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.

Inaugural Issue of the Trauma Newsletter

Trauma_Newsletter_Nov13-1I’m excited to announce the arrival of the first issue of our newest publication, the Bernstein Institute Trauma Newsletter.  Each issue of the newsletter will contain helpful, practical articles on the subject of trauma, along with a personal note from me on a vital issue catching my attention.  My aim is to consistently provide accurate information and positive inspiration for everyone who has been touched by what I’m calling the “hidden epidemic” of our time.

This first issue includes two articles: “Financial Crisis, Trauma, and Reinvention”, covering the continuing, painful repercussions from our Great Recession; and “Military Suicides: Part One”, the first in a series exploring the facts and trauma-related issues underlying the dismaying spike in suicides by military personnel.  Also, in “From Peter”, my personal answer to the question, “What is emotional trauma?”

Soon, we’ll have a way for readers to subscribe to the newsletter through our website.  For now, please follow the link to download your copy today.

A Lone Star State PTSD Debate

In 2014, George Bush will run for the office of Texas Land Commissioner.  He’s campaigning already, according to a recent article in the Mid-Valley Town Crier, and, as a veteran, he has plenty to say about PTSD and other issues regarding military service.

Julie Silva’s Crier article first caught my eye for an obvious reason—is Former President George W. Bush running for Texas Land Commissioner?  After my double-take, I discovered that US Navy Reserve Ensign George P. Bush (and nephew to our former president) is actually the commissioner-hopeful.

The next reason for my interest in the Crier article is a debate about PTSD that arose during Bush’s visit to VFW Post No. 7473 in Elsa, Texas.

George Prescott Bush served in Afghanistan in 2010 as an intelligence officer.  On returning to the homefront, he explained to his VFW audience, his greatest concerns for fellow veterans were the high rates of suicide and unemployment, as well as providing increased access to education.

Bush created some controversy when he began to talk about fellow Texan and former Navy SEAL Chris Kyle, who was killed earlier this year on a shooting range, allegedly by a fellow veteran with post-traumatic stress disorder.  Based on his own experience with PTSD, Kyle had decided to create FITCO Cares, a foundation with the goal to help veterans overcome PTSD.  “He proved that PTSD is not something permanent,” Bush stated of Kyle.  “To me, this was a call to action, not only to my generation of veterans, but to all veterans.”

But a member of the VFW audience objected to Bush’s statement.  “Many times we have a hard time getting our benefits and the last thing we need is for somebody to say that PTSD is not permanent,” a Vietnam veteran responded.  “A lot of times PTSD doesn’t hit you until years later.”  Bush clarified his stance by explaining that he believes that the condition can be permanent if left untreated.

Whether PTSD is “permanent” is a thorny issue and I’m not going to go into all the background for taking one position over another in this post.  What I want to highlight today is a point I make in my new book, Trauma: Healing the Hidden Epidemic.  There is a crucial difference between “healing” and “a cure”.

In short, I believe there can be healing for post-traumatic stress disorder.  But there is no cure.

Let me quote from “To the Reader” in Trauma:

“Healing is possible.  We have witnessed such healing time and again at the Bernstein Institute for Trauma Treatment in Petaluma, California.  However, only by addressing the wounds lodged deep in our subconscious mind and, quite literally, in our bodies can true healing begin.  The process of discovering and developing a method of healing at this profound level is described in this book.”

Notice my carefully chosen term: healing.  Not cure.  I suffer from PTSD myself (you’ll discover the multiple sources of trauma in my life as you read my book).  And although I’ve done much work to heal my PTSD and the PTSD of my patients, I know there’s no cure.  Put me in a particular set of circumstances, in the “right” situation, and I can be triggered into a reaction of violence and rage.  And to their dismay and regret, this is true for my patients as well.  For them and for myself, getting triggered happens a lot less often than it used to, but it can and does happen.  Most of the time, I’m able to stop myself from acting on my violent emotions, but their intensity can still be consuming.

Let me say, briefly, that healing PTSD means being less frequently triggered into the past, less frequently confused and overcome with potentially destructive emotions and pain.  Healing means being more often in the present, enjoying the sometimes stressful challenges of a fulfilling life and relationships, with fewer debilitating intrusions from memories of the past.

