CULTURAL AMNESIA

      PTSD is part of the American lexicon thanks to a cadre of iconoclastic Vietnam Veteran during the late 1970’s. Readers wanting a more complete history are referred to David Morris’s biography of PTSD http://www.theevilhours.com/David_Morris___The_Evil_Hours___Home.html . Today’s Washington Post article reminds us of the immense denial and avoidance of ‘invisible’ or ‘psychoneurotic’ injuries sustained by millions after WWII. 
     We have made great gains in understanding and addressing PTSD but we have not yet ‘beaten’ it. PTSD remains a vexing problem that is treatable and does improve when clients are guided by realistic, highly trained clinicians who have a broad grasp of what works and what hurts. There are no shortcuts- quack techniques appear almost weekly. Even ‘evidence-based’ techniques have been improperly applied causing injury as articulated by the Mr. Morris, then denied by a scholar reviewing his book in a national newspaper. However, I am hoping the situation will soon improve. Several recent research articles review what works and what doesn’t. The quick takeaway is that ‘interpersonal’ approaches are fundamental. I do believe we may be approaching a new zeitgeist- one where clinicians and clients will work together to transcend this timeless and ubiquitous injury. I will comment more completely in later blogs. In the interim enjoy: 

https://www.washingtonpost.com/opinions/the-greatest-generations-forgotten-trauma/2015/09/11/8978d3b0-46b0-11e5-8ab4-c73967a143d3_story.html

                                       The Do’s and Don’ts for the Newly Sober with PTSD

Published in Sober Magazine July 2015.   

http://online.fliphtml5.com/gozp/zwys/#p=1

               Early sobriety is difficult enough, but for those with co-occurring PTSD it can feel overwhelming. Without your substance of choice- typically used for self-medication – symptoms can be raw, powerful and intrusive. Do not despair; you can and will get better with proper guidance, lifestyle changes and professional care. I am often asked, “How do you deal with the PTSD?” I have distilled the essence of early treatment to a basic three S’s – sleep, safety, and sobriety. You cannot move forward without being sober, in a relatively safe setting and without getting uninterrupted quality sleep. Here are a few do’s and don’ts that might provide a basic framework for you and prove useful.

 Things to Do:

1. Do attend recovery support meetings and stick with your treatment plan.

2. Do find meetings that you are comfortable with; LifeRing, if available in your area, is sometimes a desired alternative to traditional meetings.

3. Do work with a psychiatrist familiar with both conditions and be assertive if the medications are too potent or insufficient. There are safe anti-craving medicines that may help you stay sober during those fragile first 90 days.

4. Do get quality sleep! I cannot emphasize how vital that is. There are non-addictive medicines that facilitate sleep- Doxepin or Mirtazapine , for example, as well as medicines that block nightmares. A little known secret is an old anti-hypertension medicine, Prazosin, which is remarkably helpful in easing night sweats and nightmares. The VA has been using this for years with excellent results.

5. Do develop regular sleep patterns in a darkened, quiet room with no distractions. Don’t watch the news or violent movies or play intense video games just prior to sleeping.

6. Do rule out sleep apnea; your sleep quality and health may be harmed if your breathing patterns during sleep are poor. The evaluations are simple and affordable.

7. Do get moving! Daily aerobic movement will help with depression, anxiety and anger. Break a sweat- safely, of course – once daily for at least 20 minutes. It will help in more ways than I can explain in a brief article; the positive evidence is overwhelming.

8. Do learn and practice yoga breathing. Knowing that you can calm down with a few paced, fully exhaled breaths can be a lifesaver. I also highly recommend a mindfulness discipline. Many forms of Yoga, Tai Chi, meditation and Chi Quong are invaluable to many.

9. Do clean up your diet. I strongly recommend the healthy diet of your preference- not for weight loss necessarily – but for mood management. Surges of insulin can set off anxiety or panic. If possible consult with a nutritionist and/or use a fitness diet app. Stay away from Rockstar and similar ‘energy’ drinks.

10. Do consider a canine adjunct- service dogs can enhance your recovery and perceived safety.

11. Do find a qualified psychotherapist. A psychologist, social worker or other specially-trained allied professionals can help you deal with PTSD. Be certain your provider is licensed. Look for trusted recommendations but remember to be assertive and insist on a provider who makes you feel safe. There are many approaches and techniques with many confusing acronyms and promises. If the clinician promises a ‘cure’ or insists on their own agenda, technique or pacing, find another provider. The key is quality of relationship; your perceived safety is paramount.

