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Veterans and Post-Traumatic Stress Disorder

A Conversation with Dr Frank Ochberg

Dear Reader:

Thanks to generous gifts from a new donor, Gift From Within and the Dart Society are collaborating to better serve the needs of veterans, members of the Armed Forces, and military families who carry the burdens of hidden wounds of war. PTSD is a difficult injury to understand, to tolerate, and to overcome. We asked an experienced war reporter and an accomplished trauma expert to explore several facets of combat trauma and PTSD in order to help you, the reader, contend with these issues. We hope and expect that this conversation between Jon Stephenson and Frank Ochberg will not only inform you about current problems facing our troops, but will give you a sense of partnership and participation in overcoming military PTSD.

Regards,

Joyce (Gift From Within) & Deirdre (Dart Society)

Jon Stephenson: Frank, thanks for taking the time to speak with us. Perhaps we could start by having you tell the readers something about your background and your experience with post-traumatic stress disorder (PTSD).

Frank Ochberg: Well, I'm a psychiatrist. I'm part of the team that wrote the PTSD diagnosis, and I had a government job back from 1969-79 at a place called the National Institute for Mental Health. During that time period we went from knowing that people were traumatized, that they suffered, to having an organized way to think about it.

From my own personal experience, I was fairly close to Vietnam veterans - to Vietnam-era issues - but also to the Women's movement. In fact, and I'm very proud of this, I was the male member of the Committee on Women of the American Psychiatric Association, and I learned a lot from them and with them. And it seems to me that PTSD is the outgrowth of the experiences and the observations of the men who suffered in war and women who have suffered from being battered and raped and being the subject of incest.

I don't think we were very clear at the time that PTSD was the culmination of those experiences of both genders - but looking back on it, that's how it appears to me. The common ground was the pattern of suffering of different men and women in different experiences, and the attention to that came in the '70s, and the diagnosis came in 1980.

Now more recently, I've become very close to journalists. I guess I realized 15 years ago that your profession conducts interviews very much the way mine does in psychiatry. We talk to people; we learn from people; and, in our different ways, we're the researchers. We're the ones who take a hard look and draw conclusions, and then try to help in our different ways.

I was fortunate to get the support of a wealthy family who helped me create the Dart Center for Journalism and Trauma, and the Dart Society, so that therapists, doctors and journalists could share their points of view. The goal has been to have a conversation that leads to understanding the impact of trauma, cruelty and tragedy on normal people, and to appreciating the patterns in which survivors of trauma respond.

JS: Before we continue, let's clarify a few terms for readers. What does it mean when we say someone - a veteran or a serving soldier, for instance - has been traumatized, or has post-traumatic stress disorder? What is the difference between the two?

FO: Well, being traumatized is necessary for having post-traumatic stress disorder. There are very many people who are stressed in general, who become nervous or depressed, or who have repetitive thoughts that are distressing; but in order to have post-traumatic stress disorder you have to have been traumatized. And we did struggle with that definition of what it means to be traumatized. It means to be exposed to something that could kill you; that could change your life; that could affect you in a deep and biological way - not just something that is very difficult to contend with like a divorce. It has to be more disruptive of you as a biological being - not just as someone who has dignity and a life ahead of you, a job ahead of you. It's not losing a job. It's not even losing your loved one, if the loss is through natural causes. There has to be something about the traumatic event that shocks you: that makes you feel scared or horrified or helpless at the very time it occurs. So, that basically is our definition of a traumatic event.

Having had a traumatic event, you then have post-traumatic stress disorder if you suffer in three different ways for a period of at least month. The three different ways are, first, having trauma memories. A trauma memory is different from a normal memory of a terrible event. In a trauma memory, you don't want to remember, and yet your mind or body remembers. It can wake you up from sleep. It can be in the form of a nightmare. It can be in the form of a flashback, which means you see or smell things that aren't there but that were there when you were traumatized. Or you hear things or you see things. It has the quality of a hallucination, but it's not part of your imagination; it's part of your memory.

And it can be something that you're not entirely aware of, but you feel it in your bones. Your heart races because you've been exposed to something that is similar to the traumatic event, and afterward you realize: oh, that's what it was. So, the first part of the syndrome is re-experiencing the trauma, when you don't want to experience it, in one of several ways.

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Photo Credit: Jon Stephenson.

The second part of the syndrome is quite different: it is being numb or avoidant. You don't do what you used to do; you don't feel the way you used to feel. You don't expect to have a long and good life. You've been changed, you've been diminished; you've been made less. Not necessarily depressed (which means feeling helpless, hopeless and worthless), but in some ways it's similar to depression. That's the part of the syndrome that's being numb and avoidant.

And the third part is being anxious - and anxious in several ways: not sleeping well; being irritable and angry; not being able to concentrate; being easily startled; being hyper vigilant, which means being constantly on the look-out for danger. You can think of this as having lowered your threshold for being aroused. And this is a constant; this is not just when something triggers you into returning you to the traumatic event. It's a generalized high level of fear and anxiety.

