Healing Combat Trauma

Week-long Clinical Training Program at the National Center for PTSD

Just back from the week-long and yes, truly fabulous, "clinical training program" at the National Center for PTSD, held on the campus of the VA in Menlo Park, CA. Here's a link to the program. It could not have been better.

We learned so much -- classes ran from 8:00 a.m. to 5:00 p.m. daily, and the stack of handouts, double-sided, ran to 14 lbs. of material. One of the best parts of the program, and there were so many, was the opportunity to observe the men's inpatient residential treatment program for PTSD. That was outstanding. It was hard not to want to follow those guys' progress through the rest of the 60-90 day program. They were working hard at getting better, and it was inspiring.

There'll be more to share about the experiences in the program and what we learned as time goes by, but for right now I just wanted to mention it. It was outstanding...

Understanding Post-Traumatic Stress as a Mental "Illness" without Judgment: A Sufferer Clears Things Up

Periodically we come across something great that a PTSD sufferer has written about what it's like to live that experience, not just read about it. The following post is uniquely compelling and articulate, and it's written by Joan Esnayra, Ph.D., founder of the Psychiatric Service Dog Society. Read more about Joan's organization here. But for her wonderful letter, reprinted with permission, keep on reading below:

Dear Veterans,  

Here is what I wrote in response to one of [name redacted's] posts the other day about whether or not PTSD is a mental illness.   It comes from the heart and it is offered with respect, (if not a little tough love, too).

Dear [Name Redacted],

I know that a lot of veterans are not happy hearing PTSD referred to as a mental illness.  Perhaps this is because of some latent fears about what mental illness really is.   Mental illness is quite simply abnormal brain function in the domains of speech, cognition, behavior, and/or sensory capacities.   Not all abnormal brain function is a mental illness, but all mental illnesses are characterized by abnormal brain function.  Does this make sense?

PTSD is described extensively in the DSM-IV. This is the 'Diagnostic and Statistical Manual of Mental Disorders.'   It is the bible of Psychiatry. You don't go to a podiatrist or an audiologist for PTSD treatment.  You go to a mental health professional. This is because it is a mental illness. There is no value judgment, here. It's just a fact.

I've been diagnosed for so many years that sometimes I forget how scary it was for me when I received my first mental health diagnosis at the age of 25 (Major Depression & PTSD). Having grown up with a mother who attempted suicide with some regularity throughout my childhood years, the last thing I wanted to receive was a mental health diagnosis. Voila! There it was staring me in the face. And, despite the fact that I should have been hospitalized (indeed hospitalization was offered to me), I declined the invitation, swearing to myself that I would not become my mother!  he idea of psychiatric hospitalization was absolutely frightening to me at the time.  

Since then, I have "been there, and done that". I've seen what psychiatry and neuroscience have to offer people like me (and people like you). Did you know that Bipolar Disorder is believed by some researchers to be a dysregulation of the circadian rhythm circuitry of the brain? Where is the mental illness in that?   How can a genetic malfunction of the brain's day/night &  sleep/wake cycle cause people to suicide to the tune of 25%? To say that something is a mental illness, is not personal.  There is no value judgment in the statement. It is just the category of pathology that each of these mental disorders falls under.   It is logical and nothing else.

One of the things that veterans with PTSD have to reckon with is that they do have a mental illness. For some of you, this is a no-brainer, no big deal, like "Duh, that's pretty obvious, Joan." For others, especially the newly diagnosed, this prospect is exceedingly frightening. Allow me to proffer that the fear is not in the classification, rather, it is in our own assumptions about mental illness. When I give public presentations on PSD, sometimes people assume that I am a non-mentally ill psychologist, because I come across professionally, and because I know my subject matter, and I'm articulate. I couldn't possibly be a knife-wielding psycho, right?  I mean, isn't that what mentally ill people are really like?

Of course not!  Mentally ill people are as diverse as any other group of people. You have the high functioning, the low functioning, the assertive self-starter entrepreneurial types, and the passive, quiet, stay at home types.  The whole gamut of humanity is represented on the spectrum of mental illness. There is no "type" among those who live with mental illnesses. As a result, there is no judgment, either. 

The mental health consumer community has been pioneering PSD for 13 years.   We have an intervention that the veterans community wants and needs.  Thus, we need to be building bridges to communication so that we can benefit one another over the long term. Disparaging the characteristics of persons living with mental illness is not going to get us there. So, I'm asking you to re-think your assumptions about mental illnesses and the people who live with them.  

