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Trauma

Lost

Families of service members killed in the line of duty have suffered the ultimate loss of their loved ones. Their sons or daughters, husbands or wives, fathers or mothers, will never come home. Their loss and grief are real and tangible.

But many families of service members who do return from active duty also feel that they have “lost” their loved one. To a lesser degree – but still significantly – the service man or woman they knew before deployment has changed beyond their recognition.

Military families understand that the experience of combat changes people. They would be concerned if their loved one returned from deployment exactly as they used to be, as though nothing had happened to them. But many families and loved ones are unprepared for the stranger who at long last walks through the door.

Loved ones expect a time of transition. But when time goes on and on and their veteran doesn’t readjust – or is possibly getting even more troubled – they wonder what to do. They can feel pain for the lost relationship, frustrated over how to get help, and worn out at the burden of care placed on them.

Military personnel are changed by their service . . .

. . . physically – by wounds and injuries, and the lingering disabilities they may produce

. . . emotionally – by anxiety, depression, rage, terror, and shame

. . . mentally – by changed attitudes about the world and the people in it, or by the side effects of psychotropic and pain medications prescribed for visible and “invisible” wounds

. . . spiritually – by a loss of hope and faith, by anger at God, by shame for violating deeply held principles of conduct in a hellish theater of war

The Bernstein Institute for Trauma Treatment, with the support of nonprofit Sonoma Coast Trauma Treatment, is in the process of forming a support group for loved ones of veterans struggling with the traumatic effects of their service. If you or someone you know needs our help at this time, please get in touch.

A PTSD Scenario – and a Support Group

A veteran and his wife sleep side by side in their darkened bedroom. The man moves restlessly under the covers. The woman, long familiar with his insomnia and night terrors, is somewhat conscious of his rising agitation. Something happens. It might be a sound from the external world – a passing car, a gust of wind – or a shift in the internal dream world of the man. Suddenly he is on his feet, dragging his stunned wife out of bed. He grabs the knife on his nightstand and braces his wife forcefully against the wall. She knows him as her husband, the man she loves, a troubled veteran with PTSD. But the veteran doesn’t know his wife. She is the enemy. As she pleads with him, he slowly recognizes where he is, who she is. He releases her, flooded with remorse and shame.

A dramatic scenario, I’m sure you’ll agree. Something you might see in a movie, such as the recently released American Sniper. But it’s also a true scenario, as it happened to me. I was that veteran.

My first wife and I are not alone in experiences of that kind. Many patients and people I’ve met over the years share similar stories. Many veterans and their spouses or partners make the decision to sleep apart – many of them eventually break up – because veterans with PTSD often have great difficulty with relationships and intimacy.

Intimate relationships are characterized by vulnerability. With a loved one, we drop our defenses and expose ourselves and our feelings. For veterans struggling with PTSD and other military-related traumas, vulnerability can be terrifying and intolerable. Their partners, paradoxically because they are beloved, become dangerous threats to be avoided. Veterans can fear losing control and hurting those they love. Sometimes they even sufficiently lose touch with reality to believe their partners really are the enemy. Everyone suffers, including the veteran’s loved one.

That’s why I’m in the process of forming a support group for loved ones of veterans struggling with PTSD. I’m reaching out to spread the word that the Bernstein Institute, in partnership with nonprofit Sonoma Coast Trauma Treatment, has help and hope to offer. If you or someone you know is in need of this kind of group, please contact us at 707-781-3335.

Support for Veterans’ Loved Ones

Three weeks ago, my commentary on peer counseling for combat trauma – and the connection to American Sniper and former SEAL Chris Kyle – appeared in the Santa Rosa Press Democrat’s Close to Home column. A reader responded: Yes, many veterans suffer from PTSD and other emotional challenges and need and deserve help. What about the partners, spouses, and family members of struggling veterans? We’re suffering, too, in our own ways.

This loving partner of local veteran is absolutely right. I won’t reveal her name, but she has really hit the nail on the head. Loved ones of veterans and service members struggling with behavioral health issues need information and support. They need help to take care of themselves so that they in turn can take care of the veteran in their lives and any other family members depending on them for care. My respondent asked: Did I know of any support groups for loved ones of struggling veterans?

I’m a man of action, and now I’m acting. I’m in the process of forming the kind of group this loving partner needs. I’m also involving our affiliated nonprofit, Sonoma Coast Trauma Treatment (SCTT) to help make this group a reality.