JS: There are tens of thousands of American men and women who have served in Iraq or Afghanistan, many of whom are finding it difficult to adjust to life back home, particularly life outside the military - yet spending time in a war zone, and especially time in combat, would obviously be stressful for most people. So, how can a veteran who is having trouble adjusting tell whether what he or she is going through is perfectly normal - part of a natural process - or whether they may need to seek help?

FO: Well, it helps to understand this diagnosis. You call it PTSD when the symptoms last more than a month and interfere significantly with life. The PTSD diagnosis certainly isn't the totality of the adjustment problem faced by soldiers, marines, and combatants who are returning from Iraq and Afghanistan. If you are one of them, or you're somebody who loves and cares about one of those men and women who are returning, you should know that this syndrome is quite common.

And unfortunately, it is still a source of stigma and shame. The young men that I'm dealing with right now, who have returned from Iraq wounded and with PTSD, do not like to talk about this. They make it very clear to me that they do not believe this is the subject for conversation with parents, friends, or marital partners. So, what we're doing now in explaining it is important for adjusting to civilian life.

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Photo Credit: David Swanson.

We'll go on in our conversation to talk a bit more about why this happens and what its significance is, but I just want to make the point that not everybody who's been exposed to trauma in a military setting comes back with post-traumatic stress disorder. It depends on how close you were. It depends on what happened. But I would say that if you've been in combat and you've been there when a comrade was killed, the percentage of PTSD gets over 25%. It gets closer to 50% being in a war zone.

JS: If someone feels that they're possibly dealing with post-traumatic stress disorder rather than the sort of stress response that's at the milder end of the spectrum, what should they do?

FO: This is a very important point. As I mentioned, there is a difference between post-traumatic stress and general stress. All of us encounter general stress: we've got too much on our plate; we're worried about something; somebody who we care about hasn't treated us too well. We're ruffled; we don't sleep that well that night; we can't concentrate too well. It's hard if you have a difficult job or a lot of responsibility in your life. Just being a parent is a lot of responsibility! In fact, having friends and keeping friends requires being in a good frame of mind. So, all of us know what it's like, from time-to-time, to be hassled, to be irritated. Sometimes we say, well, we got out of bed on the wrong side. You guys down in New Zealand are always getting out of bed on the wrong side!

One of the things that happens when you're stressed is that you lose your sense of humor. So, you're lacking some of the things that keep you feeling good about life and good about yourself. Traumatic stress is something else. It means for these people coming back from the theater of war, and most likely several times a week, that you're back there - seeing things, smelling things, hearing things you don't want to hear. And sometimes you feel you're going crazy. You don't necessarily know the difference between this condition - PTSD - and having a psychosis or being diagnosable with a different major mental illness that can be progressive. So, it's good to know what PTSD is and to know what it isn't. PTSD actually has a relatively good prognosis.

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Photo Credit: John Moore.
Photojournalist and Ochberg Fellow.

JS: How serious can PTSD become? What are the potential consequences for a veteran's physical and psychological health if PTSD remains undiagnosed or a veteran refuses help?

FO: Right now the most serious problem is suicide. We are seeing a frightening amount of suicide in veterans - people who have been selected for their physical and mental fitness; who have served honorably, and who are having a terribly difficult time adjusting to a lot of things, not just to PTSD. We're still doing research on the correlation of PTSD and suicide attempts, and completed suicides. But we do know that that's the most tragic of the outcomes, and I think that the higher suicide rate has got to be related to the conditions of re-deployment; to the difficulty of adjusting both to civilian life and to moving back to military engagement for the second, third or fourth time.

There is a lot of controversy about this. In some analyses it looks as though the suicides are occurring not after a fourth or fifth deployment but after the first or second. But that may be related to the pool of people who are being chosen and are being deployed now. There's a lot more we need to learn about why we're seeing the psychiatric disability rates that we're seeing in this era of American combat.

But PTSD untreated is a condition in which a person is suffering. They're having nightmares; they're having flashbacks. They're having difficulty feeling like a whole human being, and because of the anxiety cluster they're easily irritated, and they can be hostile and combative. So, the flip side of the greatest danger, of suicide, is being dangerous to others or being inhumane to others.

JS: You're talking about domestic violence, as well as violence in general?

FO: Yes, I am. I'm very concerned about helping some marines that I'm working closely with making the transition from being physically wounded combat marines who've seen their fellow marines killed in front of them to being students, and to getting on with worthwhile careers. I have a lot of faith in these men. I like them. There are two of them in particular: I sometimes meet with them one at a time, sometimes with the two of them together. They have a strong bond with one another. They're both getting out of the service now. One will become a law enforcement officer; I'm not sure what the other will become, but they both have to go to school. Going to school means dealing with students, and these students can say things which can trigger a very hostile feeling in these two patients. I understand that. We talk about it. We try, in various ways, to smooth out and ease the transition from military life to civilian life.

