PTSD: Light at the End of the Tunnel?

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Mental health problems and self-destructive behavior have always been difficult subjects to discuss, let alone diagnose and cure.   Since the 2008 Rand Corporation study on Post Traumatic Stress Disorder (“PTSD”) entitled Invisible Wounds of War:   Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery,  there has been growing preoccupation with the high incidence of psychological disorders affecting military men and women serving in Iraq and Afghanistan.  According to the Rand study, it is estimated that one in five veterans suffers from some form of mental disorder.

In February of this year,  Mental Health America (“MHA”) hosted a proof-of-concept conference consisting of 35 experts to help achieve the following goal:

By September 11, 2011, all­ active duty, retired, or separated National Guard, and Reserve Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF; Iraq) veterans, and their dependents, will have access to unlimited, free mental health counseling which meets an established nationwide standard for military-specific, trauma-informed care.

While this goal is still far from being realized, the MHA conference had what we consider to be the finest assessment of the current difficulties we have in dealing with this growing epidemic.  Because of it relevance to providing our brave warriors with access to the best treatment for PTSD, we are quoting MHA’s Key Discussion Points in their entirety.

MHA’s Key Discussion Points

  • Little has changed in the three years since the 2008 RAND study.  Approximately 18.5% of deployed personnel will experience PTSD or depression.
  • The group concurred that there are currently several significant barriers to care for military family members facing mental health challenges:
  • Lack of awareness of existing programs
    • Personal shame or embarrassment (internal stigma)
    • Organizational discrimination (external stigma)
    • Cost
    • Bureaucratic, burdensome process
    • Availability of trained expertise
    • Quality of care
    • Accessibility (phone, online, face-to-face)
    • Friendliness of initial contact
  • Passive programs whereby the military member is required to find the program and take a series of steps to receive benefits from the program are probably not adequate to fully meet the need.  Several group members felt strongly that programs needed to assertively reach out to military families to offer help.
  • One participant cited recent studies that indicate that, contrary to common belief, suicides appear to have no statistically significant correlation to deployments but occur evenly throughout the current worldwide,U.S. military population.
  • The most effective current programs empower the client to define precisely what help s/he needs and place the client in contact with “culturally competent” advisers/counselors.  There are many programs offering services that are inappropriate for the unique mental health needs of military service members and their families.
  • To have significant impact and to reach the target population effectively, programs must ensure that their representatives are “culturally competent”, that is, sufficiently familiar with the military culture to quickly establish a bond of shared life experience with the individual asking for help.
  • National efforts should focus not on developing new programs but on creating systems which lead those in need to effective existing programs.  This will require a nationwide, single-message marketing effort and a “navigator” function whereby a trained expert partners with a client to connect them with the best and most appropriate programs available within their community.
  • The availability of confidential care—within the legal constraints that mandate reporting potentially harmful behavior—is essential.  Our society in general and the military culture in particular, will not eliminate the stigma associated with mental health issues in the foreseeable future.  Thatsaid, the American public is now probably more receptive to the need for integrated care than ever before as a result of the wars in Iraq/Afghanistan.
  • Counseling must be evidence-based.  There was general consensus at the conference that the scientific community knows how to treat posttraumatic stress and its co-morbid conditions such as depression, substance abuse, etc.
  • Several in the group highlighted the need for a “navigator” to lead a military service member or family member through the maze of available resources in their communities and link that client with those programs.
  • Counselors should, whenever possible, be trauma-informed.
  • Any solution must serve military service members and their families not located within a military community or near a Department of Defense (DoD) or Department of Veterans Affairs (VA) treatment facility.
  • Community programs and services that are currently offering help must be consumer ratable in order to begin to establish a “gold standard” of care and to identify those programs that are working and those that are not.
  • There was unanimous consensus within the group that peer counseling works to establish a bond with the service person and enhance engagement, and that it should be a part of any comprehensive solution.  Specific features of an effective peer counseling network include:
    • Process to properly screen peer counselor applicants
    • Peers should be paid for their services
    • Peer specialists who are culturally competent
    • Peer specialists who are trauma-informed
    • Continuity; a sustained, trusting relationship with the client
    • Direct, clinical peer supervision and support
    • Systemic indicators to identify “compassion fatigue” among the peer counseling network
    • Near permanent client/peer assignment
    • Casual, relaxed atmosphere
    • Formal peer training and certification
    • Precise job descriptions
    • Ideally, phone or face-to-face counseling only, with an emphasis on face-to-face counseling

SFTT will be devoting an increasing percentage of its attention and resources on helping our brave warriors and their families to deal with the crippling effects of PTSD.  It is important to note that the consensus among the MHA experts that attended this conference is that “National efforts should focus not on developing new programs but on creating systems which lead those in need to effective existing programs.”   This panel of experts argues that we have the necessary resources to deal with the problem and help these brave warriors, but that we need “to establish a ‘gold standard’ of care and to identify those programs that are working and those that are not.”

