Healing Combat Trauma

Reservists, Guard Personnel at Risk for Alcohol-Related Problems

Higher Risk of Alcohol-Related Problems for Reserve, National Guard Personnel

Younger service members and Reserve and National Guard combat personnel returning from the wars in Iraq and Afghanistan are at increased risk of new-onset heavy drinking, binge drinking, and other alcohol-related problems, according to a recent study in The Journal of the American Medical Association.

Isabel G. Jacobson, MPH, of the Naval Health Research Center in San Diego, and colleagues examined whether military deployment to the wars in Iraq and Afghanistan is associated with new-onset or changes in alcohol consumption, binge drinking behavior, and other alcohol-related problems. Data were derived from questionnaires completed by participants at the beginning of the and follow-up. After the researchers applied exclusion criteria, the analyses included 48,481 participants (active duty, n = 26,613; Reserve or National Guard, n = 21,868). Of these, 5,510 deployed with combat exposures, 5,661 deployed without combat exposures, and 37,310 did not deploy.

The researchers found that among Reserve or National Guard personnel who deployed with combat exposures the rate of new-onset heavy weekly drinking was 8.8%; the rate for new-onset binge drinking was 25.6%; and for new-onset alcohol-related problems, 7.1%. Among active-duty personnel, new-onset rates were 6.0%, 26.6%, and 4.8%, respectively. Among Reserve/Guard personnel, deployment with combat exposures was associated with increased odds of new onset of all three drinking outcomes compared with nondeployed personnel, with heavy weekly drinking (63%) and alcohol-related problems (63%) showing the strongest association.

Among active-duty personnel, those deployed with combat exposures were at increased odds (31%) of new-onset binge drinking at follow-up. Those born after 1980 were at 6.7 times increased odds of new-onset binge drinking and 4.7 times increased odds of new-onset alcohol-related problems. Those with PTSD and depression were at increased odds of new-onset and continued alcohol-related problems at follow-up.

“These results are the first to prospectively quantify changes in alcohol use in relation to recent combat deployments. Interventions should focus on at-risk groups, including Reserve/Guard personnel, younger individuals, and those with previous or existing mental health disorders,” the authors concluded.

— Source: American Medical Association 

PTSD: (That's Some) Pretty Terrible Sh*t (to Have to) Deal (With), Don't You Think?

Editor's Note: We commemorate the otherwise momentous, historic signing of the GI bill into law today with this little snippet of what life was like for someone who served recently.  For everyone who doesn't "get" what sacrifice is, and that those who've served have earned their accolades and rewards, here's a grunt's-eye view of the experience of combat trauma, and how that relates to PTSD and various other topics in the news.  It's doubtful that any one of us would like to have changed places with him, at such a young age.  Herewith, his story, emphasis mine:

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I'm no Vietnam vet, but a vet of Operation Iraqi Freedom. I turned 18 while in boot camp because I graduated high school at 17. I was discharged early for having "personality disorder" after I went to Iraq.

I was in the Marines, and my MOS was a ground communications electronics technician. A couple months after graduating my training for the job and going to my first unit, I was "volunteered" to join and train with another unit that was leaving soon. The new task I was given was "Mortuary Affairs".

This group was put together with a couple dozen other Marines from other sections. Our job was to go to locations where troops had been killed and not able to be retrieved by the group they were out with due to the fact they were under too much danger or whatever the case. I had no clue the effects this would have on me. It was a horrible experience.

It was not like going and picking up a corpse and that's it. For one, you were in a hot zone, where people were just killed, not just by gunfire.

Here are some brief descriptions of the missions I was a part of...
 

The first one wasn't too bad; the body was actually brought to us at the camp we were at.

 

It was a young male Marine. He was supposedly in a Hummer going somewhere and might not have been wearing his helmet. He had a silver dollar sized hole in the side of his head.

When we get the bodies back the camp we have to take off all materials on the body, and go through and bag each individual body part. It was more of a surreal experience really, I did not know how I was supposed to feel.

Once our troops invaded Fallujah was when things started to get worse. On another of the missions, a truck carrying fuel was crossing a bridge and was shot with an RPG. The truck went off the bridge and fell, the fire burning most of everything.

 

When we went out it was usually just a dozen of us with maybe 2 Hummers of security if we were lucky. For anyone who doesn't know, most the Hummers used were old and poorly maintained/equipped... almost no armor. So we get there and head down to the bottom where the truck fell and we had to pull out burnt bodies from inside of the cabin.

 

It sounds bad, but burnt bodies are almost like burnt food... so perhaps it wasn't as bad as the rest. It did not help our appetite when we had to eat in the same building we processed the bodies in. Our shop was just a medium-sized bunker, no walls or anything so yes we basically ate next to the bodies. It is obvious why some of us didn't eat the meat.

 

The worst mission I went on was when an army tank was traveling down a road and was blown up from a roadside explosive. The bomb was so powerful: you could not identify ANY part of the tank except for the tracks. It had been tossed a couple hundred feet in different directions.