Neither of these marines poses a threat to their domestic partners. They are more likely to over-react to civilians who accost their partners in public. But many returning veterans have difficulty controlling anger and, unfortunately, the spouse can be the target of easily triggered rage. Working with couples to mitigate arguments, to prevent easy access to lethal weapons, to avoid tragic flashbacks and dissociative states in which a partner is confused with an enemy, become objectives in therapy for couples who are at risk of post-deployment domestic violence.

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Photo Credit: Jon Stephenson.

JS: Your mention of the strong bond between your two marines reminds me of something a marine officer in Iraq told me: that there's no greater love than that between one marine and another. That when you're in combat all you've got is the guy on your right and the guy on your left - that that's your world. That bond is often weakened when a marine (or a soldier) returns to the US, leaves the service, and is set free in a civilian world where, for want of a better word, there's a lot of alienation - where there are a lot of people who don't necessarily share a belief in the mission that those marines or soldiers were committed to, and can make comments that might shock or appall a veteran. How do they cope with that? How can veterans deal with that in a healthy way?

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Photo Credit: John Moore.
Photojournalist and Ochberg Fellow.

FO: I'm so glad we're talking about this. I think there are a lot of people who think they know what we are talking about. But it's one thing to appreciate intellectually the challenges that many veterans face, and another to be right there in the room with them as they share them. I guess I feel privileged to have gained a sense of these veterans' experiences - and, in a way, the bond that exists between them.

In order to help these guys I have to write letters for them. I have to introduce them to professors, to lawyers, to other veterans who know how to deal with the Veterans' Administration system to get the benefits they deserve. Let's stick with the marines, because they're in my mind right now. A lot of these people who are returning have rights: rights to disability payments, to payments for medical and mental health care, to education - rights that they often have to fight for. They're not easily given to them. So, although I'm a medical doctor, I end up almost being a lawyer, continually helping with the legal fight for rights. These aren't privileges, they're rights.

So, in a sense, I almost become part of their team. And as part of the team, I hear about the kind of alienation that you're talking about. I'm not alienated from students myself. My grandkids are students. I do some work at a university and have a lot of affection for the students. But I really worry about how my marines are going to interact with my students when somebody says something which, from the marines' point of view, is insensitive.

It's important for most people to be in an atmosphere of trust and acceptance, but the importance of being around people who you can trust and who accept you is heightened both by a marine's training and by PTSD. PTSD means that you are hyper-vigilant and on the look-out for things that are a threat or a danger - and insensitive comments can be interpreted as both.

But let me go back to what we do about these men who are having to transform themselves from this band of brothers - or sisters, if they're serving with them - to civilians. What goes on in therapy is going back to challenges that existed and sharing a bit about it, and then working hard to be better at controlling temper, and talking through the nature of a provocation. And reminding this person who's going through a transformation - them reminding themselves - of the fact that their job, their mission, is now to be a successful civilian.

In the case of the one who's going into law enforcement, he's got a dad who's a distinguished law enforcement leader, and I'm sure my marine will make it. His buddy points out to him, "Well, you know, you have command presence." And my marine says, "What do you mean by that?" His buddy says, "You know, it's the way you hold yourself, the way you express yourself; it's how you look."

I then add to that, "You don't need to be menacing. You already have the ingredients for communicating your authority. You just have to refine that, to perfect that." It's a lot like athletic coaching: it's starting with the attributes that the person has, then going through situations - sometimes even going into role-playing - to use strengths of personality, of character, and of logic, to resolve interpersonal problems in a successful way.

JS: Since we are looking at issues of alienation faced by returning veterans perhaps we can discuss the specific challenges faced by some women veterans. Men who have served often feel a sense of alienation once they leave the military but, from what I've read, women veterans may feel an even stronger sense of alienation. Some have spoken of feeling almost invisible when, for example, they're socializing with their male comrades, because there's often an assumption that they'll be a wife or a girlfriend rather than a former soldier.

While it's certainly the case that most soldiers are male, and that, generally speaking, women don't experience the same level of combat as most male veterans, women have made and are making a huge contribution to the military in places like Afghanistan and Iraq. Yet there's a sense, perhaps, that they aren't being recognized in the same way as the guys.

And can you also talk about the challenges faced by women veterans who have experienced harassment or sexual assault in their time in the military? That is something that must be very difficult to deal with because those women are potentially feeling alienated not only from the society they're returning to but alienated from the band of brothers they have served with.

FO: Let's take the second part of the question first; this is a very important issue. The rates of abuse of women in the military are very, very high. I've been talking with women in the military and non-military women who have written books about military women. Being harassed is close to 100%.

