we began meeting he bought his own house and was holding down two jobs.  Instead of complaining about his two kids, which is all he had done when we first met, he’d brag about them.

 
The time came when he raised a more ambitious question.  Given his suffering, and what he’d learned, what purpose would he devote himself to?  “People, I want to do something for people,” he’d say.  One of his dreams was to save enough money to start a summer camp for ghetto kids.  In the meantime, he began seeing the people in his daily lives as the ones to serve.

 
Jim still has bad days and times when his kids get to him, but he no longer doubts that his life is workable, which gives him a certainty that makes him proud.  He’s especially happy about the way men who live on his street now listen to him.  “They figure I must know something after I’ve been through.  They ask me how they can straighten themselves out.”  He volunteers at the local Outreach office for veterans, run by the Veterans Administration. “If a high school dropout ex-cuckoo like me can do it, anybody can.”

As powerful as that is, here's something I like just as much: Egendorf's own description of his participation in the dance between patient and practitioner:

“How did you do it?” was the question Jim kept asking.  I knew he wouldn’t be satisfied with some formula or set of rules.  He wanted me to open up, to make it safer for him to open up to himself and to me.  And so I told him about myself, but not to give him know-how.  I simply related bits of my story as they became relevant.  For example, I told him how sensitive I was when I came back.  At first, little things would get to me. I’d be overwhelmed by seeing a dead dog lying on a highway, or the picture of a mourning woman in a magazine, or newspaper listings of the soldiers just killed. Strangers halfway around the world, especially dead ones, seemed closer to me than anyone had ever been except my family and one or two lovers.

 
I also told him about how I threw myself into issues connected with the war.  Before Vietnam I had read newspapers casually.  In the months and first years after coming back I would tear into the pages to see what new horrors I needed to absorb and to find out which people in high places I would cheer that day and which ones I would scream at during the hours I spent raging in my head.  I was more deeply moved by tenderness than at any time in my life, and I was also more easily angered. I’d write scathing letters to editors, congressmen, and the President.  I’d blurt out slogans to old friends and family, who didn’t know how to talk with me anymore.

 
I didn’t tell Jim only about matters that weighed me down.  I made sure to tell him some things that were hard to admit to myself at first, things I needed guts to say, but once said would leave me feeling lighter. I told him it wasn’t just the pain that had surprised me; I had also begun to catch glimmers of some secret joy.  I was happy I had made it through the war when others didn’t, which was hard to acknowledge.  But something else delighted me even more.  Strangely, I was glad to feel so much hurt, as if having allowed something to tear me open meant one day I would give birth to something I might treasure.

 
Jim would compare himself to me and decide that I was so much better off that I had to know something that made life easy. So I also let him know about my awkwardness – the many times I flip-flopped back and forth, from wallowing in my distress to trying to hide from it.  But I also told him I learned more from my mistakes and weaknesses than from anything else.  In fact, my about-faces, in which neither wallowing in the pain nor turning my back on it satisfied me, eventually led me to the realization that I was searching for the third way.  I couldn’t say what it was at first, but I figured somebody had to know or there wouldn’t be such people as counselors and therapists.  They must know, I thought, and so, hungering to find out what they knew and daring to think I’d know too once I joined their ranks, I took a job as a crisis counselor.

 
Jim grasped the irony of my story.  Contrary to what he had initially thought, I wasn’t useful to him because of any information I had.  What I had to offer lay in my willingness to admit that I don’t have anything in particular to tell people until I hear them talk.  I’m willing to be with them without answers, so that I can assist them with their own search.  I told Jim that I’m as surprised as anyone when this works.  The moment when someone trusts me enough to tell  me his troubles a change takes place in me.  I suddenly have more wisdom for them than I usually have for myself. I listen, make comments, and without having to think or plan in advance, ask questions they find helpful.

 
In the end, what Jim accomplished by being with me wasn’t new information to pass along, something he could go out and tell someone else.  He developed an approach to life that transformed his experience of the war from a burden to an opportunity for healing.  The shift happened as a result of our being together, and by our pursuing a joint quest that fostered trust, respect, appreciation and the openness that is healing in itself.

Most crucial is the openness.  I’ve noticed this not only with Jim but also with hundreds of others I’ve worked with since, and with dozens of therapists I’ve trained.  In this book I intend to convey what I mean by openness, in such a way that healing from war dawns as a possibility for you.”

 
-- Source: Healing from the War: Trauma & Transformation after Vietnam, by Arthur Egendorf.  Boston: Shambhala Press (1986)

(Shambhala Press is what published Claude Anshin Thomas’ excellent book, At Hell’s Gate: A Soldier’s Journey from War to Peace, which we have mentioned frequently on this blog.)

 

Learning to Bounce Back: Helpful Hints for Increasing Personal Resilience

"Resilience" or the concept of "increasing personal resilience" is something we're hearing about more and more in connection with PTSD.  For combat veterans and their families, the greater the amount of personal resilience, the more fully they'll be able to "bounce back" from trauma (hence the image of the boomerang, which quickly returns to its source.)

 

According to the dictionary, "resilience" is "The ability to recover quickly from illness, change, or misfortune; buoyancy;" and the intrinisic "property of a material that enables it to resume its original shape or position after being bent, stretched, or compressed; elasticity."

According to the National Center for PTSD, and its PowerPoint presentation on PTSD 101, presented by Fred Gusman, M.S.W. and colleagues, three keys to resilience are the "ABC's" of "awareness" (of one's limits, emotions and resources); "balance") among personal and professional activities [their presentation was to clinical caregivers, so that's explains the inclusion of that sentence]; and "connection" (to one's inner self; to others, and to something "larger" (typically spiritual).) A connection with others, in particular, "breaks the silence of unacknowledged pain; offsets isolation; and increases validation and hope."

 

The short, pithy presentation also offers these

 

Helpful Hints for Personal Resilience:

• Make connections/relationships;
• Avoid seeing crises as insurmountable problems;
• Accept that change is inevitable;
• Set goals and actively move toward them;
• Take decisive actions;
• Look at problems as triggers for personal growth;
• Don’t blow things out of proportion;
• Remember and use past coping, success, strengths. 

-- Source: APA Task Force on Resilience, 2002, quoted in National Center for PTSD’s "PTSD 101," linked here.