Don’t

1. Don’t avoid or deny PTSD: Dealing with denial is not limited to addiction; trauma survivors want to avoid remembering or acknowledging they were overwhelmed by events. Remember, PTSD is not indicative of ‘insanity’ or ‘weakness’; at its core it is A NORMAL REACTION TO ABNORMAL EVENTS.

2. Don’t procrastinate: Those who begin working on trauma issues within the first six months of sobriety are much more likely to stay sober.

3. Don’t ruminate: “I just need to figure things out.”- occurs most often alone, and at night. PTSD is not ‘solved’ by thinking; in fact it gets worse when you overthink it.

4. Don’t isolate: “I don’t trust anybody and nobody can understand me”. This is simply not true. You are not alone and you should not remain alone, isolated, silent and miserable.

5. Don’t be discouraged with setbacks or relapse; relapse can be part of your emotional recovery. Do not become discouraged. Getting flooded happens. Your job is to learn to prevent those triggers from controlling your life.

6. Don’t hesitate to utilize higher levels of care, if needed. If you relapse in both the addiction and emotional domain you might need higher levels of structure, support and care. Finding the right setting or system can be difficult but you must persist and insist. These conditions, while not ‘curable’ are very treatable and your quality of life will improve.

7. Don’t grab on to newly-hyped treatments: hallucinogens, exorcisms, surgeries or supplements may do far more harm than good. Look for credible evidence, even if the technique claims it is evidence based. Medical marijuana, for example, has testimonial support but the evidence is not yet solid, and it poses a risk for dependence, relapse and mood disruption. 

8. Don’t continue with techniques, methods or groups that cause emotional ‘flooding’. Recovery is not an epiphany with Hollywood drama and a flood of tears. It is a process.

9. Don’t lose hope. Never give up. Whereas many addiction treatment models place emphasis on ‘surrender’, the goal of your PTSD recovery is finding your voice and your power- safety, articulation and empowerment, not control is the goal.

Conclusions:    Dealing with the aftermath of trauma in concert with an addictive disorder can be perplexing to you as well as your providers. Never lose faith in your own resilience, learn to derive a narrative and remember that PTSD recovery is a process, not an absolute. Your symptoms can become strengths in terms of wisdom and supporting others who struggle. Work on acceptance as well as forgiveness – it will get better!

 

 

 

 

 

Reflections on Ramadi

Ramadi has affected many young veterans struggling with the ontological aspects of PTSD. Every survivor struggles to find meaning and purpose. Leaning that the ground your friends were maimed or killed capturing sets off some of the deepest conflicts emotionally and intellectually. These are the reflections of one veteran:
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Reflections on Ramadi

Analysis MAY 25, 2015 | 09:15 GMT Print Text Size 

 

A U.S. soldier pulls security on a berm during a search for weapon caches near Ramadi, Iraq, 2007. (U.S. Military)