The Service Women's Action Network cites some important research on this topic - http://servicewomen.org/media/publications/ It makes for grim reading.

  • While one in six civilian women experience sexual assault, for military women this number climbs to approximately one in three
  • Almost 3,000 military sexual assaults were reported in 2008; 163 sexual assaults were reported in Iraq and Afghanistan
  • 79% of women serving in the military since Vietnam reported experiences of sexual harassment
  • In a study of a sample of veterans who were seeking VA disability benefits for PTSD, 71% of women and 4% of men reported an in-service sexual assault. For men, the assault was more likely to occur while out of service; for women, the opposite was true
  • Sexual assaults that occur in the military are often not isolated incidents and may involve more than one perpetrator. Of those women reporting rape, 37% report being raped at least twice, and 14% report experiences of gang rape
  • Some evidence suggests that black women in the military are more likely to experience more severe forms of harassment compared to their white women counterparts, including unwanted sexual attention and sexual coercion

Anne G. Sadler and colleagues have an excellent study, available on the web at http://www.veteransforpeace.org

What I have been pointing out to therapists who are not as familiar with working with PTSD or working with the military as I am is that any therapist who has dealt with incest will know that the problem with incest is that there's been a sexual interaction that is taboo. But worse than that, there's always a mother or a father figure involved - there's a non-offending parent. Incest is all about secrets, and these secrets mean that you don't have the trusting relationship that you need to have with your parent.

Now, in the military, the parent is the officer in command who doesn't know about this, or who refuses to take it seriously. And that creates a terrible disruption in the military family. It's important to realize that a significant number of the women who are serving in the military have come from a circumstances where they've been the victim of incest or of battering, or of abuse or neglect. That is a motivating factor for them joining the service - to escape from a hell at home.

It's not always the case. My daughter served in the military; she's now happily married and a mom and a successful professional, but she encountered many of these women who were abused. It's common, and it affects women from all walks of life. So, we are talking now about something that is not a secret. It's written about. But it's a big problem, and we have a lot of work to do to help these women come back from military service, and from sexual abuse while in military service, to have the dignity and the physical and mental health that they deserve.

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The same goes for your question about servicewomen sometimes feeling "invisible." I've also seen news reports of women veterans who attend reunions and celebrations, and who are assumed to be spouses, not soldiers, sailors or marines. As you say, all veterans are susceptible to alienation, but not being recognized as "one of the guys" - so-to-speak! - must be an added frustration for servicewomen. We owe these women veterans recognition and honor. Conversations like this one help spread the word.

JS: Let's say there's a veteran out there, whether male or female, who is having nightmares, having flashbacks, feeling seriously messed up - but, for whatever reason, he or she doesn't want to see a counselor or psychologist. Are there simple, practical steps they can take to mitigate or resolve their problem? Can yoga, meditation, or physical exercise be as effective as therapy?

FO: Well, there's a lot that you can do that can be very effective. Other colleagues and I have put as much as we can into the Gift From Within website, and you and I are talking to help that website extend its reach to those who may not have therapists, or have had unfortunate experiences with therapists and want to learn on their own.

Yes, there's a lot you can do. You can learn how to manage anxiety better - and yoga helps, exercise helps, avoiding stimulants when you're getting ready to sleep helps. A lot of people don't realize that caffeine isn't limited to coffee; it's in a lot of soft drinks. They're losing sleep because they don't realize that they're medicating themselves with stimulants prior to trying to get to sleep, and sleep is never that good when you're suffering from PTSD in the first place.

You can choose your friends carefully. A lot of people have friends and relatives who ask the wrong questions, or who simply aren't there when you do choose to have your social rest and recreation. I find with a lot of my patients, military and non-military, that we go through who you can trust as a friend. You and I are talking now prior to the American holidays - we have Thanksgiving, then we have Christmas, and these are times when extended families get together. And for a lot of people who will benefit from self-help from PTSD, holidays are hard times.

Sometimes in these situations a lot is expected of them: they're expected to drink; they're expected to be friendly, when sometimes they may not want to be. They have to be careful about limiting their dose of obnoxious relatives! That may sound so simple and so easy, but it's not easy for my patients. I find that counseling and commiserating is important, but maybe it's also about giving them license - to tell them, no, you don't have to go home again. That sometimes they can take care of themselves. This can end up being important advice.

JS: Your comment about monitoring the intake of caffeine and limiting the dose of obnoxious relatives leads me to ask about the role of medication in the treatment of trauma or PTSD. There's a section in Sebastian Junger's book, War, where he refers to a company of US soldiers in Afghanistan, half of whom are supposedly on psychiatric medication. What are the advantages and dangers of this approach to treatment?