 

It took us I think, about 15 hours to do this mission. There was gunfire when we first arrived but nothing more. I think we picked up a couple thousand pieces of flesh that day. Going through each one individually. They would range from small penny-sized pieces to legs, torsos, heads, feet, testicles, arms, etc.

 

There were a few more missions but we get the idea by now I'm sure. I guess it started to become noticeable that I wasn't doing well. I was taking whole boxes of NyQuil tablets and drinking bottles of medicine to get anything I could out of it at night. I smoked probably a pack of cigarettes a day, which is a lot for me because I have never really smoked more than a couple cigs a day if at all.

 

My officer had me go speak to the chaplain and from there a navy doctor who was a great person to have over there. He pulled strings and had me med-evac'd out of there a few weeks later.

 

In the meantime I had been moved out of my job until I was able to leave. I was harassed for leaving: superiors thought I was just faking to get out.

 

I had become highly depressed and my roommates noticed me screaming sometimes in my sleep.

 

From Iraq I spent a few days at an army hospital in Germany, talking to various doctors and such... going through the process.

 

I was being given pills for depression and for insomnia. Then I made it back to the US and once at my base I was seen by a psychologist. They actually gave me the option to get of the military, so I did.

 

I had been told the process takes several months to year until you finally leave. In the meantime I started drinking daily, and stopped taking the pills they gave me because they seemed to numb my mind and I could not stand it because I have always had such a wonderful and creative mind. It made me feel like a zombie, I could not even create artwork which was my biggest hobby.

 

A month down the road I started having nightmares, very detailed and morbid. A few times I would wake up with tears. I began having suicidal thoughts and crying at least a few times a day. Thank God my best friend was stationed not so far, he saved my life I think.

 

It was hard for me to wake up because of the medicine I had been taking, that’s another reason I stopped it, I was always drained. The first week I was back I never even reported back to my old unit, I didn't know what I was doing.

 

A week later they send somebody to come get me. There, I was harassed and treated like a piece of s%#t some more by my master sergeant. They had me sit in inventory room all day while I struggled to stay awake. I luckily had a very kind staff sergeant in charge of me at the time. He would let me sleep and go home early.

 

I admit I was very lucky in getting out, because it only took me about 2 months until I was officially a civilian again. I was going back home. I stayed with my older sister and her boyfriend at first, because I was not too fond of going back to my parents. My depression got worse and I started to drift further from sanity and comfort; people noticed I was a different person.

 

At this point I started smoking marijuana occasionally. Which was really the only time I felt anything, happy, able to think, speak, talk to people, feel normal.

 

Eventually I moved back with my parents and that's when things got worse for me. I had some additional problems I know was facing, I needed a job, and had people on my back constantly. I had no access to marijuana during this time.

 

My insomnia got to its peak to where I could not sleep AT ALL at night. I also began having more suicidal thoughts, nightmares got worse and I had them ANY time I could sleep which was usually from 7:00 AM to 12:00 PM, began having auditory and visual hallucinations everyday, and constant anxiety.

 

I knew I had PTSD and that the military used "personality disorder" so that they would not take the rap for it.

 

I finally couldn't take the insomnia anymore and was prescribed Ambien, which actually works extremely well and helped get my body back on schedule, only thing is I had to take it for 3 months and then no more because they said it was addictive.

 

So it became difficult without it. I did a long process of seeing doctors and filling out paperwork for the VA and was finally officially a disabled vet due to chronic Post Traumatic Stress Disorder, normally referred to as PTSD.

 

I started to be able to get a hold of marijuana again and when I had it things were more stable. My temper was not out of hand and I could sleep comfortably having less nightmares. At this point I had gone a year or more straight of having nightmares every night.

 

It has been three years now and I am much better. Time has healed me a little and I smoke marijuana as often as I can. I don't have hallucinations anymore, or rarely any nightmares. I do however still have bad anxiety, temper, and depression problems when I'm not high.

 

Another thing I forgot to mention is that PTSD has basically ruined my memory. Since I first showed symptoms until now, my memory does not work nearly as well as it should.

 

I still have major problems concentrating and working sometimes too. It makes interviews and other social activities near impossible for me, as I cannot speak or express myself as I used to. I get very nervous and my mind blanks out sometimes. I cannot say if marijuana will help all my problems, but I can say marijuana helps me feel alive.

 

Being high is the only time I feel good and happy, deep down. I can be around loved ones or any social crowd without tweaking out from anxiety, I can think and operate much more smoothly, I don't have a short temper, and it makes me want to live.

 

The past couple months have been rough on me and I have been going to the VA hospital here to try and get help. The first 4 times I went, they did the same exact thing which was to ask a series of questions, ask me if I want pills and send me home. I kept telling them I did not want pills because I have seen what they have done to people I know and what they have done to me.

 

All I wanted was someone to talk to.

 

After the fourth time of going in there feeling like I wanted to die, they finally got someone for me to talk to. We have just met once so far, but I think it will be good for me.