Analysis
Editor’s Note: This analysis was written by Stratfor’s lead military analyst, Paul Floyd, who served in the U.S. Army’s 75th Ranger Regiment, a core component of the United States Army Special Operations Command. He deployed multiple times to Iraq and Afghanistan in a combat role.
The Iraqi city of Ramadi has fallen again into the hands of the Islamic State, a group born of al Qaeda in Iraq. That this terrorist organization, whose brutality needs no description, has retaken a city once fought for by American soldiers troubles me. I served two deployments in Ramadi, fighting al Qaeda. Comrades died in that fight. I was shot in Ramadi. My initial reaction, like that of many veterans, is to ask what the hell it was all for, when nothing seems to change. The whole endeavor was a costly bloodletting and it seems the price we paid yielded no actual benefit. Yet, Memorial Day is as much a day for reflection as it is for remembrance and commemoration. And in reflecting, I have had to sit back and define exactly what we are memorializing on this day.
Memorial Day is about honoring those who died fighting for our country. Often those memories — and the honor we attribute — are anchored to a specific place. It makes sense: soldiers fight and die in a physical, tangible environment. Invariably somewhere that is far from home. Human nature makes us hold onto that tangibility for memory. Okinawa, Antietam, the Chosin Reservoir, Ia Drang and Belleau Wood are just a handful of names that evoke the weight of battles long since past. I have a reverence for those names, those places. We all do to a point: We bestow these places with an unconscious solemnity based on how many died there. As imperfect as it is, this is the way we measure any particular fight. Certain places become emblematic, normally where the fighting was at its most ferocious. I am often asked where I was wounded. I always respond Ramadi, though technically it was in the middle of farmland between Ramadi and Fallujah. Giving the technical answer, however, loses something in translation. Saying Ramadi instills a sense of significance in people’s minds. Our mission that day was a function of what started in the city, but had spilled out into the periphery.
Memorializing a place because of the weight associated with it is problematic on two fronts — it sets up a partial fallacy while ignoring what I believe to be another critical component that is often overlooked: Time.
The partial fallacy is in how we tie the significance of a soldier’s last valiant action to the place where it happened. A soldier might die taking or defending a critical hill, for example, but they do not lay down their life just for the hill. No one joins the military to fight for a specific piece of terrain, city or inanimate object. We join to serve our country, which is accomplished by finishing the missions we are called upon to take. Viewing warfare as an extension of diplomacy by other means, soldiers are the ultimate executors of the national political will. A specific mission may well include the taking of a particular hill, but the soldier is not there for that specific piece of ground. They are there because the mission required them to be.
The other component we ignore is time. Once death is attached to a place and its significance established in our minds, it is meaningful from then on. It is hard to think of a permanent, physical place as having only temporary relevance in time when blood has been spilt there. There is a reason why the World War I battlefields of a century ago have such special relevance. The problem is, holding permanent unyielding sentiment for a place can override better judgment.
I ruminate on all of this when I hear calls to reintroduce U.S. combat troops to Iraq because of recent events in Ramadi. Many of the justifications for such action are not centered on military strategy, U.S. foreign policy or what would be best for Iraq. Instead, they are invoked by the fact that American lives were spent to win Ramadi in the past. The question remains: If Ramadi is back in the hands of militants, what did American soldiers die for in the first place?
My initial thoughts were informed by that exact reasoning. However, further questions immediately sprang to mind. I settled on two. Does the enemy’s taking of a place that people died fighting for disparage their memory, and, should we let it influence our actions? For the first question I concluded no, though it is painful. The soldiers who gave their lives accomplishing a mission had an effect. Those effects were not limited to a single place. Wars are waged over an area and influenced by all the infinite actions that occur in that space at that time in history. An enemy’s success in the present, even if it is in that same place, does not take away from a soldier’s effect in the past. In this light, I find it hard to justify sending more soldiers to fight, where some will inevitably die, solely in an effort to protect the memories of those already dead.
Those memories do not need physical protection. This is why we have a day like today. Memorial Day is our formal acknowledgement of our comrade’s sacrifice. We remember their actions and their willingness to give all to accomplish the mission. These memories are of course tied to place, but it should not be the defining feature. What happens now in a location such as Ramadi does not debase the past actions of those that fell there. They defined themselves outside of place, in service to country, and that is what I personally want to memorialize.
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Outstanding New Book

The Evil Hours: A Biography of Post-Traumatic Stress Disorder (Kindle Edition)
Mr. Morris provides journalistic eloquence, personal intimacy, an excellent history and an honest overview of the complex features, treatments and foundations of PTSD. He is articulate and provides an accurate critique of highly touted but fundamentally flawed, mechanistic and reductionistic therapeutic approaches. He captures the essence of the experience of surviving trauma without being haughty or pedantic. Although he does not sufficiently address co-occurring alcoholism he does warn readers about risks of drug addiction. He provides an outstanding history of PTSD from ancient literature, modern underpinnings and the world changing events during and after Vietnam. His voice is honest, pragmatic and will validate as well as educate readers with active symptoms. He is not afraid to challenge hype or institutional dishonesty. He has written a book I have added to my suggested readings for new clients. I have recommended it to my Vietnam veterans, younger veterans and colleagues. I am hoping this book gets the readership and recognition it deserves. Not only has the writing of this book helped the author, it has the potential of helping readers and providers. More ambitiously I am hoping this book begins a shift back toward therapy as an art form not an assembly line. An ambitious work of outstanding scope, not perfect, but the best contribution I have seen in decades.

Beware President Obama – Pakistan ‘s New President Asharf-Ghani May Not Be As Trustworthy As He Would Appear

http://www.npr.org/blogs/thetwo-way/2015/03/22/394660553/ashraf-ghani-u-s-critical-to-afghanistans-future

A Western-friendly Afghani President may be too good to be true. As much as I was charmed by the first eight minutes of this morning’s NPR interview with him, I was horrified to hear Mr. Asharf-Ghani twist PTSD as an excuse for the recent murder of a woman* who was stoned to death by an insane mob (by Western standards). To be fair, the reported details of the event have been inconsistent; however, what took place remains clear: the crowd murdered her when they believed she had burned a Koran. 

A Western-educated former banker, Mr. Ashaf-Ghani attributed this event to his countrymens’ PTSD. I do not know if he was referring to the murderous mob or to the passive Afghani police- who, like many  of the American-trained Afghani military,  have either run away from Daish/ISIS or have killed Americans. 