No, there is no cure for PTSD.  But there is hope.  Our veterans can find healing.  And if you suffer from PTSD, so can you.

Would You Talk to a Virtual Therapist?

On June 20th, I attended the day-long “Brain at War” conference in San Francisco presented by NCIRE – The Veterans Health Research Institute, in cooperation with the San Francisco VA Medical Center, UCSF, and the US Department of Defense.  Annually hosted by the stately Marine’s Memorial Club & Hotel, “Brain at War” reports on the “ongoing examination of the physical and neurological consequences of military combat duty”.  Experts in medicine and science present “the latest innovations and emerging technologies” in the understanding and treatment of PTSD, TBI, and other brain injuries associated with combat experiences.

Some of the presentations were of great value.  Caroline Tanner, MD, PhD, the Director of Clinical Research at the Parkinson’s Institute, gave a fascinating overview of Parkinson’s disease and its possible relation to brain injury and exposure to toxic chemicals.  My father died from complications of Parkinson’s, and while I was familiar with some of the information Dr. Tanner presented, some of her material was new to me.

Robert Obana, Executive Director of NCIRE, graciously included me at a lunch table where I was able to meet several presenters and other important conference attendees.  We had a lively discussion on many topics, one of which included the day’s most thought-provoking presentation.

The presentation came courtesy of Dr. Albert “Skip” Rizzo, the Associate Director for Medical Virtual Reality at the Institute for Creative Technologies, USC.  Skip, who obviously loves his job, gave a fascinating overview of his work developing virtual reality applications for military personnel training and treatment.

Briefly, Skip’s work involves four areas: first, an intense, customized version of the Xbox game “Full Spectrum Warrior” for PTSD exposure therapy; second, a video resilience training program modeled on a “Band of Brothers” format; and third, a somewhat folksy, virtual-online PTSD mentor-coach, dispensing information and coping skills from across the table on a porch.

The fourth application involved the creation of a virtual therapist who conducts a Skype-style counseling session from a comfortable chair.  The program uses a fairly young, female image to probe for emotional dysfunction in her real patient by instantaneously tracking patient verbal responses while reading both vocal patterns of distress (by microphone) and visual body language (by web-cam).  The virtual therapist is programmed to then respond verbally and physically in real-time to the issues shared by the military patient.  “That sounds difficult”, she acknowledges when a veteran reveals a painful memory, and leans forward when her real-life patient leans back.

The therapists, social workers, and counselors in the room reacted strongly to this simulation.  I felt a visceral dislike for what struck me as a removed and cold treatment approach to the complicated issues and deep wounds of many of our traumatized combat veterans.  A “sensitive” machine is still a machine.  Won’t troubled service members feel belittled and dismissed if they assume they don’t rate face-time with the empathetic, skilled professional help of a real, live therapist?

This chilling prospect was remedied, somewhat, by Lieutenant Colonel Steve Countouriotis, US Army (Ret.), NCIRE Board of Directors, and fellow resident of Petaluma, in his closing remarks.  He brought humanity back into the day and touched me deeply.

So, on to the question of this blog post title: Would you talk to a virtual therapist?  There’s a possibility, I admit, that feelings of intense embarrassment or shame could make confiding in a virtual, not-real therapist seem safer or easier.  I would appreciate it if you’d weigh in on this one.  Could you see yourself participating in virtual therapy?  Or, do you see it more as I do, as an approach which could oversimplify and disrespect the complex nature of trauma and being human?

PTSD Awareness Day

The United States Senate has designated June 27th as National PTSD Awareness Day.  Every day in my practice I’m doing what I can to bring more awareness to trauma and the “invisible wounds” that contribute to post-traumatic stress.

It isn’t just the military who suffer from PTSD.  Anyone and everyone who has experienced overwhelmingly traumatic events can find themselves suffering from hidden, emotional wounds.  Firefighters, EMTs, police, nurses, emergency room personnel, crime victims, abuse victims—all of these and many more are at risk.

I’ve tried to highlight issues and misunderstandings about PTSD in my recently published book, Trauma: Healing the Hidden Epidemic.  To further contribute to PTSD awareness this day, let me quote from my chapter, “A Note to Veterans and Their Loved Ones”.  What I’ve written in this chapter regarding veterans applies to all those suffering from post-traumatic stress.