FO: I've got a lot to say on this, and I've talked with several of our colleagues in journalism about how heavily medicated our military are. It surprised me when I first learned about it, and it discouraged me that we are deploying into combat zones soldiers and marines who are being treated for depression. You wouldn't do that - you wouldn't allow that - for an airline pilot. And it's not because the medication is bad. It's because having depression and being treated for it presents a risk to everybody who's on that airplane. There's a lot of risk to fellow combatants, to civilians who can suffer collateral damage, when we deploy an army that requires psychiatric medication. That's one thing.

But let me talk about the advantages of medication for veterans, who are in a different situation from those on active service. Veterans are people who are back at home and now in civilian life. If you're a veteran and you need help falling asleep or staying asleep, it's good for you to know how the anti-insomnia medication works - and there are often times when medication for insomnia is useful.

The drugs that help you fall asleep are habit-forming. But there's a drug that helps you stay asleep called Trazodone that's not habit-forming, that's not harmful, and it's very, very useful if you're the kind of person who wakes up at two in the morning and can't get back to sleep. There are a couple of drugs in its class, but the longest one on the market, which is safe and easy to use, is Trazodone - and I think that it's useful to know about it.

You can read up on it. You need a prescription for it. But it can change your life if you're living with two, three, four hours of sleep. It helps you get six or eight hours, because it restores the pattern that is interrupted by something called early morning wakening.

That's just one example. The anti-depressants, the drugs that are called selective serotonin uptake inhibitors, like Lexapro, Prozac, Zoloft, and these drugs have different names in different countries, but they're generally related one to another, and they help with depression. And they help with a form of anxiety that comes all at once as a panic attack. They help with obsessive compulsive problems, and, in a way, you can think of PTSD as an obsessive compulsive problem. Your brain is causing you to go back over and over again to something that you don't want to go back to; that you want to forget about. Well, it's not as though these pills cure PTSD, but they help with the symptoms.

There are also a lot of veterans who have pain from nerve damage. They've withstood explosions, they've had broken bones. And there are some anti-depressants that are also good at relieving the perception of pain when the pain is due to nerve damage or nerve impingement - pressure on nerves. The medication's name in America that I find most useful for the combination of emotional symptoms and this type of pain is Cymbalta.

I'm not here to recommend or advertise any particular medication, but I do think there are medications that make a big difference - that help relieve symptoms and help you get on with all these other things you have to do to transform yourself from a military person to a civilian. And that's where the psychiatrists have an advantage. They understand the medications and they can prescribe the medications. But there aren't enough psychiatrists to go around.

JS: You mentioned before something that is very important: the matter of relationships, and the importance of choosing carefully which friends you can rely on. However, those veterans who are married or have partners don't really have that choice - and neither do their family members, who often suffer as a result of the psychological pain their loved ones are living with. What do they need to know about PTSD and trauma? What can they do to help a husband, a wife or a partner - or a son or daughter - who has come back from war with invisible wounds?

FO: You know, they can read articles like this. They can become, if not experts, very well informed about PTSD. I think if you are a loved one of someone with PTSD, you want to be the smartest person on your block when it comes to understanding PTSD - and it's easy to understand. I actually wrote an article for the partner, (http://www.giftfromwithin.org/html/partners.html) and it's been well-received on the web. It gets a lot of hits.

But you don't need to stick with what Frank Ochberg has to say about the subject. Learn about it; learn just what the definition is; and learn that your role as a partner can be a very helpful role. But you shouldn't be presumptuous; you shouldn't presume that you know what's best for a loved one with PTSD. Ask around. Talk to other spouses of people with PTSD. Ask your partner how you can be helpful. Some partners do want you to be there as a sounding board. Others don't really want you to ask too many questions.

Now, I have wives of men with PTSD and husbands of women with PTSD, and I really appreciate when they say they want an appointment with me. Of course, I have to ask my patient if it's alright, and sometimes they say it's not alright. But usually they say it's alright. Then we have a discussion. I don't have to give away private information. The discussion is a tutorial on PTSD, and listening to the specific things that come up in that discussion.

It's very frustrating to be the loved one of someone who has PTSD. I mean, by definition it means your partner doesn't have a full range of feeling. I've had people with PTSD say: "I know I love my wife. I just don't feel it the way I should." Now, that's a hard message for a wife to hear - and there's a better message: the message that "I know I love you, and I don't feel it the way I know I should." That's a much better message than "I don't love you."

JS: It sounds cliché, but an observation that is commonly made about veterans is that they tend not to talk much with their families about some of their more disturbing war-time experiences, and you alluded to this earlier in the conversation. How important is it for soldiers to share what they went through, what they saw in combat?

FO: I don't know how important it is. I think it's important for many soldiers who have gone through something terrible to be able to protect their loved ones from the images, the memories that they have. By now I must know hundreds of men who have PTSD, and they take a certain amount of pride from protecting others from the full force of what they went through.