SFTT is committed to that effort and over the next several months will begin unrolling a national resource center to our brave warriors find the support they need and, most importantly, deserve!

If you would like to help, consider becoming a member of SFTT.

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PTSD: A Needs Assessment of New York State Veterans

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Editors  Terry L. Schell and Terri Tanielian  of the Rand Corporation have recently issued a Technical Report for the New York State Health Foundation which chronicles some of the mental health challenges faced by returning veterans in New York State.  “The study found substantial elevated rates of post-traumatic stress disorder (PTSD) and major depression among veterans. ”  The Technical Report to the New York State Health Foundation from the Rand Corporation may be read online (or downloaded).  A report  summary is provided below.

“Mental health disorders and other types of impairments resulting from deployment experiences are beginning to emerge, but fundamental gaps remain in our knowledge about the needs of veterans returning from Iraq and Afghanistan, the services available to meet those needs, and the experiences of veterans who have tried to use these services. The current study focuses directly on the veterans living in New York state; it includes veterans who currently use U.S. Department of Veterans Affairs (VA) services as well as those who do not; and it looks at needs across a broad range of domains. The authors collected information and advice from a series of qualitative interviews with veterans of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) residing in New York, as well as their family members. In addition, they conducted a quantitative assessment of the needs of veterans and their spouses from a sample that is broadly representative of OEF/OIF veterans in New York state. Finally, they conducted a review the services currently available in New York state for veterans. The study found substantially elevated rates of post-traumatic stress disorder (PTSD) and major depression among veterans. It also found that both VA and non-VA services are critically important for addressing veterans’ needs, and that the health care systems that serve veterans are extremely complicated. Addressing veterans’ mental health needs will require a multipronged approach: reducing barriers to seeking treatment; improving the sustainment of, or adherence to, treatment; and improving the quality of the services being delivered. Finally, veterans have other serious needs besides mental health care and would benefit from a broad range of services.”

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Two disturbing stories focus attention on plight of military veterans

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Two disturbing stories were recently published by the New York Times which draw attention to the tragic plight of military veterans whose lives and those of loved ones have been severely affected by combat stress disorders, commonly referred to as PTSD.    While one hopes and prays that our brave heroes will soon return home from deployment in Afghanistan and Iraq, it is almost certain that – left untreated – the stress of combat will eventually manifest itself in ways that are harmful to our veterans, their loved ones and our communities.  Can we allow that to happen?  What should be done to make sure our veterans receive prompt and adequate treatment for PTSD?

The first article is by Lawrence Downes entitled “The V.A. Tries to Get Beyond Its Culture of No” which chronicles efforts a “small wing” of a Veteran’s Administration hospital inCanandaigua, N.Y. to help military veterans in crisis.  At this hospital, a staff of about 120 runs a national phone and Internet chat service for veterans in crisis.

The pleas for help come from everywhere.  According to the article, “one Vietnam veteran has struggled with survivor’s guilt for 43 years. Another has lost his job and his marriage, and agrees to try V.A.-sponsored therapy, ‘if it will stop these dreams.’”  The counselors, who field these calls, “aren’t therapists or case managers; they just tell people where and how to get care and then follow up if they can. They can’t always know if a person really is in crisis or is even a veteran.”

Mr. Downes claims that “there are now two million veterans of the wars in Iraq and Afghanistan, a small but growing portion of the total veteran population of 23 million. Not all saw combat; not all bear physical or psychological scars. Those who do pose a challenge this nation is only beginning to confront.”  Indeed, many assume that wars end when a truce is declared.  Unfortunately, the effects of these conflicts will be with many of our veterans for years.

It would appear that the Veterans Administration is totally unprepared or, perhaps, overwehlmed by the needs of our veterans.  The article cites a federal court who recently “blisteringly criticized the V.A. for ‘unchecked incompetence’ in failing to provide mental health care to veterans. The judges cited backlogs of hundreds of thousands of benefits claims and the lack of suicide-prevention experts in hundreds of outpatient clinics. Veterans can wait months for treatment and years to have their disability claims processed.”

The second story is from Erica Goode entitled “Coming Together to Fight for a Troubled Veteran,” chronicles the heart-breaking story of 36-year old veteran Staff Sgt. Brad Eifert who apparently tried to commit suicide by firing on police officers.  A compassionate judge, tireless lawyer and inspired prosecutor agreed that untreated combat stress disorder or PTSD had probaly triggered this hostile and dangerous behavior.   I encourage SFTT readers to read  Erica Goode’s excellent article since only a few of the more relevant points are highlighted since it involves great cooperation from a number of people to give Brad Eifert a “fighting chance.”