“Post-traumatic stress disorder is just a name for a catalogue of symptoms that follow a stressful situation.  Veterans are not the only people on earth with PTSD.  Yet the term has a very negative connotation in the military world.  Veterans often feel that a PTSD diagnosis reduces the uniqueness of their individual reactions, feelings and struggles.  Or they may feel stigmatized, labeled, and devalued by their peers.

“In truth, veterans experience a wide range of reactions following deployment, and the symptoms can be minor or severe.  Instead of using this name as a label, it is important to reestablish post-traumatic stress disorder as merely a collection of possible symptoms caused by trauma.  It is not limited to war veterans, and those suffering from PTSD may not be permanently damaged; they can heal with proper treatment.”

Let me say that again: PTSD is not a permanent condition.  With help, it can be healed.  That is the essential message of my book, a message of hope.  Of all the awarenesses that could occur on this National PTSD Awareness Day, let that be the overriding one.

Military Suicide and Military Families: Part 3

Military suicides happen far too often.  Alarming statistics from studies of suicide by active duty service members and veterans both paint a tragic picture.  The years of combat in Iraq and Afghanistan, the multiple deployments, have taken their physical and emotional tolls.  Over the last few months, I’ve kept this issue in the forefront of my blog posts.  Lately, I’ve highlighted a side to military suicide about which few studies have been done and statistics are largely unavailable: suicide by military spouses.

I’ve drawn heavily from the words of two military wives:  Ms. Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, and Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation.  I’ve reviewed the symptoms of post-traumatic stress (including suicide and suicide attempts), and the inadequate mental health treatment currently available to military spouses.  Today I’m going to go into more detail about the stresses experienced by military families.  I’ll conclude with Deborah and Kristy’s suggestions for ways the Departments of Defense and Veterans Affairs could better serve the mental health needs of military families.

In January, 2011, Deborah Mullen addressed the Military Health System Annual Conference.  She opened with a direct quote from a letter by a young military spouse.  “It is infinitely worse to be left behind,” she read, “a prey to all the horrors of imagining what may be happening to the one you love.  You slowly eat your heart out with anxiety and to endure such suspense is simply the hardest of all trials that come to an army wife.”

The letter’s young author?  Libby Custer, wife of General George Custer, writing in May of 1876.  “The nature of war changes,” Ms. Mullen observes.  “Weapons get smarter . . . tactics get sharper . . . breakthrough medical advances save more and more lives.  But the stress and the anxiety felt by those who are left behind NEVER changes.”

Besides the agony of waiting, other sources of stress for military spouses and families include reintegration and reunion challenges, Deborah explains.  “A combat tour may last a year, but the effects of that tour on the service member and family may last much longer.”  Spousal and child abuse cases are rising in military families.  Families of service members who’ve sustained serious physical injuries may endure long-term relocation to receive treatment, and children “may be left at home with family or friends”, breaking the immediate family apart.

Or maybe the returning service member has suffered the signature wound of our Iraq and Afghanistan conflicts: an “invisible” wound from PTSD or TBI.  Spouses and children “don’t understand why their parent looks the same, but isn’t the same,” Deborah continues.  And “for those children whose mom or dad died – either by the enemy or by their own hand – this war will never really end.”

How can the DoD and VA better serve the mental health needs of military families?  Deborah Mullen and Kristy Kaufmann, writing for the New York Times, make the following key suggestions:

1. Really listen to military families, look at things through their eyes, to better understand their special needs and challenges.

2. Provide “home-centered” assistance for families in crisis, in which counselors and other assistance personnel come directly into the home to provide needed support.

3. Do a better job of following up on the results of programs currently in place.  New programs are being created all the time, but too often they aren’t reviewed and modified, as necessary, to become truly effective.

4. Develop a more holistic strategy that integrates military families and community support.  Society has a crucial role to play in helping keep military families strong and healthy.

“Ultimately,” Deborah concludes, “spouses tell me they don’t need another program, they don’t need more training.  What they need – what they want – is time.  Time with their spouses.  Time together with their family.  Time with a counselor or a doctor or a minister.  They want time to explore and understand what is happening to them . . . and the patience and understanding of loved ones, friends and the system itself.”