Part of SCTT’s vision is to provide emotional trauma-related services and support for local veterans and their families. This new support group fits squarely into their mission. It also fits squarely into my passion to give back to the military men and women and their families who have sacrificed so much for us and for our country.

We are now forming the Support Group for Loved Ones of Veterans with PTSD. If we can help you, or if you know of someone who could use our help, or if you would like to contribute financially to this outreach, please contact us. You will have my deepest gratitude.

For more information about SCTT and our new support group, please contact either myself or group coordinator Hilloah Levy, at 707-781-3335.

Shortages – Of Mental Health Providers and Real Healing

A recent Wall Street Journal special report on health care included a revealing article titled “Where Are the Mental-Health Providers?” Reporter Louise Radnofsky presents convincing evidence and sounds the alarm about the increasing difficulty of finding much-needed mental health care in many regions of the United States.

Radnofsky quotes statistics from a recent study by Mental Health America, a patient advocacy group. The study found that while 42.5 million adults in the United States have a mental illness (18% of the population), the ratio of mental health providers to people in the US is just 1:790, while only 41% of people with a mental illness report receiving treatment.

“That’s prompting a sea change in attitudes among mental health advocates,” Radnofsky writes, “who are starting to look at solutions that are broader than just training more psychiatrists.”

It’s about time. In this month’s article and book excerpt, I explain my thinking on the Dr. Jekyll and Mr. Hyde nature of trauma treatment by psychiatrist-prescribed medications. I will stress again that there is an important role for psychotropic drugs in effective therapy. But—too often—drugs are presented as the complete answer for trauma sufferers. Nothing could be further from the truth.

Chemically locking away traumatic memories may help people temporarily, as I’ve outlined above. But I firmly believe that the hope for healing lies in unearthing and resolving the painful past. Drugs can make this process all but impossible when patients have great difficulty accessing their memories. And, over time, serious and life-compromising side effects of medication pile up.

Well-trained psychotherapists play a vital role in our nation’s mental health. I’m all in favor of greater recognition of this serious gap in our mental health system.

The Loss of Robin Williams

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

On Monday, August, 11th, Robin Williams took his own life. Robin was a brilliant, gifted actor and comic who struggled with addictions to alcohol and cocaine. He admitted to experiencing episodes of depression and displayed manic tendencies in his work. Personal experiences of trauma, I believe, left their mark on his life in recognizable patterns. His death is a tragic loss for his family and fans.

After the suicide of a friend or loved one, people often ask themselves if there were signs that they missed of the individual’s intent to suicide. In some cases, the troubled individual does exhibit warning signs, which can be subtle or obvious. In the following excerpt from my book, I provide guidance and suggestions for finding and recognizing signs of potential suicide.

“First, be observant when dealing with a traumatized individual. Loved ones of suicide victims often recognize too late that there were warning signs. Understand the possible warning signs of suicidal behavior. If you suspect a person may be contemplating suicide, trust your judgment.

“Suicidal behavior results from many different traumatic experiences, from sexual abuse to a disabling accident to the death of a loved one. It can also be caused by seemingly less serious life situations that are uncontrollable, such as a successful professional’s job loss or an exemplary student’s experience of poor grades. As this book illustrates, almost anything can lead to trauma if the event is unexpected and the person has a negative reaction to the experience, particularly if she has suffered developmental trauma in childhood.

“Look for specific, telltale behaviors in your loved one, such as the following:

  • Crying and withdrawal
  • Recklessness
  • Quitting activities and lack of interest in former activities
  • Loss of appetite
  • Lack of interest in appearance
  • Diminished physical energy
  • Frequent minor illness
  • Sadness, hopelessness, guilt, loneliness
  • Scattered thoughts
  • Drug or alcohol abuse

“Pay special attention to any individual with a previous history of suicidal behavior or suicide attempts. And certainly, take action if someone close to you begins talking about suicide or shares plans of suicide. At this stage, professional help is absolutely necessary and should be sought as soon as possible. If you feel your loved one is at a very high risk of suicide, don’t leave him alone; call help to the scene.

“Drastically elevated moods after a long period of deep depression can also be a warning sign that a suicide attempt is imminent. Once a person has resolved to commit suicide, he or she may exhibit behaviors that seem almost euphoric. The shift is usually sudden and without any change in life circumstances. The change can distract loved ones and friends from the victim’s condition, giving them hope that things are turning around. In fact, such a dramatic change in behavior is a smokescreen for the increasingly dark feelings and can be a sign that a suicide attempt is just days or even hours away.

