Bureaucracy, Trauma, and the VA

Newspapers and media outlets are carrying daily revelations of serious shortcomings in the Veterans Affairs healthcare system. Those who have served our country, with honor and sacrifice, are receiving far less than their due for their medical and psychological needs. In 2010 and 2011, I provided resilience training to VA combat crisis treatment teams in the VISN 3 network—case managers, nurses, social workers, psychologists, suicide prevention coordinators, and other staff in eighteen medical facilities in the New York and New Jersey area. My firsthand experience with the VA system during this year-long contract, combined with experiences of my patients and friends, matches and confirms much of the recent reporting. Unfortunately, I’m not surprised at the level of bureaucratic dysfunction in our Department of Veterans Affairs.

Bureaucracy can have its own brand of trauma. Certainly, the VA treatment teams I worked with named “the bureaucracy” as their number one source of trauma on the job. Considering that these health professionals served a high-needs, often highly-traumatized population of Iraq and Afghanistan war veterans, this was a disturbing finding.

Bureaucracies, by nature, are hierarchies. Each level of the hierarchy possesses a level of power and authority over those levels below it. These positions of authority are proscribed, and by that I mean that the authority belongs by definition to the job position, not the person. The organizational chart dictates who has power and control over whom. When people who are natural authorities—skilled, mature, capable leaders in their fields—are also those with the proscribed authority, all can go well in a bureaucracy. When less-qualified professionals take positions of control, mistakes and abuse can follow. Poor leaders with proscribed authority can be capable of cutting corners ethically, making unreasonable or impossible demands on front-line staff, and creating both dangerous and even toxic work cultures and deficiencies in delivery of services.

This is what we’re seeing now at the VA. My heart breaks to witness it. Corruption has crept into a system that some of our finest men and women depend upon for their very health and well-being.

While working with the VISN 3 treatment teams, I found many highly dedicated, skilled, and compassionate professionals providing care to the best of their abilities, within some significant constraints of time and resources. As caregivers, they worked long hours, often donating their personal time to meet the needs of veterans and their extended families in ways the VA system couldn’t or wouldn’t provide. Pressure from above to meet quotas and keep up with voluminous paperwork were actual sources of trauma for them. While some already knew effective self-care techniques to stay resilient, too many of them were also close to burning out.

Losing effectiveness of the job and watching their home life deteriorate was the last thing these health professionals wanted to have happen to them. They wanted to continue serving in a calling they loved and were committed to. I think of them now—how hard they worked and how much they cared—and hope that real reform in the vast bureaucracy of our Veterans Affairs will happen soon. Veterans, and their caregivers, deserve better.

A New Yardstick 2014

I’m in the midst of a vigorous bout of simplifying my life, enthusiastically getting rid of a large quantity of possessions I no longer want or need. The process is personally liberating and financially rewarding at the same time. I’m reminded of a blog post from several years ago, during the depths of our recent recession, titled “A New Yardstick.” At that time, many people were working very hard just to keep up financially. I believe today that this same situation is still an unfortunate reality for a large number of people.

When we struggle daily to survive, we get physically and emotionally exhausted. We become vulnerable to negative emotions like worry, frustration, discouragement, and despair. Our view of life can become dark and hopeless. But that view is not an accurate picture of where we are. 

What we need—what I strongly urge my friends and patients—is to find a new “yardstick”.  We need to change the way we measure our progress and success.

Specifically, this means we must stop measuring our success in dollars and cents. That’s an old yardstick we all have in us. It can be easy to mark our progress in life by our savings account balances, the value of our homes, our cars, and other material possessions. Here are three ways to change your mindset and turn in your old yardstick for a new one.

1. Stop trying to live up to your own unrealistic expectations.

Do you value yourself based on your net worth? If your answer is ‘yes’ to this question, at least part of the time, you’re not alone. Identifying ourselves with our possessions, equating our worth as a person with our money and belongings is a temptation as old as man. Remember you are a unique, valuable, irreplaceable human being with intrinsic worth and abilities. You have immeasurable value in yourself and in the contribution only you can make to the lives of those you love and to your community.

2. Stop trying to live up to others’ unrealistic expectations.

Does what other people think of you tend to run your life? Do you see yourself mostly through the eyes of others? Have you exchanged the pursuit of your own passion and calling for a pursuit of status or acceptability? If you didn’t feel driven to live up to other people expectations, how would you see yourself differently, and what might you do differently with your life?