Of course, when you look at this logically, their wives, sons, daughters, fathers, they read the newspapers, they watch television, they go to the movies. We are a generation that has seen this sort of stuff, so family members can put two-and-two together. But still, there's a certain amount of protective feeling that soldiers, marines, others have - that they don't want to spill that stuff onto people that they love.

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Now in certain circumstances, they will. In some circumstances veterans will talk to those close to them about their experience of war - but there is a way that war stories are told. The way war stories are told by veterans to their family is not the same thing as them talking to a psychiatrist or a psychologist about a very poignant and distressing experience.

Let me give you an example. I asked one of my marine patients, I'll call him Jim: "Do people understand what you're telling me?" Jim said, "No, no. They don't." And I said: "Well, who understands?" He had to think for awhile and said: "There was this guy who was in the hospital bed next to me. He was in combat and his leg was shattered. Another marine came up to help him, to rescue him, and this marine got shot in the neck."

I don't know the name of the marine whose leg was shattered. I just know him as the marine from Terra Haute, in Indiana. So, the guy from Terra Haute was trying to stop the bleeding and comfort his fellow marine, who died. And the guy from Terra Haute believed that he caused the other marine's death by allowing himself to get shot in the leg and needing to be rescued. Well, in a way, he did.

My patient, Jim - the marine who was telling me this story - had a similar experience. And I think every combat marine who lives through something like this lives with a sense of guilt because other marines died. But the point is, when Jim talks to me about his experience that's not the same way he's going to talk to someone else when he tells a war story.

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Photo Credit: John Moore.
Photojournalist and Ochberg Fellow.

Marines don't tell war stories the way they tell their stories to psychiatrists - and I don't think they tell their stories the same way to every psychiatrist. I hear about other psychiatrists who are held in contempt by these marines because they asked for details before they had earned the marines" respect.

I think war reporters understand what we are talking about here - it's the difference between people swapping stories and then people telling you what's really close to their hearts. That's what I'm talking about: the difference between recounting a combat story, and telling it with...well, I don't want to say with tears in your eyes, but you know what I mean.

JS: I think I do. Several years ago in Washington DC I met an Army veteran who had served in Iraq, and while he was talking about what he'd experienced there he broke down, started sobbing, and collapsed in my arms. Although I hadn't served in Iraq in a military role and hadn't had the sort of traumatic combat experience this veteran had had, I'd spent a fair amount of time there - including time with the US military - and could relate to a lot of what he was telling me. I'm not entirely sure what led him to talk about the things that led him to break down, but I guess he might not have felt able to get to the point where those emotions came out if he'd been speaking with someone he felt didn't have some understanding of what he'd been through.

FO: Did you think that he was getting something in the direction of health from having the opportunity to reach so deep and tell you his story?

JS: I really don't know. This young guy was dealing with a lot of trauma, including the death of a comrade who'd been killed next to him on patrol. It seemed to me that once he started talking about some of these things he just couldn't keep all that pain inside; but whether or not it helped him to talk about his experiences is hard to say. Fortunately, when he broke down, one of his buddies came over and took care of him and led him away. I say "fortunately" because I was far from sure what to do or say. Frankly, I'm not sure there's anything one can say in those situations.

FO: You know, I need to figure out what journalists can say in those situations. I'm in a position now, as a psychiatrist who talks with journalists, where I'm helping to create a network of journalists who have learned through trial and error what seems to work.

JS: Well, I guess that's the point: dealing with these situations is a very inexact process, and one that relies a lot on intuition and judgment. Intuitively, I wanted to reach out and offer some kind of support. But at the same time the enormity of this guy's pain was such that I felt I should say nothing, and just be there. And I guess veterans' family members may be wondering how they can tell when they need to be proactive in offering support and when they need to give their loved one some space. Are there any clear guidelines here?

FO: It's a good question. First of all, it's not too good to say something that is superficially comforting. The "there-there" kind of statement, or: "You'll be alright." I think it's good to remember this phrase I learnt as a Red Cross volunteer, which is called "the ministry of presence." It's just plain being there - and if you have to say something you might say: "Thanks for telling me such a hard truth. I'm listening." Or: "Is there more?" But you don't have to say something optimistic when it isn't called for.

Now, what I do as a psychiatric listener is try to figure out what's going on. And what you just described to me sounds like the person brought himself back to the trauma scene, so, as he's talking to you he's going back into the trauma. I wouldn't necessarily rush him out of the trauma, and very obviously change the subject. I think I would want to be there with him to be sure he had said it all, then move on to something else, and not leave him right in the middle of his trauma story - even if I had to keep another patient waiting. That's a decent and important thing to do.

JS: We do know, from research and personal reports, that one thing that makes dealing with trauma much more difficult is a sense of being alone or of feeling abandoned. So, I guess just having someone there, just having another human presence, can help people with the process of dealing with trauma.

FO: Yes, good point.

JS: But can we get back to the matter of advice for veterans' partners? A veteran's struggles can take a tremendous toll on those closest to them. What can the wives and husbands of veterans do to maintain their own psychological well-being?