“Many family members of suicide victims wish their loved one had shared their despair and plans with them. If so, they feel they could have stopped it. But most people contemplating suicide keep their plans to themselves. Therefore, it’s up to those around them to stay in tune with their behaviors. If you are suspicious, ask the other people in your circle what they have noticed.

“Even if you aren’t convinced that your loved one is contemplating suicide, reach out to her and show you care. Be open to hearing what she has to say, but also tell her what you have noticed in her behavior, referencing specific actions and incidents. Then, ask direct questions about her current state. Don’t be afraid to say the word suicide. Talk to her about her plans, previous attempts, and thoughts about suicide, if applicable. Listen, talk openly, and let her talk. Try to be understanding and open-minded about her thought process and feelings. This is the time to determine her risk for suicide.

“Most important, try not to become upset or over-emotional during these conversations. Becoming upset might discourage at-risk people from talking to you again about their situation, and you want to keep an open dialogue so you can continue to monitor them. By mitigating your reaction in this way, you pause your own feelings and emotions about the situation in the moment. Remember, you must deal with these emotions at some point, allowing yourself to experience your feelings when it’s more appropriate. Ignoring your feelings indefinitely or overriding them for an extended period will only do you harm, and you will likely become a secondary trauma victim.

“Finally, offer hope and solutions to those at risk. Discuss the option of seeking professional help to deal with their pain. If they are resistant, help them imagine what life could be like without pain and despair. Let them know that such a life is possible for them with the right help and support, including that of friends and family, and counselors and therapists. Resolve to find help for your at-risk loved ones even if they are resistant. Be firm and diligent about your intentions to get help for them, even if they refuse to get it for themselves. When the danger signals are present, don’t wait for confirmation of their plans to seek professional help; move forward on your own if at all possible. (See chapter 6, “Seeking Treatment.”) They might ask you to keep your conversation secret. Don’t. Secrets can be deadly.

“There is hope, and there is a solution. We have learned a lot about the effects of trauma in recent decades, and even more about the process of healing from it.”

From Chapter 8, “Danger Signals and Trauma First Aid”

Traumatic Reenactment

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

 

Today I want to introduce the concept of traumatic reenactment. Reenactment is a process that includes compulsively repeated thoughts, attitudes, and patterns of behavior. The goal of reenactment is to resolve and heal a past traumatic experience or series of experiences. Reenactment arises out of our past and can seriously disrupt our present lives and relationships.

In a further excerpt from my book, I offer the following example of reenactment:

“Children who were abandoned by a parent or who went through the divorce of their parents may also reenact this experience in future relationships. They will often set themselves up to be abandoned or abused by seeking out friendships and romantic attachments in which they are destined to be left, discarded, or rejected.

“Men will become attached to women who are certain to leave them, or they will adopt behaviors that drive women away. Women will form attractions to men who are unattainable, abusive, or noncommittal. They approach life with the mentality that they are always doomed to be abandoned and create real-life situations in which that belief is validated.

“Another patient, Lucy, for example, grew up in a home in which her father left her mother for another woman when she was a little girl. Her parents divorced, and Lucy was raised by her mother who did her best as a single parent. When Lucy was old enough to date, she developed a pattern of pursuing boys who weren’t really interested in dating her. She would manage to persuade them to date her for a while until they finally, inevitably, broke up with her. She would be devastated every time.

“As an adult pursuing more serious relationships, Lucy continues to be involved with men who don’t value her, who cheat on her, and who eventually leave her. She doesn’t understand why her dating life is this way. Lucy attributes it to the immorality of men and to her worth as a woman. The truth is that there are plenty of men in the world who could love and cherish Lucy, but she is blind to these individuals because of her experience with her father. He was supposed to love and cherish her, but instead, he left her behind. Lucy doesn’t know how to build a healthy relationship with a man. She only knows how to experience the pain of her father’s leaving over and over again. 

“It is important to remember that reenactment does not occur on a conscious level. Rather, these patterns surface as a result of the pain and turmoil felt on a subconscious level. And because we do not actively choose these patterns, we are unable to actively choose something different. For the most part, reenactments rarely succeed in completing the energy discharge so desired; instead, they cause additional despair and pain in our lives. Usually after much pain, we discover they are false solutions.”

                        From Chapter 2, “Emotional Blueprints and Developmental Trauma”

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.

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.