For many years now I have heard many sociopaths, lawyers and members of the media misuse PTSD as an explanation for violence, but Mr. Asharf-Ghani has topped them all. The ‘romantic’ words he used to describe American soldiers who allegedly told him their hearts remain in his country suddenly soured. I could not help thinking he is trying to hustle President Obama to  keep our troops in his dysfunctional country longer. Yet again I sensed another set of lies from a long line of mideastern dissemblers- then I had this intrusive image of the late South Vietnamese president Nguyễn Cao Kỳ and experienced  a flood of anxiety that more American lives will be lost supporting a smooth sociopath. Oh, but wait- maybe that is my own PTSD in action. Mr. Obama, you must be wary of new leaders telling you what we would like to believe.


*How a slain Afghan woman became an unlikely champion for women’s rights:

“Farkhunda’s killing shows that Afghanistan is still the most dangerous place in the world for women,” Fawzia Koofi, a prominent Afghan lawmaker and women’s rights activist, said at the march Tuesday. “If there is no rule of law, not only women, but any human being in this country is not safe.”

http://www.washingtonpost.com/world/asia_pacific/how-a-slain-afghan-woman-became-an-unlikely-champion-for-womens-rights/2015/03/24/395e181e-d19d-11e4-8b1e-274d670aa9c9_story.html?hpid=z1

Unacceptable Decline From Front Line of Care

If this article is accurate the degree of sophistication in treating active duty soldiers is declining just as the level of complexity of co-occurring PTSD is spiking. Inexcusable. Readers, please note this reflects Army programs, not programs from other branches of service and not the Veterans Administration.

http://www.usatoday.com/story/news/nation/2015/03/11/army-substance-alcohol-abuse-clinics-poor-treatment/24251091/

60 Minutes Marine Reunion Interview: 2009 Golf Company, 2nd Battalion of the 8th Marines, Scott Palley’s Superb Interview

http://www.cbsnews.com/news/combat-marine-vets-scott-pelley-60-minutes/

For the all the controversy surrounding the validity and accuracy of war correspondence, stolen honor, bloviating and other questionable journalistic behaviors, Scott Pelley’s 60 minute interview with Golf Company, 2nd Battalion of the 8th Marines, displayed not only journalistic integrity but superior sensitivity and skill in dealing with combat Marines at various levels of readjustment. Scott Pelley clearly communicated sensitivity, empathy, and respect. He knew these men and respected their struggle. He demonstrated a mature and knowing sensitivity beyond the skill-set of many new and seasoned mental health professionals. Viewers witnessed respective disclosure which was instructive as well as constructive. Too many vetrans are forced to provide painful details to people they do not know or professionals who follow a mission disconnected from reality and readiness. I do not want to sound polemic or critical of my profession but I am witnessing too many iatrogenic (treatment caused) injuries from providers and institutions not as skilled as a CBS journalist. One Marine stated it with clarity: “it never goes away, you just have to learn to live with it”. Others spoke about the comradere and sense of purpose. One tearful Marine spoke about survivor guilt – he lost his closest friend to an IED. Palley’s interview modeled a process of articulation, patience, acceptance and respect – well beyond the so-called gold standards embraced by too many providers.  Give me Pelley’s grace, style and respect coupled with a certified canine support over any  poorly delivered ‘evidence-based’ bloviation. Our soldiers need the best care we can offer. Mr. Palley, if you get tired of journalism you have another career ready for deployment.

50 Years On – Vietnam Veterans Heal by Helping – An Inspiring Newscast reflecting on anniversary of Marines Landing in Danang – March 8,1965

http://www.pbs.org/newshour/bb/50-years-veterans-find-healing-returning-vietnam-help/

It is amazing to me that within a 12 hour period we are exposed to an extremely upsetting news story (as per the Whisltblower Mental Health article posted this morning) to this evening’s PBS Newshour story focusing on veterans who have returned to Vietnam with a mission of healing. The report focused on helping clean up the aftermath and assist with injury associated with Dioxin saturation – Agent Orange. A former soldier now helps care for Vietnamese children born with physical and intellectual impairments. Another retired veteran returned with a mission of creating jobs in software for the Vietnamese. The pragmatic, warm and grateful spirit of the Vietnamese is remarkable, given the estimated 2,000,000 deaths associated with the war. Today was the 50th anniversary of the landing of our Marine advisors in Danang; we know how quickly we surged to 500,000 American troops, Search and Destroy, Hearts and Minds, Air America, and 58,000 American deaths. It’s a bit of a naive hope that we will celebrate sanity, wisdom, forgiveness and healing in Iraq and Afghan 50 years from now. Vietnam was invaded and oppressed for a thousand years- their forgiveness, ambition and pragmatism doesn’t appear to be taught or mirrored yet in the Mideast. This remarkable report reminds us healing is difficult but possible.