3. Stop using “if . . . then . . . “ thinking.

Does this sound at all familiar? “If I could get (fill in the blank) dollars saved in the bank, then I’d be happy”—or feel safe—or be ready for retirement—or be able to go on a nice vacation—or free to try a new career, the list could go on and on. This is a form of wishful, magical thinking. It’s a way of postponing life and action. The truth is that there are no guarantees. As I’ve written about before, we don’t know what tomorrow will bring. While planning is important, we truly need to live one day at a time, making the best of what is in front of us today.

Seeking Treatment: Part Two

In a previous post, I included an excerpt from Trauma: Healing the Hidden Epidemic on the topic of seeking treatment. Perhaps you’ve occasionally wondered if something painful from your own past, which you can’t quite let go of, could indicate that you carry unresolved trauma. In this post, I will further address some of the challenges of seeking treatment.

“Treatment can help you move past painful and traumatic experiences that have troubled you all your life. It can illuminate the connection between your current struggles—emotional, physical, spiritual, or otherwise—and a distant, even repressed, event that occurred years or decades earlier. Treatment is a way to heal emotional wounds just as you would nurse a physical wound back to health. It gives you the opportunity to move beyond your traumatic experiences instead of allowing them to define you.

“If there is so much to be gained from psychological treatment, why is it that so many shy away from it? Treatment, therapist, shrink, and disorder are scary words in our society. No one wants to appear to be mentally unstable or ‘crazy’; people fear that seeking treatment is an indication of that. Many also feel shame around traumatic experiences. They feel a cultural obligation to be strong, and they fear that if they are troubled by these experiences, they are weak. Unfortunately, the stigma of mental and emotional wounding keeps millions of people in need out of treatment.

“People are afraid of being judged by employers, friends, and family members. Expectations and codes of conduct operate just underneath the surface of our consciousness. As a result, innumerable people, including soldiers, nurses, paramedics, firefighters, police officers, and civilians, are in denial about their own need for treatment.

“Some traumatized individuals are ashamed of things they’ve done—or things that have been done to them—to the point that they cannot imagine sharing the details with anyone, not even a trained therapist. Sometimes they are even afraid of what might change in their own emotional state if they finally fully acknowledge those experiences. They fear that the cap containing their unresolved, stored energy and emotion will break its seal, and they will lose control of their lives as a result.

“Trained, experienced therapists hear shocking, tragic, even horrific stories from their patients. Through it all, their responsibility is to listen to a patient and help if possible, never judging. Good therapists have a unique insight into the human condition that those in other professions don’t always have; they understand why people behave in certain ways and what motivates them to do the things they do. When you know that unresolved pain motivates a person’s actions, judgment doesn’t come so easily.”

                        From Chapter 6: Seeking Treatment

Relationships and Trauma, Part Two

“Trauma and its psychological wounds often destroy relationships, families, and communities, even claiming lives.”

From Trauma: Healing the Hidden Epidemic

Last month, we looked at the ways unresolved trauma affects, or almost “infects” relationships. We examined both the practical and the personal burdens that partners of individuals with unresolved trauma can bear. But what happens when both individuals in a relationship—a family, a marriage, a business partnership—carry wounds from the past?

Yours, Mine and Ours

The challenges in a relationship where both individuals carry unresolved trauma can be illustrated by considering the challenges in blending a step-family. As in a marriage between two individuals with children from other relationships, each individual may bring personal difficulties into the relationship that have nothing to do with their new partner, family member, or loved-one. These painful issues may express themselves in a variety of negative or undesirable symptoms and behaviors.

Each individual in the relationship may have some awareness of their own troubling issues. Each individual may also have some awareness of the emotional difficulties their new partners struggle with. Often, however, such awarenesses are hard to grasp. A great deal of confusion and conflict can arise in the day-to-day give-and-take of relationships when pain from the past is influencing behavior and attitudes in the present.

The confusion only deepens when the third set of challenges arise. To use our illustration, if the painful issues of each individual are the “yours” and “mine” stepchildren of the blended family, the third set of painful challenges will be the “ours” children, or the issues the new couple have with each other. These are the challenges and difficulties which arise precisely because of the nature of being in relationship.