 

In the meantime I have not been able to smoke recently because I am trying to find another job, which is not going too well and I only have a couple weeks before my current job ends.

 

I have had a few interviews but blow them miserably because it’s getting harder and harder for me to go through the whole thing without my nerves choking me to death. It’s only been a week or two since I smoked last and my temper and depression are already busting through the door. I worry too easily and stress out to the extreme.

 

Take what you will from this story, but I know for a fact marijuana has saved my life numerous times.

 

-- One young former Marine's story, in his own words. Used with permission.

Editor's note: "Mortuary Affairs" was also the detail highly-decorated Marine ("Marine of the Year") Daniel Cotnoir worked in Iraq, before a combination of circumstances, including PTSD, triggered an event in his hometown of Lawrence, Massachusetts -- which got him arrested, and barely escaped conviction.  We have blogged about Daniel Cotnoir's case many times on this blog, going back several years, when it was current.  It's safe to opine, that even within the trauma of war, some things are harder to endure than others.  Our guess would be, mortuary affairs really qualifies for extreme hardship and exposure to things that make PTSD an occupational hazard.

The Blunt Truth: Combat Veterans, PTSD and Medical Marijuana

There's a great article on the Web from the Salem (Oregon) News-Record of June 11, 2007, called "Marine Combat Vet Discusses Iraq, PTSD and Medical Marijuana," linked here.  The former Marine in question is Nicholas Burgin, and the subhead to the article is, "The courage of an Iraq War veteran continues in his honesty about PTSD."

In the tradition of Tony Neff's story, "All I Want is What I Deserve," about getting his veterans benefts for a service-connected disability, linked here, Nicholas Burgin's story is another great, first person narrative account of his experience, and what actually happened to him.  (We're in the process of seeing if we can get Burgin's permission to reprint his story in full, here, because it would help so many readers.)

In the meantime, read his story, while it's still up on the Web, or save yourself a copy of it, for future reference.  It's powerful.  And don't neglect reading the comments section, either, that follows the article.  A whole lot of people checked in and said they knew what he was talking about, and they agreed, from Vietnam vets through other OIF/OEF combat vets.

Burgin is a young Marine who, like a highly decorated Marine with PTSD we've blogged about here, Daniel Cotnoir, worked in mortuary affairs for the Marines in Iraq - a more gruesome job hardly exists -- and saw enough stuff to last a thousand lifetimes.  Later on, of course, Burgin had trouble with the memories, and despite trying everything recommended to him, found one and one thing only that helped him ease the pain.  He details his struggles, and his victories, in the excellent, first person narrative, and closes with the line, "Take what you will from this story, but I know for a fact marijuana has saved my life numerous times."  Good for him.

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In the 60s, draft dodgers and anti-war types in the U.S. made their way to Canada to ride out the Vietnam war.  Many stayed for years.  Today, with an all-volunteer military, "escaping" to Canada isn't nearly so popular; but if anyone compares the drug laws in the U.S. and Canada re: marijuana use, and finds themselves overly hassled by the perspective in the U.S. that it's still a criminal offense, they might start to find Canada more attractive again.  Depending on whether the party in power is liberal or conservative, their drug policy waxes and wanes, but more than 51% of Canadians are in favor of decriminalizing marijuna use, says the BBC, and using is often treated differently there than selling (possession v. intent to distribute).

One Marine Reflects on His Battle with PTSD

Back in January, The Marine Corps Gazette published the account of one Marine's own struggle with PTSD.  The Marine was 1st Staff Sergeant Travis N. Twiggs, and the article was called "PTSD: the War Within - A Marine Writes about His PTSD Experience."  Twiggs had four deployments with OIF/OEF: one to Afghanistan, and three to Iraq.  He writes fairly bluntly about what his experience with PTSD was like; how it crept up on him; what the process of admitting that he had it was like; and what he did to recover from it.  He also writes a postscript about what his like has been since then.  I've tried to contact Twiggs several times and the Marine Corps Gazette, to see about getting permission to reprint Twiggs' story on this blog; but haven't heard anything back.  That makes me concerned that perhaps the end of the story isn't as positive as it seemed it was going to be; but I hope that I'm wrong about that.  Twiggs' writing his story about his own fight with PTSD is a very powerful thing.  While many veterans obviously suffer from PTSD, not many have come forward to really talk about what it's like to have had it, and to have made progress in overcoming it.  That's why Twiggs' story is so valuable.  It also has the added benefit of being a story by a combat veteran to other veterans -- with all the shared camaraderie and empathy that implies. I hope things continue to go well for Twiggs -- his example and his openness can really be helpful to other veterans who are suffering from combat trauma.