Someone in this group recently disparaged others' talk of suicidal ideation and self-injury. This is incredibly disrespectful to our community members.  Unless you have walked a mile in someone else's moccasins, it is inappropriate to disparage a legitimate feature of their disability. To do so is tantamount to making fun of someone who wears a colostomy bag.  "Hey Poopy Boy, You Stink!" That would be terribly rude. Don't you think?

One of the assumptions that people who are not comfortable with the concept of mental illness make is that people with mental illnesses are victims. This strikes our community as a completely bizarre attribution. What is a victim? Ostensibly, it is someone who, through no fault of their own, is harmed, used, or taken advantage by some force that is more powerful than they are. Using this definition, one might conclude that persons living with mental illnesses are indeed victims to the same extent that anyone is a victim,...of their own genetics!

But, there is another way of using the term 'victim' that disparages the sufferer. In this instance, there is implicit judgment that the person is weak, cowardly, ineffectual, and quite frankly, worthless in the eyes of society.This is the version of 'victim' that I was responding to when I read the term in your previous post. It offended me. I am not weak or cowardly or ineffectual, or worthless, and I AM mentally ill. I have no shame about saying to the world, "I live with mental illness". If I did have a problem with this, then, it would be more so a problem of self-acceptance. The fact is, I am mentally ill. Underestimate my abilities and I will prove you wrong.   Call me mentally ill, and I will agree with you.   Do you see the challenge, here, to familiar assumptions?

The veterans community needs the PSD community, and the PSD community needs the veterans community. We are like newly reunited cousins.  My side of the tracks has never gained societal acceptance because we could never hide the fact that we live with mental illnesses.  (We've been symptomatic our entire lives). Your side of the tracks has experienced societal acceptance in your role as non-mentally ill soldiers. Importantly, your side of the tracks (your peer group) has accepted you on the condition that you are not mentally ill.   

Well, guess what? Living with PTSD means that you ARE mentally ill.  So, do you go into the proverbial closet (a lot of people do), or, do you establish a separatist agenda ("we are not like those people"), or are you going to challenge society's fundamental assumptions about mental illnesses?  It is my sincere hope that you will choose the more enlightened path and look for ways to challenge societal assumptions about persons living with mental illnesses with an eye towards growing a more equitable society for all of us.

Joan

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. 

After Combat: Looking for Health in a Handful of Pills?

From a week ago: The Savannah Morning News had an excellent article, by Pamela E. Walck, called "One soldier's struggle: Sgt. fights anger, treatment system," linked here. (There's also video, but it's not as on target as the article is.)

Sergeant John Jones, now part of the Warrior Transition Unit at Fort Stewart, Georgia, is the subject of the article, and by any standard he has a lot on his plate.

He was deployed with the 3rd Infantry Division's  2nd Brigade's 1st Battalion, 30th Infantry as a gunner, serving his second combat tour at age 29, when he was injured by an IED blast in July of 2007.  Less than six months later, doctors also discovered a brain tumor, and operated.  Since then, though the difficulties you could anticipate from those incidents alone would be enough for one person to cope with, there's been more. Symptoms of PTSD, trouble with authority both on and off the base, difficulty sleeping, the sense in Jone's own words that his personality is not what it was before, a (fortunately) failed suicide attempt, etc.  Really a painful story, of what sounds like a good man, having trouble coping with the after-effects of his injuries. The one peace in his life appears to be a rented cabin, where he goes for solace (and to fish!), yet is in danger of being taken away from him.

Walck does a great job reporting the story, and not settling for just the usual details. Through her work and Jones' own words, you're drawn into the story of what amounts to really a typically "wounded warrior." And while you find yourself pulling for Jones to survive and thrive, you can't help noticing that the "hope" held out for him is not much more than a handful of pills. Who he feels like he's lost, in his words -- echoing that of so many other combat vets with PTSD -- is "the old John," who he's now all but lost entirely. How he's going to get that guy back... is unfortunately anybody's guess. (As an additional difficulty, it's unclear whether his brain injury is making his behavioral issues worse -- it's likely that it is.) In the meantime, we can hope for peace and a healthy solution for Sgt. John Jones -- but for those who want a broader-than-usual, fully-developed "portrait" of one wounded warrior, struggling with the ravages of combat and PTSD, be sure to go here and read his story.