Putting it briefly, two key ingredients in significant relationships are intimacy and dependency. For traumatized individuals, intimacy and dependency are very substantial challenges in themselves. The experience of trauma—whether prolonged developmental trauma or events of shock trauma—frequently, if not always, damages an individual’s ability to trust and feel safe in the world. Healthy intimacy and dependency require some ability to trust, and the willingness to allow that trust to grow and deepen. Individuals must be able to feel some essential element of safety in the relationship and be willing to help create a safe place for their partners and loved-ones.

Often, individuals with unresolved trauma lack the objectivity and awareness to sort out the “yours, mine, and ours” in their relationships. They may find themselves creating unfulfilling, destructive relationships over and over in similar patterns, or their painful pasts may be so overwhelming that they avoid relationships altogether. Competent, effective counseling can help with the sorting-out process to help individuals heal and strengthen their relationships.

Stress, Compassion Fatigue, and Burnout

Personal resilience—the ability to recover from stress, or painful, difficult experiences—is essential to resolving trauma. Resilience is a life skill that can be learned. Under contract with the Department of Veterans Affairs, our institute provided a year-long training in resiliency skills to treatment teams in eighteen medical facilities in New York and New Jersey. What happens when people, particularly caregivers, lose their resiliency? Under stress without relief, they can develop compassion fatigue or spiral into burnout.

Compassion Fatigue

Stress, compassion fatigue, and burnout exist on a spectrum. We all experience stress and can learn self-care techniques to dissipate its effects. When stress buildup starts to take a toll, we move into a state of depletion called compassion fatigue. Let me illustrate the difference between experiencing stress versus existing in a state of compassion fatigue.

Even when experiencing stress and secondary or vicarious trauma, caregivers and others feel that they like their jobs. They like or love the people they serve and want to continue to be there for them. They are able to maintain a healthy balance between their needs and the needs of the people they care for. They get tired, but can usually recover with a day or two of rest. They use self-care techniques that work for them to recover and return to serving others.

Caregivers and others who have not kept up self-care methods to resolve their stress and vicarious trauma will start to feel lingering dissatisfaction with aspects of their jobs. They usually still like or love the people they serve, but they feel depleted in ways that might take a week or more to replenish and refresh. They find themselves consistently putting their client or loved one’s needs first. They are less satisfied in their work and are at risk, if they don’t turn things around, for burnout.

Burnout

Compassion fatigue progresses to burnout when stressed and traumatized caregivers and others abandon self-care in essential ways. They no longer like their jobs and feel like they want to quit. They have a hard time caring for the people they’re helping and can become overwhelmed with their needs. They can become almost dysfunctional in meeting their own needs or the needs of those they care for. These caregivers and others are exhausted. It would take a significant amount of time for them to return to a healthy, rested state, capable of doing good work.

Addressing Compassion Fatigue and Burnout

Developing a repertoire of self-care techniques and practicing them regularly is essential for combatting compassion fatigue and burnout. Caregivers and others need to practice self-care that addresses all aspects of their health—physical, mental, social or emotional, and spiritual. There are many good resources available with suggestions for self-care activities. Ask others in your situation or profession, do some research on the web, or read our book, Trauma: Healing the Hidden Epidemic, for some helpful, practical guidance. With discipline and determination, you can remain resilient and effective in your calling.

Seeking Treatment: Part One

Have you ever wondered if something painful from your past, which you can’t quite let go of, is evidence that you carry unresolved trauma? In this excerpt from my book, Trauma: Healing the Hidden Epidemic, I address some of the challenges of seeking treatment. I’ll continue this topic in my next post, as well.

“If you have ever considered seeking treatment, even if you have yet to follow through with it, I acknowledge your courage. Facing reality and accepting that we need help can be a very difficult and even painful process.

“In the United States and in many other nations around the world, we embrace a culture of independence and self-reliance. Accepting help has a stigma that many people aren’t comfortable with. But disarming this ideology is an important step that we must take if we want to truly embrace our natural capacity for healing and resilience. The truth is that almost everyone needs help, and they need to be empowered to get it.

“Because we are often blind to signs that indicate a much larger, trauma-related issue, many people don’t know that they need treatment in the first place. It’s easier to ignore the parts of our lives that are dysfunctional than to look at them and think, “Something bigger is going on here.” We ignore and deny these problems, which more often than not causes additional damage.