Some items that stand out from his story:

• A triggering point: arriving back in the U.S. after his third deployment, and being greeted by the families of the two Marines who were killed in action on his tour at the homecoming for his battalion.  It seems to have pushed to the forefront of his mind the question, "Why them, why not me?" which is classic for people to ask.  "From then on my life began to spiral downward," he says.
• At another point he describes being back from the front: "When I arrived back in the States, it was as though I had never left. All of my symptoms were back, and now I was in the process of destroying my family. This was all taking place because I did not understand what was happening to me. My situation worsened, if you can believe that. I started neglecting my work, and my answer for everything was alcohol."
• In other point, he describes with great poignancy the real battle within himself: "The true horror of war is coming home without all of your Marines, because at some point you have to look at yourself in the mirror and wonder, “Did I give them my all?” “Did I train them to the best of my ability?” I could not answer yes to either question. I still can’t and wonder if I ever will." (That last point also makes me concerned about how fully he's been able to put this in the past; it's probably still far too difficult to - and there's definitely no shame in that.)

Another constructive part of the article is the recommendations he offers as a layman, about what he believes helped his PTSD, and what might help others.  Here are the majority of things he says he learned from the experience, that he can recommend to others:

• Medication alone will not calm PTSD symptoms. Therapy is a must, and it has to be done with others who have experienced the same war or conflict. In other words, veterans of Operation IRAQI FREEDOM should not be undergoing therapy with Vietnam or Operation DESERT STORM veterans. The symptoms are the same, but the time periods are different.
• Alcohol and pills don’t mix. The Marine/sailor should never be told that moderate alcohol consumption is acceptable.
• It is okay to mourn those you’ve lost, but remember, they don’t want you to be sad. They want you to celebrate their lives.
• PTSD is not a weakness. It is a normal reaction to a very violent situation.
• I firmly believe that a lot of my [subsequent] problems were caused by overmedication. The medication affected my judgment and my ability to cope with the true issues that haunted me. I also have since suffered from a seizure, which is believed to have occurred from the same cause. So, ensure that the Marines/sailors know that it is okay to question the amount of medications they are taking and why.
• Place more emphasis on the post-deployment health questionnaire all Marines/sailors have to fill out before leaving theater. I remember Marines being told that if they marked “yes” to anything, it would cause problems with their taking leave. They don’t know that PTSD is not even noticeable until they come home. Marines/ sailors should fill out these questionnaires honestly when they get back in garrison, and they need to know that it is okay if they are experiencing difficulties readjusting.
• Leaders should sit down with their Marines/sailors prior to releasing them for leave and cite different examples of PTSD so that they know what to expect and how to recognize the symptoms. When they return from leave, leaders should get them enrolled in as many schools as they can. Regardless of whether they can get them into the schools or not, leaders should set up a well-planned schedule for them.

Wherever you are, Travis Twiggs, best wishes for your continued health and healing.  Thanks for being strong enough to write this; thanks for sharing it with your fellow combat veterans. 

Editor's Note: A copy of the original article is linked here; a PDF copy of it on the Web is also linked here.

Alcohol No Cure for Painful Memories, Study Finds

Many people, including combat veterans, say they turn to drink to "drown their sorrows," or attempt to "wash all their troubles away," however momentarily.  The idea of turning to alcohol consumption, even alcohol abuse, to deal with stress and trauma is a common one in today's society, not just among injured combat veterans and other trauma survivors.  People typically believe that alcohol numbs painful experiences, and veterans often turn to alcohol to deal with sleep disturbances and insomnia. 

Now there's scientific evidence that says alcohol may actually be having the opposite effect.  A recent study in the medical journal, Neuropsychopharmacology, says that, in layman's terms, drinking actually increases sorrow, not minimizes it.  The study, which was done with rats, indicates that the ethanol in alcohol is apparently able to block painful memories from being acquired,; but for painful memories we've already acquired, it has the opposite effect - it locks them into our minds, or reactivates them.  Yikes.  Yet another reason to not look for a best friend, or a therapist, at the bottom of a glass.

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Additionally, as the U.S. Department of Health and Human Services - Substance Abuse and Mental Health Services Administration points out, alcohol addiction prevents larger healing from taking place.  They state, "Many victims turn to alcohol or other substances in an attempt to get some relief from their emotional turmoil and suffering. All trauma survivors manage their experiences in different ways. However, substance abuse is not only ineffective in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult."

What They Found in the Wastebasket

The McClatchy newspapers continue their great series about whether and how the VA system is serving, or under-serving, returning combat veterans with PTSD.

In their recent story, "Suicide Shocks Montana into Assessing Veteran's Care," which by the way is an excellent fact-filled article, there is this troubling mention about what Chris Dana's dad found in his wastebasket, after Chris shot himself last March.  Let's let the McClatchy papers tell the story:

HELENA, Mont. — Chris Dana came home from the war in Iraq in 2005 and slipped into a mental abyss so quietly that neither his family nor the Montana Army National Guard noticed.He returned to his former life: a job at a Target store, nights in a trailer across the road from his father's house. When he started to isolate himself, missing family events and football games, his father urged him to get counseling. When the National Guard called his father to say that he'd missed weekend duty, Gary Dana pushed his son to get in touch with his unit. "I can't go back. I can't do it," Chris Dana responded.

Things went downhill from there. He blew though all his money, and last March 4, he shot himself in the head with a .22-caliber rifle. He was 23 years old.