EFT: "Emotional Freedom Technique" for Combat Veterans

If you know anyone who's watched "The Secret," with its emphasis on "the Law of Attraction" -- heck, if you know anyone who's watched Oprah, who promoted "The Secret" extensively on her shows -- you know someone who's probably heard of EFT.

What you might not realize is there's a body of work developing that shows its effectiveness with PTSD.  And some of its biggest fans are the veterans themselves, who've tried it.

"EFT," or "Emotional Freedom Technique," is a form of what's known as "energy psychology," or "energy work."  It was developed by a Stanford engineer -- note, not a psychologist -- Gary Craig, who calls it accurately "a needle-free form of acupuncture."

Craig and EFT practitioners have done some remarkable work with PTSD veterans.  If this subject interests you, or you've looked into various forms of treatment before, and you're even slightly open-minded about trying something with a large upside and very little (or nonexistent) downside, this video in particular is worth watching.  Here's the link. 

The most moving part of the video, in my opinion, is the obvious before and after shots of the veterans themselves, going from visibly struggling, to visibly coping, in very short amounts of time. The excitement of a family member, shown later on the video, is also palpable.  A few studies have also been done on EFT and PTSD -- a book has also just been published -- with more studies to come.  The results are refreshingly impressive, though, for such a low-tech technique.  According to the video, veterans report symptoms drop 63% after treatment, according to a self-reporting scale used by the military.  Symptoms of depression and anxiety reduced by 50%, on average. Cortisol levels -- we've talked about their significance here, here and here -- drop 25% after one hour-long treatment.

Watch the video first, to orient yourself as to what EFT is and how the sample of combat veterans from various wars -- Vietnam, the Gulf War, and Iraq -- responded to it. Then, to learn more, here's an article from the Scottish press about a combat vet and his experience with it.  Here's a story about a Vietnam vet and his experience with EFT. There's a new book by Gary Craig on EFT for PTSD. If you're a veteran, there's a study you can be part of that we blogged about the other day, and that study includes several sessions of EFT. (That post is linked here.)

But if you're intrigued -- after watching the video -- and you want to know more, you probably want to find an EFT practitioner to try it out with.  There's a subset of practitioners listed on the Web, linked  here, who are interested in working with veterans, including -- gasp! -- some who already work at the VA.  If there's no one in your area, you could try this link instead, to find an EFT practitioner who may not have a special interest in veterans, and yet could introduce you to the practice.  It seems to be something low-tech, affordable, simple to learn, and an after an initial introduction, very much DIY (Do It Yourself).  Practitioners may also be willing to negotiate or lower their fees for veterans: Ask.

---

Editor's note: Talking about EFT, or any other technique, should not imply or be misread as an endorsement. In any case, YMMV (your mileage may vary).

 

Veterans Sought for National Clinical Study on EFT and Combat Trauma

Veterans sought for combat stress study

Veterans from wars in Vietnam, Iraq and Afghanistan may be eligible to participate in a clinical study investigating the effectiveness of Emotional Freedom Technique (EFT) at releasing combat-related stress, trauma and memories.

Qualifying veterans will receive six free private sessions of EFT with a professionally trained coach, including follow-up assessments after 3-6 months.

Combat-related conditions include insomnia and/or nightmares, drug and/or alcohol dependencies, anger, anxiety, depression, paranoia, obsessive compulsive behavior, panic attacks, phobias, rage, grief, survivor’s guilt, feelings of isolation or jumpiness around people.

The study is organized and sponsored by the Iraq Vets Stress Project (http://www.StressProject.org), a project of Soul Medicine Institute, a nonprofit research corporation.

For more information contact Susan Maloney, an integral life coach and EFT practitioner, at (707) 888-0246 or susan@susanmaloney.com.

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.

"Purple Mountains' Majesty and PTSD": Colorado VA Hospital Hosts Three-Part Series on PTSD

According to an article in today's Grand Junction (Colo.) Free Press, the local Veterans Affairs hospital is sponsoring a three-part series for veterans, their families, and the community on PTSD.  The series apparently started yesterday (Wednesday) and will continue on the following two Wednesdays, July 16 and July 23.  According to the article, session was led by social workers Gerry Mitchell and Austin Sorensen and "educated the group on the symptoms, perceptions and impacts of PTSD on the soldier and his or her family."  Next session will discuss "veterans’ family members coping with PTSD." (Hey, I hope they see our blog entry from yesterday on that exact subject -- "Home Sweet Home -- After Deployment, What? Support for Returning Veterans and Families," -- linked here!)  The third week's session will let veterans discuss their own experiences with PTSD. (My buddy, Kathie Costos, over at "Wounded Times," mentioned this upcoming series with great excitement the other day.  As she knows, veterans are often not that eager to seek help, but this series looks like a very positive development.)