“If you have a broken family,” Kristy warns, “chances are you’re going to have a broken soldier – and vice versa . . . . It will take a nation working together to keep us strong.”

As a young Marine wife told Ms. Mullen, “It doesn’t matter if it’s the first day they’re gone, or the last day before they return home, you’re scared all the time.  You pretend to be happy, but you’re living in fear.”  And, Deborah urges, military spouses should not have to face that fear alone.

Through my work, I’m committed to the health and well-being of our nation’s service members and their families.  I don’t want them to be left alone to struggle with their issues of emotional trauma and post-traumatic stress.  I encourage you to join me, in whatever way you can.

Military Suicide and Military Families: Part 2

In my last post I sought to bring attention to an overlooked aspect of the current tragedy of military suicide – suicide within military families.  While hard statistics are unavailable at this time, anecdotal evidence indicates elevated levels of suicides and suicide attempts by military spouses, due to high levels of stress and secondary trauma.

I quoted two military wives – Ms. Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, and Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation – as they eloquently spoke out about this troubling issue.  Deborah pointed out that stigma still exists against military spouses admitting their mental health challenges and post-traumatic stress.  Depression, anxiety, sleeplessness, panic attacks, and self-medication with alcohol and drugs have become a part of military spouses’ lives, as well as the lives of their active duty and veteran partners.

I ended my last post with the question: What happens for the desperate spouses who do gather the courage to seek treatment within the Department of Defense and Veterans Affairs mental health services?  I draw my information here directly from Ms. Mullen’s address to the 2011 Military Health System Annual Conference.

 

The experience of spouses who seek help is “disappointing”, Deborah states.  “Misdiagnosis.  Lengthy waiting periods.  Red tape.”  Obstacles that “discourage and indeed damage the healing process”.

At the same military post hospital, she reveals, two spouses who sought treatment for help with classic PTS symptoms – one with suicidal thoughts – were prescribed five and seven medications each, with no followup appointments.  And, “Neither was ever referred for psychological help.”

I’m going to make a very strong statement here.  I believe a system that would allow a general practitioner to prescribe multiple, heavy-duty medications for psychological symptoms and then not see the patient again, is broken.  This is especially true for patients with suicidal thoughts.  Several prescription anti-depressants have been recently shown to create or intensify suicidal thought ideation.  I believe the actions of the doctors at this post hospital were unethical and unconscionable.

But there is even more going wrong for suffering military spouses within the mental health approach of the DoD and VA.  According to Ms. Mullen, spouses refer to it as the “15 and one rule”.

“It goes like this,” she explains.  “No matter WHAT may be bothering you from a health perspective, you are allowed to discuss only one symptom and only then for 15 minutes.  That’s it, no exceptions.  If we accept, as we have, that spouses suffer a PTS all their own . . . and if we know, as we do, that PTS manifests itself in many different ways in many different people, why would we not accept the need to treat the whole person?  Why would we fail to look at the totality of issues confronting a young spouse?  And why would we ask that young spouse not to confront them all herself?”

As a professional in the mental health field, with over 40 years of experience, I’m appalled and angry at what I see as insensitive and unprofessional practice within the military health system.  Patients must have the time and opportunity to reveal an accurate picture of the issues they face and the symptoms they experience.  With suicide as a potential outcome for desperate patients, I would characterize the treatment protocols for military spouses as very irresponsible and dangerous.

Kristy Kaufmann has strong words of her own on an additional obstacle.  “The fact is,” she wrote in a New York Times opinion piece last fall, “even if everything in the Pentagon and the VA were working perfectly, the government simply does not have the resources – or culture, for that matter – to support the level of need after 10 years of war, and it never will.”

Are you angry yet?

Combat and active duty experiences create their own patterns of post-traumatic stress for our service members.  What are the special problems that enter the lives of military spouses and families, leaving trauma in their wake?  I will return to answer that question next week.

Military Suicide and Military Families: Part 1

Today I want to return to the topic of military suicide and discuss a different and sadly overlooked side to this tragedy.  Yes, active duty service members and veterans are taking their lives at alarming rates, but suicide within service member and veteran families – among spouses in particular – is happening as well.

