Tuesday, June 18, 2013

PTSD: it's not what you think it is

I really don't know what PTSD is.  Nor do I know what is PTSD.  I know the definition, what the DSM says, but that definition seems way too small to me, inadequately capturing the full human experience.  Most of the "symptoms" described in the DSM are either expectable adaptive response to dangerous conditions and/or conditioned emotional responses.*   The DSM's purpose is to define a disorder, but I can find no basis for distinguishing a normal response to horrific events from a "disorder."  How much is "too" much of a response, too big an effect?  Who's to say?  If I imagine a mother seeing her dearly beloved child hit by a car, how long "should" it be before any thought, any reminder of her child will not bring up the image in her mind and a flood of tears?  Years later, when she comes across a toy in the attic, might she not break down in sobs again?  If so, does that mean she's suffering from a disorder?

I recently read a review of the book Wave by Sonali Deraniyagala. The book describes her experiences subsequent to loosing both her parents, her husband, and her two children to the Indonesian tsunami. She, as she said, "lost my world."  When I thought about that, I thought she was exactly right.  Doesn't our world, the world we really live in, consist of the web of primary relationships in our lives?  That's the meaningful world, the world that concerns us.  My connection to everything else is much more tenuous and abstract.  What's the right response to loosing a world?  She tried to kill herself several times, drank as much alcohol as she could get, did nothing "productive" for years.  Any inclination I have to judge her response, call it too much, "pathology," is instantly tempered by my own knowledge that in her situation, I have no confidence at all that I would do anything in any way substantially different.  I know I certainly couldn't guarantee it even though I see my writing this blog as demonstrating some level of resiliency.  The only way I can imagine one makes such a judgement is to perform some sort of disconnect from one's own fears and knowledge about one's self.

Categorizing a person's response to combat or other horrific life events in terms of a set of "abnormal" symptoms is insane.  It seems to me to resemble nothing so much as whistling in the dark.  We are all faced daily, by the possibility of tragedy, horror, and loss.  Each time we get in a car, or our loved ones do, some part of us is more or less aware of our vulnerability.  Do you track your loved ones' flights?  As a parent, are you a little anxious when your children, even though adults, embark on a long drive?  The reality of sudden, "unexpected" death is all around us.  We all need, and find, ways of dealing with the fear of sudden, catastrophic loss, this reality stirs.  One way of lessening our fear is, I believe, to say to ourselves: "Those people who are still suffering?  They're different, got a disorder."  Implied is "I wouldn't be like them."  Really?  Are you sure?

I think it is arrogant on our parts to imagine we can define what is a normal or abnormal response to what is essentially a personal existential crisis.  What will a soldier decide to do about all she/he has seen and done?  They have seen how the animal drive to survive obliterates all man-made ethics, laws, morals.  They have seen human beings, who they may well have believed to be made in the image of God, engage in wanton butchery.  They may have done the same and tasted a blood-lust in them which, being so foreign to our conception of ourselves, they cannot/will not acknowledge.  They have experienced our essential, undeniable vulnerability and meat-like existence; that a little blob of metal can reduce to non-existence, obliterating everything.  They know that we, too, live in a dog eat dog world.

They have seen that which everyone has told them were inviolate, first principles of our social order betrayed like so much dust. Things like duty, honor, trust, loyalty, decency, basic humanity. They may have done things that violated there most deeply held and cherished values and believe there is no real possibility of redemption or forgiveness.  These are some of the real issues combat veterans struggle with and then they come back to a world that refuses to know much of this.  A society that, all too often, makes them either cardboard heroes, demonic "baby killers," or passive victims of a malevolent government and, at best, offers them a disorder as a way of understanding all they are going through.

So since I have no idea what the "proper" or normal response to all this is or should be, I can't imagine defining some responses as a disorder and others not.  I don't know what is PTSD: what response is a disorder, abnormal, too much, "pathology."  So because I don't know what is PTSD, I don't know what PTSD is and neither, I believe, do you.