“The effects of trauma are cumulative—they can progress and intensify over time. In fact, time does not heal all wounds. Trauma left untreated can grow from a manageable problem into a significant one. Time merely gives the effects of trauma the opportunity to fester and cause deeper wounding, both physical and emotional. Trauma-related wounds seldom subside on their own. Many victims require treatment before they can recover from their experiences and restore peace and functionality to their lives. Without treatment, they may spend a lifetime trying to figure out where their lives got off track and why physical and emotional pain seem constant. It’s an uncomfortable, if not tragic, existence.

“Happiness, joy, fulfillment, peace—all are abstract terms that may be difficult for us to define. We don’t always know when they are present in our lives, but we sure do miss them when they’re absent. If you have a history of trauma, it is affecting your current life whether you realize it or not. Treatment is the best way to liberate yourself from a past that prevents you from experiencing the great things in life that are possible. It may sound philosophical, but it has become a reality for many of our patients.”

                        From Chapter 6: Seeking Treatment

Relationships and Trauma, Part 1

Relationships and Trauma

Excerpts from Trauma: Healing the Hidden Epidemic, by Peter M. Bernstein, PhD

“Trauma and its psychological wounds often destroy relationships, families, and communities, even claiming lives.”
                                    From Chapter 7: “A Note to Veterans and Their Loved Ones”

Trauma affects, or almost “infects” relationships. The partners of individuals with unresolved trauma bear burdens that can be both practical and personal.

Practical Burdens

The lives of partners of trauma-affected individuals are burdened in practical ways because they must often fill in for their loved-one who is in some way “not there” to help with the daily demands of life. The spectrum of “not there” can range in severity from mild impairment to highly dysfunctional. Not only is the individual “not there” to help, they can add to the partner’s burdens with their trauma-related demands and needs for care. Trauma-affected individuals can have symptoms (including depression, anxiety, sleep disturbances, sexual dysfunction, mood swings, chronic fatigue, panic attacks, physical pain and disease, See Chapter 1: “Understanding Trauma”) which require care or accommodation. They can also have self-destructive behaviors (addictions, infidelity, risk-seeking activities) which result in negative consequences to the relationship.

Personal Burdens

Partners of trauma-affected individuals are also burdened personally within the relationship. Trauma-sufferers often want to avoid their pain by staying numb, isolating themselves, and refusing to be vulnerable. By limiting the amount of relating or connecting they do with their partners, they reduce the level of intimacy in their relationships, which removes the likelihood of having to feel pain. Partners become a “threat” to the traumatized individual’s sense of safety because they challenge the individual’s carefully constructed defenses against feeling.

The story of Brandon, a veteran of the war in Iraq, illustrates the desire for “numbness” shared by many traumatized individuals:

“But when he was home, the numbness began to wear off. He began to feel the emotional and physical pain of his experiences. Without the tools to successfully confront those feelings and learn to interact with his civilian family and friends, the feelings were completely overwhelming. The symptoms of his trauma were so intense that they were unbearable. Many service members, such as Brandon, feel that the only way to find relief is to be numb again.”
From Chapter 7: “A Note to Veterans and Their Loved Ones”

Self-medication through substance abuse is one way trauma-affected individuals attempt to remain numb, with often devastating effects on their relationships. They often turn to drugs and alcohol, I explain in Chapter 7, “because they want to numb symptoms of trauma. These substances keep the feelings and memories at bay. Their symptoms return when the high wears off, however, and the need to alleviate these symptoms creates an addictive pattern. It isn’t accurate to say that they want to abuse drugs and alcohol. Rather, the issue is that they will do anything to feel ‘normal’ again, or at least, comfortably numb.”

Partners of trauma-affected individuals often feel alone and rejected on some level. They may feel they must always tread lightly in their relationships. They may end up feeling helpless and powerless to make a difference in the lives of their suffering loved ones. Trauma-affected individuals often promote these feelings of powerlessness, because they are committed at all costs to maintaining control and protecting themselves from feeling their pain. Instead of cooperating with their partners by working through their traumas in order to have better relationships, they can actively resist and thwart their partner’s compassionate efforts. This conflictual, combative pattern, if it continues, can destroy trust within the relationship.

Resilience Cafe February 10th

The next meeting of Resilience Café will be held on Monday, February 10^th at Aqus Café from 7:00 to 9:00 PM. Please join us for this continuing public forum for the discussion and healing of trauma. We offer all who attend the opportunity to “Listen, Share, Heal,” as together we fight the stigma often associated with mental health challenges and the isolation trauma sufferers experience from our “hidden epidemic”.

My message – then and now – is one of hope. With help and hard work, trauma can be resolved and transformed to restore meaning and purpose to our lives.