Two voices have recently spoken up about this underreported issue.  Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, delivered an address to the Military Health System Annual Conference in early 2011 on the topic.  Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation (a nonprofit organization dedicated to bridging the gap between civilians and military America), published an opinion in the New York Times last November.

Both Deborah and Kristy point out that we have no accurate accounting of rates of spousal suicides within the military, due to privacy rules, and that this in itself is part of the problem.  Recent studies of military suicide have excluded the mental health of military family members, “effectively ignoring half of the problem”, Ms. Kaufmann stresses.

Only anecdotal evidence exists on the numbers of suicides and suicide attempts.  “Three Army wives I knew personally all took their own lives,” Kristy writes.  “Suicide attempts and completions among family members occur far more often than many realize or care to acknowledge.”  She adds that “suicide among service members, veterans and families is an indicator of the amount and duration of stress we continue to bear.”

“War comes home,” Kristy eloquently tells us.  “No soldier comes back the same, which means no family is ever the same.”

Deborah Mullen’s revelatory conference speech deserves to be read in its entirety.  She points out that there are many specific programs in place to help spouses with challenges such as the day-to-day demands of being a single parent or being a new caregiver to a wounded veteran.   But, “we are still discovering, still revealing, fissures and cracks in the family support system,” she observes.

The first “fissure” she mentions is “secondary post-traumatic stress”, and I see this as an extremely important and relatively misunderstood phenomenon.  Secondary post-traumatic stress, or secondary trauma, is the stress and trauma we are not directly exposed to but experience through someone else’s eyes and memories.  It is also the pain we feel as we watch someone we care about suffer and change from those first-hand experiences.  Kristy put it well: War comes home.

Suicide is the most extreme and tragic symptom of secondary trauma, but there are plenty of other symptoms as well. Ms. Mullen clearly identifies many of them.  “Families experience depression, anxiety, sleeplessness, and headaches,” she observes, as well as cold sweats, lost concentration, panic attacks, and dread of contact with the outside world.  Many spouses are “unable even to get out of bed, to get dressed, prepare meals, or leave the house.  Some won’t even get their children off to school, leaving the care of little ones in the hands of older siblings.”

“We shouldn’t be surprised,” Ms. Mullen continues, “to learn that some spouses turn to the same remedies that troops with PTS turn to – alcohol, prescription drugs, and some even contemplate suicide.”

The military branches have recognized for some time the stigma attached to mental health issues within the ranks.  Programs have been put in place to address the issue so that more service members can get the care they need and deserve.  But Deborah Mullen points out something I think most people are unaware of: the stigma against military wives seeking help for their own mental health challenges.

First of all, she believes, they’re “embarrassed” to seek help.  They also “worry that in doing so, they could negatively impact a husband’s or wife’s military career.”  As a final straw, “the service member even warns the spouse against getting help.”  “The services have worked hard to reduce mental health stigma in the ranks,” Deborah states, “but we need to continue to work to eliminate it from our homes as well.”

What happens for the desperate spouses who do gather the courage to seek treatment within the Department of Defense and Veterans Affairs mental health services?  Deborah Mullen’s insider assessment paints a bleak, disturbing picture.  I will begin with that distressing portrait when I return next week.

Surprising Findings on Postwar PTSD

A recent op-ed piece in the New York Times by Anthony D. Mancini reported surprising and disturbing preliminary findings from a military PTSD study soon to be published in the British Journal of Psychiatry.  Mancini, an assistant professor of psychology at Pace University, and his colleagues set out to examine the stress responses of over 7000 United States service members, pre- and post-deployment to Iraq and Afghanistan.  The verdict?  “Fewer than 7 percent showed signs of PTSD following deployment”, and “among those with multiple deployments . . . only 4 to 5 percent” suffered from PTSD.

I don’t buy it.  Those numbers are way too low.

While we must wait for the full study to be published before drawing firm conclusions, Mancini’s contention that “the prevalence of PTSD among veterans” is “substantially lower than is commonly believed” should be a cause for concern. 

I want to see how the researchers set up the study, look at the guidelines and approach they used, and examine how they interpreted their data.  Researchers always go into a study with a goal, something they hope to prove, and possibly even additional agendas they are not fully conscious of.  These agendas can color the findings they report.  The study results quoted in Mancini’s piece on the low prevalence of PTSD among returning service members are so counter to what I’ve seen in my work that I suspect some bias crept in.