But even more importantly, what does it matter?  Are only the diagnosed entitled to help, care, concern, understanding, compassion?  Only those with a disorder should be held deserving?  Given the potential damage that the diagnosis of PTSD can do, as I have detailed in this blog, insisting on the absurd administrative requirement of a diagnosis before help is offered is nearly criminal.  EVERY combat veteran should have easily available opportunities to seek assistance on his or her own terms without the necessity of agreeing to be defined as having a disorder.  When we designed the program at Walter Reed we explicitly defined it as available to any combat vet "having difficulty re-adjusting to life in the US" with no mention of PTSD.  I refused to do a CAPS ** on prospective program candidates, believing to do so would increase the likelihood of them seeing themselves as "having" a disorder, rather than struggling to come to terms with their combat experience.  It was only because we stood "outside" of the normal military mental health system that we were able to do this and that reality was no small part, I believe, of what made our program effective.

So let's admit we don't know what PTSD is.  Let's admit we don't know how a person "should" cope with things we can barely imagine.  Let's stop the focus on "symptoms" and symptom relief.  Instead, let us, as individuals, therapist, and society, embrace the whole, struggling person in humble commitment to travel alongside.  I think it will improve the assistance we offer.  And probably us too.

* In the June 3, 2013 New Yorker article "In the Crosshairs" Jonathan Shay defines combat PTSD as "the persistence into civilian life, after danger, of the valid adaptations you made to stay alive when other people were trying to kill you."

** Clinician Administered PTSD Scale: the so called "gold standard" for PTSD diagnosis.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."

Thursday, May 9, 2013

Leadership and PTSD

When trying to understand who exhibits PTSD and who doesn't, we mostly consider just two variables: the degree of "the trauma" and any preexisting vulnerability.  But when considering the effects of combat, I suggest a third factor:  failure of leadership.

What does it take to get a normally self-preserving person to face deadly fire in combat?  To willfully approach an enemy intent on killing him/her?  An answer I came across but can't relocate said three things:  A belief in the justice of the cause, faith in the integrity of the officers, and trust in the fidelity of your fellow soldiers.  Of these, the second is the most important.

Officers make the strategic, operational, and tactical decisions that determine soldiers' destiny.  The decisions that put them in harms way, require enduring unendurable hardship, demand effort exceeding capability, and result in losses beyond bearing.  With such power comes commensurate responsibility.

I believe Eisenhower captured the full import of this responsibility in a single sentence:  "I believe the American soldier can endure almost anything as long as he knows his officers are looking out for him."  By "looking out for him" Ike doesn't mean tucking them in bed at night.  Nor does he mean just ensuring they have food, weapons, and training, although those are all a part of it.  What he means is that in every decision the officers make they are "looking out for," caring about, the lives of their soldiers.  And, most vitally, they decide how to conduct combat operations with a sole focus on doing what is necessary to achieve victory and doing it only because it is necessary, not for any other reason.  It is necessity that steels a soldier's will.   If any part of the officer's motivation is self preservation, self-promotion, a failure to exercise due diligence, or any other concern, the troops will know and morale will suffer.  In truth, soldiers have a huge tolerance for such failures; we all know we are all human.  But  it is also true that every person also has their limits and when that limit is exceeded, a seismic shift occurs.

Betrayal refers to "the breaking or violation of a presumptive contract."  A soldier signs a blank check.  S/he enters an opaque contract, putting his/her life in the hands of unknown, anonymous others.  Whenever any officer in the chain of command, commissioned or non-commissioned, up to and including the Commander in Chief, issues any order or command not based on military necessity he or she violates that contract and the soldier has the lived experience of betrayal: someone's failure to faithfully execute the duty to care (about my life.)  The person may feel treated as if their life has no value.