Editor's Note: The article, by Marija B. Vader, called "PTSD attracts crowd at VA hospital," is linked here. The main website of the VA Hospital in Grand Junction, Colorado, is linked here.  (That site also includes driving directions.)  The hospital is located at 2121 North Avenue, in Grand Junction, CO 81501, and the phone number is (local) (970) 241-0731 and Toll Free:(866) 206-6415.  The sessions apparently start on Wednesdays at 5:30 p.m. in Building 6 on North Avenue.

PTSD Drugs: Better Living through Chemistry, or Purely Popping Pills for PTSD's Psychological Ills?

There was a story in the news recently about four young combat veterans in West Virginia, all seemingly in decent physical condition beforehand, who nevertheless all died in their sleep recently.  Besides combat PTSD, one thing the vets all had in common was the cocktail of drugs they were taking: Paxil, Klonopin and Seroquel.  (The Charleston, West Virginia Gazette-Mail reported this story on May 24, 2008 - it's linked here.)  An investigation is pending, but the story obviously raises the question: what are vets with PTSD being prescribed, and is it really working, or what's best?  (Continue reading, and you'll learn more about those specific medications as well.)

---

Where to go for information about PTSD medications?  Here are a few, carefully-chosen selections, and their pros and cons - as appropriate:

Jonathan Shay, M.D., Ph.D., well-known VA psychiatrist and outstanding veterans advocate, has written before about medications used to treat combat PTSD, and his impressions of them.  He wrote the material for a lay audience, in the version that's kicking around on the Web, in several different locations, and although it has been quoted by many as gospel, it's more than 12 years old by now (first published in 1995), and that's much too much time that's elapsed to consider that information really current. (The Dr. Shay list, "About Medications for Combat PTSD,"  is linked here.)  So that information is interesting for background -- and particularly for Dr. Shay's explanation of how things work and/or what makes a good PTSD medication, and what doesn't -- it out of date and should not be considered current. 

There's another list on the Web -- a table, really -- that's much more current (2006), and it lists the drug names, brand names, and how the drugs are thought to work with PTSD.  That list is linked here.  It may be a little difficult to read if you're coming to the topic cold, but perhaps not.

Some other suggestions:

If you have access to a public library or academic library, you can check out the PDR -- the Physician's Desk Reference -- and read up on a drug's profile, side effects, warnings, etc.  But since you're already on the Web, we can assume, reading this -- try going to PDRHealth.com, linked here-- and read up on the prescription drugs prescribed for PTSD.  Of the three drugs mentioned earlier, Paxil is linked here; Klonopin is linked here; and Seroquel is linked here.  You can also do a straight search for any OTHER drug used in PTSD treatment, or one with possible interactions with a drug used for PTSD, at the same site, by searching within prescription drugs by name (e.g., Zoloft, Chantix, etc.), at the general search interface, linked here.

---

But the information in the PDR, whether on the Web or in the desk reference, is going to dry and technical, though worth reading -- pretty much exactly like the fine print that's packaged with the medications themselves. What you're probably going to want to know more about is what in software is called "the user experience" -- how other patients like you have experienced the medications.  For that you will need to turn to some other sources.

For what amount to "user reviews," try PsychCentral, or Revolution Health, both of which have increasingly robust user communities who will comment on their own experiences of the medications.  (Of course, not all their users taking medications for PTSD have PTSD from combat trauma, so be aware that their cases may be substantially different.)  Combined with the technical information about the drug's effects, side-effects and warnings (see links, above), it might be helpful in creating a broader picture of what the user experience is like:

Dr. John Grohol's PsychCentral website:  Paxil (Paroxetene) is linked here; Klonopin (Clonazapam) is linked here; and Seroquel (Quetiapine fumarate) is linked here. A general search through the medication library is linked here.

AOL Founder Steve Case's Revolution Health:  Users in the "User Community" provide "Community Ratings" on various medications.  The items on Paxil, Klonopin, and Seroquel are linked here (click on any of those hyperlinks to take you to the community ratings), or, use a more generic search here, and look for the tab beneath that says "Community Ratings." (We will be blogging more about Revolution Health shortly.)