Aqus Café is located at 189 H Street, Petaluma.

A Resolution for Hope

It’s a new year and the news sounds good. The stock market is hitting new highs, employment and housing starts are up, consumer confidence is rising. We’ve just celebrated joy-filled holidays with family and friends and now we can make a fresh start in 2014.

With so many things on their way “up”, why can it be so easy to feel down? Here are two possibilities. The holidays – whether you recognized it at the time or not – were not as joyful as you hoped. Your family relationships may have a history of pain and conflict you’d rather not admit. Or, while the media may report that our economy is improving, your personal situation continues to look bleak. Your life may still feel like a daily grind to make ends meet.

It’s very common, after the rush of the holidays is over, for people to feel let down and depressed. For people with unresolved trauma from the past, this rebound reaction can be particularly exaggerated. Unrealistic expectations for family harmony meet with constrained finances to produce deep disappointment. Discouragement and despair often follow. Hope in the holiday season can degenerate into hopelessness in the New Year. Instead of a fresh start, we can feel stuck in the same mire of immobility.

I write about this phenomenon in my recent book, Trauma: Healing the Hidden Epidemic. In chapter 9, “Crises and Hard Times”, I explain that unresolved trauma can cause people to collapse emotionally and psychologically during prolonged hard times.

“[People] may be stuck in the ‘freeze’ portion of the stress response from prior trauma. Rather than working frantically to solve the problem at hand, these individuals will be paralyzed, absolutely unable to take action. They cannot do what needs to be done to create solutions. Unfortunately, a passive, paralytic response (or lack of response, as it were) can exacerbate their wounded physiological and psychological state, causing them to ignore the needs of the present situation.”

Let me point out something else that people suffering from unresolved trauma often ignore: options. During despair and discouragement, people often fall back into their old default coping patterns. They may put their heads down and keep plowing on without looking around for new paths of opportunity. They may allow the buildup of toxic rage beneath their helplessness to explode in destructive acts instead of looking for new outlets for their energy. The new option they need – to counteract the intensity of their negative emotions – is a new perspective.

Let me illustrate. Again, from my book:

“Remembering the lessons we have learned from past hardships and experiences can be extremely valuable in times of trial. Recognizing that the lessons we will learn from the present challenges will be highly beneficial to other areas of our lives is valuable as well. If we survived the past, we can survive the present. Life experiences – both traumatic and otherwise – prepare us for future challenges that we will be responsible to overcome. They help us develop survival mechanisms and coping skills. In a way, they are blessings in disguise.”

No matter how difficult our circumstances, we always have the power to use our rational minds to explore options and make positive, productive choices. If you are struggling with post-holiday let-down, let me encourage you to make one such choice – come to the third meeting of Resilience Café, a local forum for talking about and healing trauma. We will discuss practical ways to deal with a painful past, gain a fresh perspective, and find new options. Plan to join us Monday, January 13^th at 7:00 PM at Petaluma’s Aqus Café, 189 H Street.

I believe each of us have it in our power to make 2014 a truly new year. Add Resilience Café to your calendar and you’ll be making a great start.

The Season of Light

We are entering a season for celebrations, and the symbol of light plays a part in many of our spiritual traditions. Light in the darkness can be a powerful metaphor for important ideas: courage in spite of fear, empathy in place of judgment, love instead of animosity, faith in place of doubt, and hope in the face of despair.

The experience of trauma can cast a dark shadow over our lives. But I believe the light of healing can turn tragedy into an opportunity for change and growth. Often, we can’t find the light we need on our own. Finding the courage to take the first step – asking for help – can start us on the path to transformation.

Those in our community who attended the first Resilience Café last month were able to take some steps toward healing. People filled Aqus Café to capacity the evening of November 11^th to learn about emotional trauma, take part in small group discussions, and fight the stigma and isolation so often imposed on sufferers of our hidden epidemic. It was truly an opportunity for all to “Listen, Share, Heal.” Please join us for our next Resilience Cafés scheduled for Monday, December 9^th and Monday, January 13^th, at 7:00 PM.

Soon, 2013 will draw to a close.  For many of us – including me – this has been another challenging year of struggle and change.  As painful as many of these challenges have been, I am grateful for the opportunities they have offered me. I look forward to 2014 with excitement, trusting that great things can happen when I act with courage and strength. Take hold of this thought and put it into practice in your life. Amazing things can happen.