As Gary Dana was collecting his dead son's belongings, he found a letter indicating that the National Guard was discharging his son under what are known as other-than-honorable conditions. The move was due to his skipping drills, which his family said was brought on by the mental strain of his service in Iraq.

The letter was in the trash, near a Wal-Mart receipt for .22-caliber rifle shells.

All across America, veterans such as Chris Dana are slipping through the cracks, left to languish by their military units and the Department of Veterans Affairs.

It's implied, but not stated, that Chris Dana might have been driven to suicide by the one-two punch of PTSD and then being discarded by his own unit as unfit to serve (and therefore to collect benefits).  The timing is certainly...troubling.  It's a heartbreaking story, and it wouldn't be surprising if it is, in many ways, being played out all across America, as returning veterans struggle with their own private demons -- grief and loss and trauma, from combat -- and find a system that not only doesn't embrace them, but makes it difficult for them to find the care they desperately need, when they need it.  In Chris Dana's case, the system created more difficulties for him -- not helped him deal with the difficulties he already had.

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I've read a lot of stories by now about young veterans killing themselves, and my sympathies are really with them.  Not instead of the veterans who, battling their own demons as well, end up harming others, sometimes but not always before harming themselves.   One common thread to the stories where young vets take their lives is they often are aware that they have a problem, but the timing is bad about getting help.  They, and their families, are often aware that something is wrong -- Johnny went off to war but didn't come back the same sweet, fun-loving guy who left -- but the drag is, they can't get in to get seen in enough time by competent mental health professionals.  There's often an unconscionable wait to be seen at the VA.  And of course they're often also pretty well-mired in the not-exactly-advantageous experience of self-medication with drugs or more commonly, alcohol -- to keep the demons at bay.

So they don't get seen in time enough, even though everyone knows something's desperately wrong, and the next thing you know, they're dead, and they're leaving families who are quite shell-shocked themselves by the double horror of having their child come home from war a substantially different person, and having them take their own lives, often in the family home.  There's such a list by now, of callow young men, deep in a struggle with combat trauma, not getting the timely help they need, and dying by their own hands, leaving anguished families in their wake.  Joshua Omvig, Jason Cooper, Jeff Lucey, Noah Pierce, Chris Dana, the list literally rolls on...120 a week.

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It's becoming apparent that PTSD is, in many ways -- except for the possibility of windfall payout -- a real lottery.  It's a lottery whether you'll get it -- not everyone who goes to or through combat, does.  It's a lottery when it will  happen -- it often shows up a delayed interval after combat, not immediately (immediately would be more convenient for everyone).  (In fact, it can show up many years -- as in, decades -- later.  That's why you see Vietnam-era vets finally realizing they have it, as they reprocess their own trauma in sync with veterans coming back from Afghanistan and Iraq.)

There are a few more lotteries, though.  It's a lottery whether the VA will know how to treat you -- you'd be unhappily surprised if you saw the searches various VAs do on this very blog.  Doesn't exactly inspire confidence that they know the direction to go in; seems quite a bit more like they're clutching at straws.  It's also going to be a lottery whether you'll get evaluated in a competent way, and ascribed the correct percentage of disability.  News reports lately, particularly from the McClatchy Newspaper chain, which did its own independent research, show that VAs vary widely from state to state in terms of how they confirm or compensate PTSD in their centers.  (We blogged about it, here.)  It's also a lottery whether the military will even see your case of PTSD for what it is; because it might create behavior problems that they start to see as failures in discipline, and demote or discharge you because of it (as they did in Chris Dana's case), and then you really won't be in a position to pay for your own care.  And of course, it's really a lottery to see if your family, community, job, and social network will embrace you, accept you, or reject you. (It won't have much to do with your own worth; more to do with them, but no matter.  It'll still hurt.)  Then there's the lottery of whether you'll be able to afford to live on the meager proceeds of your disability pay, should you be "lucky enough" (there's the lottery concept again) to receive any.  And the true, ultimate lottery of whether you'll end up becoming homeless -- a good one quarter of homeless males in America now, and the figure stands to go much higher, has been show to be veterans, many of whom have PTSD.

And of course there are also the lotteries of whether you'll become addicted to drugs and alcohol, in your quest to cope with the pain and self-medicate, either while you're waiting around for the VA to see you and/or take your case seriously, or, just because it's a socially-acceptable option that's within easy reach, and in some ways more instantly accessible than dealing with the ups and downs and unknowns of medications offered.

The only problem with all these lotteries? (and they are gambles, after all...)   No positive payout.