Mancini states that “many assume that humans are inherently vulnerable to trauma”, but that “a growing body of scientific research is telling another story”.  Only the first part of that statement is true.  Our nature as human beings, our biology and psychology, program us to respond to traumatic events in patterns that ensure our survival.  Almost everyone has heard of the “fight, flight, or freeze” responses, arising from our sympathetic and parasympathetic nervous systems.  These responses to danger make it possible for us to survive and then learn from threatening experiences.

Trauma, short-lived or lasting, arises when we fail to complete our natural trauma response.  Because we can bury and refuse to deal with the painful and overwhelming events of our lives, the intense emotions aroused by trauma (leading to that fight-flight-freeze) may never be released.  This happens all the time.  We can go back and resolve past trauma, but we are always “inherently vulnerable” to it, and our vulnerability to trauma increases the more we bury our previous “invisible wounds”.

The authors of the British Journal of Psychiatry study defend their results by characterizing their respondents as “not seeking treatment” and “representative of the military as a whole”.  They add that “[the participants’] reports were confidential and had no bearing on their military careers”.

I want to make a couple of points here.  First, and most importantly, why didn’t the study include service members who were seeking treatment?  How could the researchers’ study be “representative” without them?

Secondly, confidentiality is certainly an essential factor in getting accurate disclosure, but did the researchers take into account the lingering mindset of stigma within the ranks attached to a diagnosis of PTSD?  Most service branches have campaigns in place to de-stigmatize the invisible wounds of combat, but that message hasn’t yet been fully embraced by the military culture as a whole.

Mancini reports that “about 83 percent of respondents showed a pattern of resilience: they exhibited a normal-range ability to cope with stress both before and after deployment”.  What I want to know is, how did the study’s researchers define “normal-range ability”?  I have first-hand experience with government agencies who work with veterans, and I can absolutely state that their baseline definitions of good coping function are set appallingly low.  Their “good enough” is far from what I consider healthy, as a professional in the psychotherapy field for over 40 years.  I believe the average person would agree with me, and wouldn’t want to see the men and women who have served our country limited to life on such unsatisfactory and unfulfilling terms.

I am particularly suspicious – convinced, even – that the study’s parameters or methods were flawed due to their finding that service member resilience went up with multiple deployments.  This is absolutely counter to everything I’ve witnessed in my work and what many other professionals in my field have seen as well.

I also “do not want to stigmatize those with the disorder” of PTSD, as Mancini cautions.  But I also don’t want to minimize or mislead the military or the public about the true dimensions of what I and many of my colleagues believe will be a hidden epidemic.  I give Mancini credit for stressing that “even an estimate of 1 in 10 represents a public health issue of the first magnitude, requiring our full attention and resources”.  How much more, then, will be required if the real prevalence of PTSD is closer to 30 percent, which is my opinion?

Mancini closes his piece with a truly alarming statement.  He starts well by saying that “PTSD is a treatable condition and a realistic and informed understanding of our inherent coping abilities can only assist treatment”.  But he goes on to propose that “perhaps one day, even prevention of this debilitating disorder” will be possible.  That Mancini could make such a proposal betrays a profound misunderstanding of the nature of human beings and our innate, invaluable trauma response.

To prevent PTSD we would have to rid the world of cruelty, abuse, violence, and evil.  Or we would have to develop into one of two kinds of people: impervious automatons, able to turn off our feelings at will; or psychological super-humans, able to easily experience and quickly and completely resolve every shock, crisis, and horror, from the cradle to the grave.

My take on this?  Won’t happen anytime soon.

Military Suicide and Unemployment

Many factors contribute to the current unacceptably high rates of military suicide.  I’ve written before about a recent policy brief by Dr. Margaret Harrell and Nancy Berglass of the Center for a New American Security, “Losing the Battle: The Challenge of Military Suicide”, which identifies several causes and recommendations for this unfolding tragedy.  Combat injuries, including such invisible wounds as PTSD and traumatic brain injury; mental health issues such as depression and anxiety; other symptoms of trauma such as sleep disturbances, substance abuse and addiction, and high-risk, adrenaline-fueling behaviors – all can play a role.  Harrell and Berglass also observe that the relative absence of three protective factors – belongingness, usefulness, and an aversion to pain or death – are crucial predictors of a service member or veteran’s likelihood of succumbing to suicidal tendencies.