Don't forget books as well.  Mark Goulston, M.D.'s Post-Traumatic Stress Disorder for Dummies (2007), linked here, is very recent, and contains a whole chapter entitled, "The Role of Medication in Treating PTSD".

---

You'll also want to learn as much as you can -- though this is primarily your healthcare provider's reponsibility, yet it's in your best interests to care about this as well -- about possible interactions, if you're taking a number of medications; as well as thinking through carefully whether the risks involved are ones you want to agree to, such as the potential that a medication -- bizarrely enough, prescribed for PTSD or depression -- may actually increase risk of suicide. (An example of news coverage about this is linked, here.)  Strange, and perhaps unavoidable, but true.

---

Use caution whenever evaluating information about medications, especially as a non-professional, but at the same time, don't "just" believe what a healthcare provider tells you: be sure to check it out for yourself or your family member, at reputable sites like the ones mentioned above.  Your health is in your hands, so while you want and should actively solicit the expert advice of healthcare providers familiar with PTSD -- and don't settle for less :-), at the same time, YOU are the one who's going to be bearing the brunt of anything that goes wrong, so be sure to do your own due diligence and figure out what the possible side-effects, interactions, and unpleasant experiences might be for you, before you commit to a course of treatment.  You and your healthcare provider can be partners -- that's the new model -- not just "master" and "servant," or "priest" and "parishioner."  Take an active, informed role in your own healthcare, particularly where medications are concerned. 

Healing Hands: Cranio-Sacral Therapy, Veterans and PTSD

Before we leave off talking about Complementary and Alternative Medicine (CAM) therapeutic strategies for dealing with PTSD (usually, in addition to other approaches, not instead of other approaches) -- as we have been discussing lately on this blog, an index to which is linked, here -- it's important to mention one other therapeutic technique: Cranio-Sacral Therapy, developed by Dr. John Upledger (pictured at left).  You'll have to go elswhere -- like the Upledger Institute's website, linked here -- to learn more about the practice -- it would take too long to explain here, because there are several schools of thought on why it might work, and it's a fairly esoteric practice to begin with.  But...an important but...it is a bodywork therapy, akin to massage but not the same as massage, which has shown some effectiveness in improving the symptoms of PTSD.   Digging around on the Upledger Institute's site may help you learn about who practices it in your area of the country, but that is unlikely to be a completely comprehensive list.

For those who believe -- and it surely isn't everyone who does, but many do -- that the physical body "stores" trauma, craniosacral therapy attempts to "release" the stored trauma through the very light, deft touch of the craniosacral therapist.  Not everyone who's been through trauma wants to "talk about it," or "take medications for it" -- for those who are comfortable with a massage-like experience, craniosacral therapy is an opportunity to see if trauma can be cleared, lightly or substantially, using a different method.  (Rumor has it that the Navy and/or the Marine Corps, on the West Coast, is experimenting with using craniosacral therapy to treat PTSD -- more news as that develops.)

Dr. Upledger, and another West Palm Beach, FL-area craniosacral therapist, who I have known for years, and who used to practice together, worked in a novel program years ago to treat Vietnam veterans who were struggling with the effects of PTSD.  In their program were a handful of veterans and at least one medical nurse who had served during Vietnam.  The treatment program allegedly helped some, didn't help some others, and had at least one anomaly as a result: a patient who died in an unrelated car accident, soon after he reported to his family, unfortunately, how much relief he was gaining from the program.  So the results were mixed, but in general, more positive than negative.  (There was even some interest from a famous Hollywood filmmaker, who shall remain anonymous, but who's a big fan of veterans and the Vietnam experience, in filming the experience of veterans undergoing the treatments, but that created controversy for the program, and the idea was eventually dropped.)

Years later, Dr. Upledger did more work with other veterans, and at least one of them, Steve Shumelda, LMT, an ex-military guy with injuries of his own, including PTSD -- was so impressed by the treatments that he gave up whatever he was doing for a living before, and studied craniosacral therapy instead.  He has a practice in South Florida now, and has written about his experience with craniosacral therapy.  You can read more about the Upledger Institute's work with veterans and PTSD, here.

Dr. Upledger has apparently done a video that is available via his Institute on PTSD and veterans and craniosacral therapy.  You can contact their office to see about purchasing a copy.  For additional resources to read up on the topic of craniosacral therapy, veterans and PTSD, click here for a separate blog entry we did recently that consolidates a few in one place.  To read about Vietnam veteran and former Navy corpsman Steve Shumelda, LMT's experience with PTSD and craniosacral therapy, click here.