I'm beginning to think, as I read story after story in the press of hapless veterans colliding with a system that doesn't care, and harming themselves or others, or just plain checking out, when they've reached the wall and can't find, or get, help for their suffering -- that the only "lottery" I know that resembles this is a very famous one indeed.  "Survival of the fittest," a phrase that came to prominence with Charles Darwin, and the concept of natural selection.  Only the very strongest can survive: the sick, the weak, the ailing, all fall behind and get taken out.  Combat trauma -- a very natural reaction to very unnatural events -- weakens those it affects.  And the system, such as it is, exemplified by the VA -- doesn't really stand ready to help in any pro-active, instantaneous, constructively helpful way.  Not to mention, it's almost impossible for those traumatized to simultaneously also aggressively advocate for their own care.  So the veterans who are struggling with trauma are weakened, and the system picks them off, one at a time -- by attrition, if not by outright neglect.  I think that's why you see some Vietnam-era veterans jumping in to do what they can to help young vets just coming back.  They literally don't want to see today's crop of veterans have to struggle as long or as hard as they've had to for the care that they need. I applaud the heart behind those vets' efforts, but at the same time I'm discouraged that, if PTSD is a lottery, we can't have a care system based on natural selection -- where only the strongest can survive its delays and haphazard care.

NOTE: Callow -- it's not an insult, it's a description.  It means, lacking adult maturity or experience.  Which sometimes allows you to put into perspective that whatever you're going through is not worth killing yourself over.  Sometimes, but not always.

Don't Make it a Blue Christmas - Veterans, Depression, Suicide and the Holidays

There is a dominant impression that many of us have that suicide somehow spikes at the winter holidays.  Fortunately this turns out to be just a myth -- though there is an increase in suicide after the holidays -- perhaps in part because of the general letdown after a period of increased stress, combined with frequently crummy weather and potentially mounting financial pressure from holiday overspending.  Even if suicide didn't peak anywhere near this time of year, it's still worth looking at what can be done to help people feeling the pressure and stress of the holiday season.  Combat veterans (and their families) face special stresses at holiday times, including increased time with family and friends, often increased exposure to alcohol and drugs, and the special pangs of realizing loved ones -- combat buddies -- are no longer with them or able to celebrate the holidays with their own families (survivor's guilt).

Fortunately there are some decent resources out there for lending a hand.  First off, the generic but helpful ones; secondly, the more veteran-specific ones.

Good, generic advice:

• "Ten Tips for Coping with Holiday Stress" 
• "How to Remain Sober and Healthy During the Holiday Season"
• "Dealing with Grief in the Holiday Season"

An excellent one on "Coping with a Family Member's PTSD During the Holidays;" and

Veteran-specific advice:

• Article by a Vietnam-era vet, who tried to kill himself on his first Thanksgiving back after combat.  He's got a very interesting point of view in this article.  One of the things he says is that since he arrived in Vietnam first on Christmas morning, it was hard for him for years afterward to ever have a good Christmas.  He covers all the big topics from his point of view, including anger, flashbacks/hallucinations, fear, dread, hyper-vigilance, anxiety, intimacy issues, drug and alcohol abuse, avoidance/immersion, sleep disorders, guilt, memory loss/cognitive dysfunction, intrusive thoughts, and depression.  Pretty good stuff, and he definitely can relate.  He also talks about "anniversary reactions," which is another important topic in the discussion of veterans and combat trauma.
• Patience Mason's wonderful advice for veterans and their families.  This is a link to an article specifically on "PTSD and the Holidays," and it's quite comprehensive and excellent.  She also covers the anniversary reaction the veteran may be having, and talks about how to create a healthy balance between who can handle what at the holidays, without fostering resentment and anger between the veteran and his or her loved ones.  Excellent stuff, again from someone who can relate.

Alcohol Abuse as Self-Medication for Stress

The British journal, Public Health News, which has gone out of business(!) since this article was published, last year had a good article by Shannon McKenzie entitled, "Self-Medication through Alcohol May Leave Millions More Vulnerable."  Because we've been talking lately in this blog about how veterans (and others) sometimes can turn to substance abuse as a way to deal with enormous life stressors, such as combat trauma and/or PTSD, we though this article was worth citing.  It was written to a British audience, and does not address combat specifically. It does, however, make the point that society is increasingly turning to numbing as a way of coping.  Unfortunately, as the article indicates, it's not a strategy that works well enough, long enough; and it can ultimately backfire.  Here's what it had to say.  It shouldn't be hard to make the mental leap to the problem of veterans self-medicating for symptoms of PTSD.

Millions of UK adults are using alcohol to deal with stress, anxiety and depression, according to a new report by the Mental Health Foundation ("MHF"). But their efforts to self-medicate could in fact increase their vulnerability to more serious mental health problems.

A National Opinion Poll survey carried out for the MHF showed 48 per cent of respondents aged 35- to 44-years-old said alcohol made them feel less anxious, while 26 per cent of all those questioned reported alcohol made them feel less depressed.

The MHF report – Cheers? – notes that alcohol consumption has doubled over the past 50 years.

Alcohol, it appears, is one of the British public’s favourite coping mechanisms. MHF chief executive Dr Andrew McCulloch said drinking alcohol seemed to be a common response to problems, and this was a cause for concern.

‘The research confirms our worries that people are drinking to cope with emotions and situations they can’t otherwise manage to deal with – feelings of anxiety or depression,’ Dr McCulloch said. ‘Drinking alcohol is a very common and accepted way of coping.’