FO: This is an important issue. There's a term that's relevant here and that's "care-giver burden," where the loved one in the family becomes a care-giver and there is a certain burden. And sometimes that means that you, the family member, need to get help yourself. It could be professional help, and it could be a social worker, a psychologist, even a psychiatrist who takes you on as a patient due to your role as a family member. You also may need a rest now and then. So, everything that's useful for the person with PTSD is useful for the person who's caring for them. That involves taking care of your fitness; understanding your own spirituality and being sure those needs are met; keeping up your sense of humor; having a decent diet, and getting educated about PTSD-related issues.

JS: This is important, isn't it, because they're giving a great deal to their partners. They're having a lot of demands made on their physical and psychological resources, and they're not necessarily getting a lot back because the people they're helping are obviously struggling to deal with their own problems.

FO: Absolutely. You know, I've had a number of PTSD patients who have been referred to me by their spouses. It's often women who are the spouses. They read, and they find out about people like me. I'll bet a lot of us who are known for our work in PTSD are approached by other family members. We get accustomed to that. And I find myself talking with my patients who have PTSD about their wives. There's one wife of a marine, and she's a lovely young woman - they're both in their 20's - and it's a tremendous resource for me, as I deal with her husband, that there's someone in that household who's tolerant, caring, resourceful. In some situations I find that I get ideas from a perceptive spouse that I hadn't thought of.

JS: There will be some veterans who have been dealing with intense psychological pain for months or even years. Some will be wondering: Will I ever feel normal again? How long will it take to sort out my problems?

FO: And the answer to that is: the prognosis is generally good. There are some very hard cases, and the hard case isn't just because the trauma was so difficult, it's because the life that you're returning to is so difficult. But nobody likes to give a general statistic about how long PTSD going to last.

JS: Obviously each case will be different, and someone's background, as well as their personal qualities, will influence how they react to and deal with PTSD.

FO: Yes, that's right. I'm working with Vietnam veterans now, and it's 40 years since the war, but they're still deeply affected. But then they have other problems: they get diabetes; one guy had a couple of strokes; another is in a very miserable financial situation. The PTSD is part of it, but there are complicating factors. I can say this: all of my Vietnam-era PTSD patients are involved with me in helping younger veterans. I've kind of conscripted them, and I think they're getting some gratification out of it. So, there's quite a fraternity - and now there's a sorority too - of people out there who have dealt with these problems, are still struggling, but they have enough ability and experience and wisdom to help others.

JS: What would you say to any veteran reading this who is really struggling - who's feeling overwhelmed, who's feeling desperate, who's beginning to lose hope? What would you say to someone like that?

FO: Well, you always want to inspire hope, optimism, confidence - but in a realistic way. To go through a period - even a long period - of depression is part of the expected consequence of having been to war and having seen its impact, particularly on people we love and we bonded with. So, the cruelest legacy of the war is to have been right there and to have witnessed the killing of one of our brothers and sisters in arms. I think that's the worst consequence.

But short of that, there is a lot of trauma and tragedy that our veterans have to stomach, have to digest. PTSD means that you've developed a medical condition that's a little bit like epilepsy in which, instead of having a seizure in which you fall down and you get unconscious and you shake, you have a seizure in which you remember what you'd rather not remember.

That's PTSD, and we're getting close to seeing it in a brain wave - a very sophisticated analysis of what's going on in the memory centers of the brain. That's coming out of research centers in Minnesota, and I'm very taken with this research. I think - I don't know, but I think - that it's going to lead to quite a physical understanding of PTSD.

So, if you have PTSD you have a certain kind of a brain injury. It's not permanent; it gets better by itself. But it's very, very difficult while you have it, and particularly if you have a severe case.

A severe case means it's not just severe in that your memory mechanism has been disrupted, and your ability to calm yourself and get back to normal in terms of feeling aroused has been disrupted, and your ability to have a full range of human emotions has been blunted - it's not just bad for those reasons. It's bad because of the reality you've seen. You're keeping hell alive, and you're keeping it alive for the rest of us.

It's a burden that you carry, and I want to see that burden honored. This is an injury like every other medical injury earned in combat. A medal won't do a whole lot of good, but I'd feel good to be part of an America that bestows a purple heart for PTSD.

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Photo Credit: Jon Stephenson.

JS: You've dealt with a tremendous number and range of people with PTSD. In your experience, what are the most important factors in ensuring a positive result for those who suffer from it?

FO: Knowing what it is, for starters. Not allowing yourself to be totally demoralized because you have the condition - bucking up and putting it next to other conditions. There are people walking around with Lou Gehrig's Disease which is a lot worse; it is relentless and it kills you. PTSD doesn't get worse through time. It's not lethal unless you let it be lethal.