According to the article, “In daring the police to kill him, Mr. Eifert, who had served in Iraq and was working as an Army recruiter, joined an increasing number of deployed veterans who, after returning home, plunge into a downward spiral, propelled by post-traumatic stress disorder or other emotional problems.   Mr. Eifert’s behavior is not uncommon with others who suffer from PTSD and “their descent is chronicled in suicide attempts or destructive actions brings them into conflict with the law — drunken driving, bar fights, domestic violence and, in extreme instances, armed confrontations with the police of the kind that are known as ‘suicide by cop.’”

While Mr.Eifert could have ended up in a jail with a long prison term or worse, an enlightened judicial process and law enforcement experts seemed to agree that  “when a veteran’s criminal actions appear to stem from the stresses of war, a better solution than traditional prosecution and punishment is called for. The society that trained them and sent them into harm’s way, they say, bears some responsibility for their rehabilitation. And they point to other exceptions in the legal system like diversion programs for drug offenders and the mentally ill.”

“’I don’t interpret it as excusing behavior, but as addressing what the behavior is,’ said Judge Robert T. Russell Jr. of Buffalo City Court, who founded the first special court for veterans there in 2008. It can provide an alternative to punishment, mandating treatment and close supervision and holding them to strict requirements.’The benefit is, you increase public safety, you don’t have a person reoffending and, hopefully, that person can become functioning and not suffer the invisible wounds of war,’ Judge Russell said.”

Another person who took a strong interest in Mr. Eifer’s situation was Judge Jordon, the son of a World War II pilot, who is passionate about veterans’ issues, an ardent fan of “Achilles in Vietnam,” Jonathan Shay’s book on combat trauma. After hearing about the veteran’s court in Buffalo, he started a similar one in East Lansing. The court, which meets twice a month, not only gets veterans into treatment, it also provides them a mentor who is also a military veteran. The veterans have a chance to avoid jail by meeting a set of rigorous criteria.

Mr. Eifert’s case, Judge Jordon said, was “at the core of anyone’s concept of a treatment court.”

On Aug. 2, Mr. Eifert, having pleaded guilty to a single charge of carrying a weapon with unlawful intent, a felony, will officially enter the veterans court program. He separated from the Army on June 9. Twelve to 18 months from now, if he adheres to the strict regimen of treatment through the Veterans Affairs hospital in Battle Creek and supervision set by the court, the charge could be dismissed or reduced to a misdemeanor.

Brad Eifert  “is at home now, with his wife and stepchildren, slowly learning to cope more constructively with his problems. He has abstained from drinking since his arrest — he wears a monitor on his ankle that records any alcohol he consumes. He is working part time at a family farm. He has ups and downs, but on most days, he sees some possibility of a future.”  “’We’re a long way from this being over,’ said Sgt. Maj. David Dunckel, the mentor assigned to Mr. Eifert by the veteran’s court, who keeps a close eye on him. ‘There is some resolution to his legal problems, but the demons that haunt him are still pretty deeply embedded.’”

“Still, Sergeant Major Dunckel said, ‘I’ll put my money on Brad getting through this O.K.’”

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PTSD: The Unintended Consequence of War

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Almost daily, we receive reports of the devastating impact of PTSD (Post Traumatic Stress Disorder) on our men and women in uniform and the terrible side-effects on their families and friends.   The US Army is aware of the terrible cost of PTSD as evidenced by the 2010 US Army Report on Health Promotion, Risk Reduction and Suicide Prevention.

Many publications suggest that the origins of PTSD are unknown as evidenced by this recent commentary from a government organization: 

“The cause of PTSD is unknown, but psychological, genetic, physical, and social factors are involved. PTSD changes the body’s response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters). Having been exposed to trauma in the past may increase the risk of PTSD.”

While this may be true, there does appears to be a clear linkage between PTSD and the effects of increasing IED (improvised explosive devices) attacks on US and Allied military forces serving in Afghanistan.   While many believe that PTSD is a psychosomatic discorder, it is becoming increasingly clear that concussion-like head injuries are contributing to PTSD and its debilitating physical and mental consequences.    The US Department of Veteran Affairs estimates that between 11% and 20% of veterans who have served in Iraq and Afghanistan may have PTSD.   If so, this is an alarming number – almost of epidemic proportions.

SFTT has long argued that ill-fitting military combat helmets afforded little protection to our men and women in uniform.  The US Army has been painfully aware of this problem for sometime as evidenced by their decision some years ago to implant sensors in helmets to track trauma related injuries.    Recently, we have been told that a “simple tweak” in the amount of padding in combat helmets would reduce head trauma injuries by 24%.    Why did it take so long to realize we had a serious problem?  More importantly, how long will it take our procurement process to get better protective gear to our troops in the field.

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