The report outlines two major problems with such a coping mechanism. Firstly, self-medicating with alcohol can become self-perpetuating. Underlying anxiety can lead to increased alcohol use, which can in turn alter the chemistry of the brain, making people even more anxious and in need of even more alcohol to ‘numb’ their anxieties. Over time this can result in individuals becoming tolerant of alcohol.

Secondly, the report states it is difficult to maintain the right amount of alcohol needed to reduce negative feelings. And, given alcohol is a depressant, feelings of anxiety and depression may rapidly return. Even worse, these negative feelings can be amplified. The report notes that as many as 65 per cent of all suicides have been linked to excessive drinking, and 70 per cent of men who kill themselves have alcohol in their system.

People with psychiatric disorders are also more likely to turn to alcohol to self-medicate.

The coexistence of alcohol and severe mental ill health problems is well-known – the prevalence of alcohol dependence among those with psychiatric disorders is estimated at twice that of the general population. People with severe and enduring mental illnesses, such as schizophrenia, are at least three times more likely to be alcohol dependent. 

Related Links:

The British Mental Health Foundation; and we would add, for our British readers, Combat Stress UK, the "Ex-Services Mental Welfare Society," which has a section of its website devoted to PTSD.  Click here for that link.

"Must Have Been a Real Mean Bottle" - Veterans, PTSD and Substance Abuse

The relationship between trauma and substance abuse, or in our case, PSTD and self-medication through drugs and alcohol, is well-known. Some "sobering statistics" about substance abuse and veterans -- pun quite intentional -- follow here:

• Substance abuse rates are higher among veterans than their non-veterans counterparts.
• 76% of all homeless veterans suffer from drug, alcohol, or mental health problems (National Survey of Homeless Assistance Providers and Clients, 1999).
• According to an Army Post-Deployment Reassessment Study completed in July of 2005, alcohol misuse among soldiers rose from 13% among soldiers to 21% one year after returning from Afghanistan and Iraq.

(These statistics from the excellent fact sheet at the National Veterans Foundation - "The Lifeline for America's Veterans" -- called "Facts about Veterans: Needs and Solutions." Click here for the link to the fact sheet; click here for the link to the organization.)

There's even at least one scholarly book written on the subject, Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders, edited by Paige Ouimette, Ph.D., and Pamela J. Brown, Ph.D. Washington, D.C.: American Psychological Association (2003).  [Editor's note: "comorbid" means "appearing together."]

In a review of it by psychiatrist Edward J. Khantzian, M.D., of Haverhill, Massachusetts, he writes that his experience, "spanning four decades of clinical work involving patients with substance use disorders," has led him to conclude that "suffering is at the heart of addictions.  Nowhere is this more evident than with individuals who have developed posttraumatic stress disorder (PTSD) and resorted to addictive drugs to medicate the distress and pain associated with PTSD."

In future blog posts, we'll cover this topic in greater depth, but for the present, it's important to note how closely intertwined the two concepts are: if combat trauma or PTSD is a "normal reaction to abnormal events," it's no surprise that so many veterans of combat attempt to medicate the most troubling and painful experiences away through misuse or overuse of drugs and alcohol.

(The blog post's title comes from the country song, originally written by Vince Gill, and performed by Bob Seger and Kid Rock on Seger's latest album, Face the Promise.  To see a video of Seger and Rock singing this in concert recently on YouTube, click here.)

The toll free number for the National Veterans Foundation is 1-888-777-4443.

Self-Treating PTSD with Drugs and Alcohol

The American Bar Association had an article in its GP|Solo magazine -- devoted to general practitioners, solo and small firm practitioners -- late last year about "Returning Veterans."  It's a decent article, covering a variety of topics, from legal services for vets to what happens to lawyers who serve in combat and then need to come back and rebuild their own practices.  Sections of the article address, in a somewhat generic but still helpful way, PTSD, Substance Abuse, and Domestic and Personal Challenges.  It also lists resources for returning vets who struggle with these issues.  Here's what it has to say about problems with substance abuse, a real threat to veterans as a form of self-medication for PTSD and combat trauma:

Substance Abuse

In addition to traumatic stress reactions—and frequently as a means of self-medication to cope with these reactions—veterans may struggle with alcohol and drug abuse or dependence. The military is a zero-tolerance drug-free workplace for both enlisted troops and civilian employees. Regulations state that “drug abuse will not be tolerated and there are serious consequences for such misbehavior.” The Army Substance Abuse Program (ASAP), created by AR600-85, engages in prevention, enforcement (random drug testing is standard), and treatment. Soldiers identified as drug abusers are referred for clinical screening but are also subject to administrative separation, non-judicial punishment, or courts-martial. Those involved in alcohol-related misconduct are referred to ASAP for clinical screening and may be referred to alcohol and drug abuse prevention training, sent to another agency (clergy or marriage counselors), or sent to ASAP rehabilitation treatment, with a possibility of disciplinary action.