More and more of us understand it; can help treat it; can help enlighten general society about what it is. It's no fault of your own if you have it. It doesn't mean that you're weak. You shouldn't be stigmatized. But let's face it: America has a lot of ignorance and a lot of arrogance, and there are people out there who are calling veterans cowards for having PTSD. That's just stupid. More and more veterans are identifying themselves as having the PTSD injury and are confident about their general ability to cope with it, and to help others with it.

I don't want to paint too rosy a picture, but it's a hopeful picture. It gets better - and we're getting better at understanding it, at treating it, and living with it.

JS: And some of these young military men and women are very resilient, aren't they? What some of these guys have gone through and survived is amazing.

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FO: It is. The flip side of focusing on what PTSD does to hurt you is realizing that most people come back from military exposure without PTSD, and those who do come back with PTSD recover relatively quickly. What's important is that those who take a longer time to recover get decent help, professional help - that they get the help they deserve from the Veterans' Administration and the military hospitals. I think it's outrageous when we have cost-cutters who not only limit access to benefits that veterans have earned but tell veterans that they're lying or that they're faking it when they're not.

It's been exposed. There have been some abuses in America where people who are rating veterans for disabilities have been told to look for pre-existing personality disorders. This has happened to one of my patients. He got into fights at school, but he went on to become a damn good marine. But somebody has refused to diagnose him with PTSD because he had a history of being in fights at high school, and claimed that all he had was a personality disorder. We're doing our best to get that turned around.

JS: Frank, trauma and PTSD among veterans is a huge topic, and we've barely skimmed the surface. So, why don't we conclude by telling readers where they can get additional information and more detailed advice about how to deal with these invisible wounds?

FO: Yes, I've put together a website called PTSDinfo.org - it's a gateway to other websites. There's a lot of information out there, but I can vouch for the information that you'll find at that site. I have a little letter of introduction at that site, and then there are four different organizations that you get referred to.

One of them is the National Center for PTSD, which is part of the Veterans' Administration. It's run by Matt Friedman, who's a psychiatrist and a pharmacologist, and he is a world authority on PTSD and its treatment. Anything that you read that comes from that website you can trust. It's been reviewed, vetted, researched. It's particularly good for people who want scholarly articles about PTSD, but it isn't all over your head.

Another website that's there is the National Center for the Victims of Crime. Now this isn't geared specifically to veterans, but it's geared to anyone who's encountered human cruelty; and it's one of the few places where there's a call-in hotline. It has a lot of information. Again, while it's not related specifically to the military - it's related more to civilians who encounter crime and who suffer - it helps you know where to go for help.

One of the good things about that resource is there are a lot of pro bono lawyers who help out. If you're a victim of crime, in addition to everything else, and you need a lawyer, this is the place to go.

Since I mentioned that, I just want to mention that I've been in touch with an old friend of mine who is the former top JAG of the Air Force, Jack Rives. He is now the executive director of the American Bar Association, and we were talking about how Bar Association members can help veterans deal with the legal issues they face. Hopefully we'll have some initiatives to announce in the not-too-distant future.

Another website that is there is the Dart Center website: www.dartcenter.org It was set up for journalists to learn more about PTSD, but it is also excellent for non-journalists who can take online courses there on PTSD and learn everything that journalists are learning about PTSD.

Finally, there is Gift From Within, which is run by Joyce Boaz. She's not a professional therapist, but she's done a wonderful job of putting together thousands of pages of information for people with PTSD. You can meet other people through the Gift From Within website who are dealing with PTSD-related issues. Anything that I've written recently, as well as audio and webcasts, is available on that website.

Now, there are a lot of specific veteran-to-veteran and veteran family websites. I don't know them all, but most of them have a lot of good information. That's a matter of seeing what you're comfortable with and finding information that feels like it's written with you in mind. There's a lot out there.

JS: Frank, thank you for your insights and advice.

Jon Stephenson is a New Zealand journalist who has reported on conflict in Afghanistan, Iraq, Lebanon, Gaza, and Zimbabwe. He was a 2008 Ochberg Fellow at the Dart Center for Journalism and Trauma, and is a member of the Center's Australasian advisory board.

Additional Resources:

(PTSD) The Truth In Numbers
Military Family Resources - Selected articles, webcasts, and music from Gift From Within
Dart Society Homepage | Dart Center for Journalism & Trauma
The Military Family Network
Girls Come Marching Home - Gallery

© Gift From Within 2010- www.giftfromwithin.org

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Dr. Frank Ochberg, GFW's Founder testified in Cleveland for the prosecution in the Castro case. Here is a video clip and a short article.

I am very proud of the work he has done in this case. I am hoping that this case will bring forth a nationwide conversation about the women and men in this country who have been abused behind closed doors.

Respectfully, Joyce Boaz, Director.
http://www.wkyc.com/news/article/308869/3/Psychiatrist-explains-where-the-survivors-go-from-here

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