In a New York Times op-ed piece responding to Harrell and Berglass’ study, Peter D. Kramer, a clinical professor of psychiatry at Brown University, proposes another factor overlooked in the policy brief: relatively high unemployment rates among young veterans of Iraq and Afghanistan.  In “The Best Medicine Just Might Be a Job”, he cites an astronomical unemployment rate of 28 percent for male veterans 18 to 24 years old.

Kramer respects the “comprehensive” brief but expresses his concern about the omission of unemployment among the list of causes identified.  While he characterizes himself as “hardly an expert”, he reveals that “study after study correlates unemployment with suicide”.  “When soldiers leave the military,” he continues, “they lose what service provides: purpose, focus, achievement, responsibility and the factor the CNAS report calls ‘belongingness’.  The workplace can be stressful, but especially for the mentally vulnerable, there is no substitute for what jobs offer in the way of structure, support and meaning.”

High unemployment rates among veterans have no one simple cause.  In “As Wars End, Young Veterans Return to Scant Jobs”, Shaila Dewan of the New York Times (who cites unemployment rates for veterans aged 20 to 24 at 30 percent) lists several issues and challenges for both employers and potential veteran employees.  Employers “fear the aftereffects of combat or losing reservists to another deployment”, and veteran job-seekers need to learn basic interview skills while often still “overwhelmed by the transition from combat to civilian life”.

Veterans can be characterized as mature for their age, disciplined, and possessing valuable skills transferable to the marketplace, Dewan emphasizes.  But employers aren’t so sure military service training and experience really translate to civilian industry.

And the competition for jobs is high.  Veterans often serve as reservists or in the National Guard and Dewan points out that this can impose a particularly heavy burden on companies.  Employers of reservists potentially face losing their valuable staff to deployments of up to 12 months in length, while being required to guarantee a job on the reservist’s return.  Even though it is illegal to discriminate in hiring based on military service and status, these requirements can make it nearly impossible for small companies to survive and compete in our difficult economy.

And, in my experience with veterans, both characterizations mentioned above are true.  Former service men and women are more mature and disciplined.  They are skilled, purpose-driven individuals with the kind of values I respect.  But they can also be very troubled individuals, still reeling from their traumatic, combat-related, employment-complicating experiences.  They are often in need of help to work through their lingering psychological invisible wounds.

I assist service members and veterans in this kind of healing.  I hope to do even more when our non-profit, Sonoma Coast Trauma Treatment, begins accepting veterans into its planned comprehensive, case-managed treatment program, which will include providing job-readiness training and skills.  Another promising development to address veteran unemployment is the creation of entrepreneurship programs specifically tailored for vets.

The Wall Street Journal recently reported on several of these programs in “Military Veterans Prepare for a New Role”, by reporter Sarah E. Needleman.  Independent-minded veterans who want to start their own businesses, but lack business start-up know-how, are starting to have a resource in “business accelerators”. Accelerators are programs offering everything from cubicle space and peripherals like Internet and copy/fax services, to expert guidance with business plans, financing, and marketing.

I’m familiar with the business accelerator model.  In my community, my good friend Dr. Michael Newell heads up Sonoma Mountain Business Cluster, an excellent “incubator” program for emerging technology start-ups.  Michael and his team of talented mentors, with the financial backing of local businesses, support aspiring men and women with innovative ideas by providing the best possible opportunity to transform their ideas into jobs and income through facilities, services, and training.  The business school of Sonoma State University also gets involved, helping incubator members create high-quality business plans.  A program of this sort would be an excellent resource for returning veterans in our community and I would love to see one get established.

I recognize the causes and solutions for veteran unemployment are complex.  Nevertheless, I also believe, with Dr. Kramer, that veteran unemployment is a factor we need to consider in addressing our tragedy of military suicide.  We must do a better job of providing employment-related “structure, support, and meaning” for returning vets.  Meaningful work is essential in the process of restoring our service members and veterans, who have sacrificed so much for us, to health and wholeness, and to a place of value in their families and communities.  We owe them nothing less.