At the same time, servicemembers are encouraged to self-report their substance abuse issues. They can receive treatment, and the negative actions that can be taken against them are limited. Attorneys may draw comparisons between the dual enforcement/treatment structures of ASAP and state bar associations that maintain bar discipline (enforcement) programs as well as voluntary, confidential lawyer assistance programs.

Whether self-reporting or mandated to treatment, it’s important to note that 12-Step meetings (such as Alcoholics Anonymous) are available on military bases and among deployed servicemembers, carrying on a tradition of recovery that began in 1935 and was road-tested in World War II.

After discharge, returning veterans can receive treatment for substance abuse from the Veterans Administration (VA). It’s helpful to note that these benefits are not limited to newly returning vets. When alcohol or drug abuse has depleted an individual’s financial resources, determining eligibility for veterans’ health benefits can be a lifesaver when the cost of long-term residential treatment would otherwise be prohibitive.

It also lists some resources for coping with these issues:

Substance Abuse and Mental Health Services Administration (SAMHSA)
SAMHSA’s publications on veterans include several short reports from the Agency’s Office of Applied Studies (OAS). Recent reports include Substance Use, Dependence, and Treatment Among Veterans and Alcohol Use and Alcohol-Related Risk Behaviors Among Veterans (see SAMHSA News , January/February 2006). Visit SAMHSA’s website at www.oas.samhsa.gov/topics.cfm for a complete list under the topic “veterans.” Other SAMHSA resources include:

SAMHSA’s National Mental Health Information Center
800/789-2647 (toll-free)
240/276-2550
www.mentalhealth.samhsa.gov

SAMHSA’s National Clearinghouse for Alcohol and Drug Information
800/729-6686 (toll-free)
800/487-4889 (TDD) (toll-free)
800/767-8432 (Spanish) (toll-free)
www.ncadi.samhsa.gov

SAMHSA’s National Helpline
800/662-HELP (4357) (toll-free)
(English and Spanish)
800/487-4889 (TDD) (toll-free)

Veterans, PTSD and Homelessness: One Man's Story

The Duluth News Tribune in Duluth, MN has a heart-rending story in yesterday's paper about a Gulf War and Afghanistan veteran who became homeless because of severe symptoms of PTSD.  On the surface, the story is about Kevan Boman, 52, a decorated veteran, who "walked out on his former home and family several years ago as he struggled with the symptoms of post-traumatic stress disorder."  Earlier, before PTSD, Bowman "had a family, a house and a good job - until his mind was overwhelmed by the guilt and shame from post-traumatic stress disorder, and he walked out on it all."  In the larger sense, though, the story is about homelessness among veterans, which is significant.  It's estimated that nearly one quarter of homeless are veterans.  Says the article, in brief:

On any given night, according to the U.S. Department of Veterans Affairs, there are about 200,000 homeless veterans across the country, and about 400,000 veterans experience homelessness over the course of a year. About 97 percent of them are male, and they account for 23 percent of the total homeless population. Using a VA formula, it’s estimated there are well over 100 homeless veterans in Duluth. There’s no easy answer to why there are so many homeless veterans, though 45 percent suffer from mental health problems and substance abuse.

“Some people develop alcohol abuse or dependence as they try to treat themselves,” said Dr. Ira Katz, the VA’s national chief consultant for mental health. “Then the two conditions together can lead to difficulties with work and social relationships that could lead, in turn, to unemployment, separation or divorce, and homelessness.”

NOTE: the Duluth paper is subscription only on the web, so you may have to register to find the link to the story.  The original title is, "Walking Wounded: Duluth Veteran's Life Shattered by PTSD."  The byline is Brandon Stahl.

PTSD and Alcohol Abuse

Alcohol is commonly used as "self-medication" by those who are suffering from combat trauma.  If nightmares where they're revisiting combat stress and combat scenes keep people awake, alcohol has traditionally been a way (not necessarily a constructive way, but certainly an easily accessable, socially acceptable one) to de-stress before sleep, and try to avoid the nightmares.  Unfortunately, of course, it usually doesn't work to improve things, and there can be a huge rebound effect; or, heavy drinking can cause other problems.  So at most it's a stop-gap solution, despite its popularity.  A fact sheet from the VA discusses alcohol use and PTSD.  Click here for the link.

Alcohol Abuse, Stress and Divorce

A recent article in the Stars and Stripes indicates that returning veterans struggle with alcohol abuse and experience divorce in greater numbers following their return from deployment.  (The article is linked from the National Gulf War Resource Center, Inc., whose website is here.)

Alcohol abuse can be an attempt at self-medication as well as an easily available, socially acceptable "sleep aid," since combat veterans often experience significant trouble falling asleep or staying asleep.  When alcohol consumption passes from "recreational" use to "medicinal" use, it's probably time to seek professional help.  Anything that can be done to improve sleep quality or length, without causing other problems, is also a great idea.  Experts are increasingly beginning to link quality of sleep to ability to withstand and recover from significant life stressors, such as PTSD symptoms.