Almost without exception, every Service member I treated while at Walter Reed expressed some sense of betrayal.  He or she stated, not always explicitly but more or less clearly "I did what I was told to do and they didn't take care of me."  Who the "they" was and how specifically identified he/she was varied but their was always a someone who they felt had betrayed them.  Often, my task was to help them know and verbalize the exact injury done.  What, exactly, had happened.  Who had precisely what responsibility for what?  Who failed in their responsibilities and exactly how? Frequently many of the charges were against themselves and overstated while their characterization of the betrayal was most often understated.  A common line I came to use was "You're charging X with a misdemeanor but the behavior you've described is a major felony."

Such a betrayal is an intolerable diminishment.  It is unacceptable to anyone with any degree of pride and can be crushing to those with a less solid sense of self worth.  Ordinarily it stirs anger that demands action, some fight-back.  But in the military, the huge difference in power across the ranks may make this all but impossible.  A corporal has virtually no way to hold a colonel accountable.  "Having PTSD" offers a way.  The dysfunction of PTSD can be understood as a communication, a statement that says "See what their incompetent leadership did to me.  See the effects of their cowardice (or incompetence, uncaring, etc.)  This is what I suffered because of them."

I offer one story to illustrate.

I had already been treating veterans at Walter Reed for many years when this story begins.  A new group included two men from the same unit who immediately told of the poor leadership of their unit and its consequences.  But I experienced one of the two as unusually aware, and conscious of the subtleties and circumstances surrounding the story he was telling.  He seemed quite self-aware and told the story of his betrayal with a lighter touch, even a hint of irony that was uncommon.  Based on my assessment of his strength I made a mistake with him:  I invited his attention to his contribution to his present difficulties well before I should have.  He said nothing, but the next day the two returned to the group and announced their plans to become professional hitmen after they were released from active duty.  Hearing me as blaming them, they came back placing the blame firmly where they believed it lay.

I realized this indicated I had made a mistake but was not clear what to do about it.  Everything I tried to find some way to connect with them, understand them, confront them, yielded nothing.  They masterfully deflected my every move.  At some point I decided I had no choice but to abandoned them and try to limit the damage done to the rest of the group.  Undoubtedly they left the program feeling betrayed again and they were right.  Here, I was the "officer" who failed in my duty to understand and effectively engage them.

Only after the program was over and they had returned to their duty stations did I finally recognize the accurate emotional logic of their statement.  By going to the extreme, they were helping me see what I had missed earlier.  To this day I wish I had had the wisdom to say, sincerely, " Brilliant!  You've found the perfect way to speak the truth that can't be spoken.  To show how the criminal incompetence of your unit's leadership created a situation so horrible that it turned two decent country boys like you guys into soulless killers.  I can only hope the country hears you."

Betrayal is a bitter bill, toxic if swallowed but so hard to spit up.  The desire for revenge is as human as the desire for justice.  In addition to having to struggle with all the horrors of war, the killing, mayhem, and losses; in addition to having to struggle with one's own history and specific vulnerabilities to having old wounds reopened, in addition to all that, the combat veteran must also often struggle with his/her desire, and inability, to say to some other "Look what you did!  Take responsibility for the god-awful mess you made!"

Some will say I diminish the soldier by saying these things of those who are struggling with the effects of combat.  But I say I honor him/her, offering a vision of what they are doing that respects the meaning of what they have been through and are trying to do.  That acknowledges the need to express that which can't be said.  That this is their desperate attempt to speak truth to power.  And hopefully, by recognizing this, they may be able to find a less personally costly way of doing so.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."

Wednesday, May 1, 2013

Some Interesting Comparisons

                                             CARS          SCOOTERS             GUNS
Age limit to use                      16                  None                     None
License required                     Yes                 No                         No
Insurance required                  Yes                 No                         No
Training required                    Yes                 No                         No
Registration required              Yes                 No                         No
Lock included                          Yes                 No                         No
Marketed to children               No                 Yes                        Yes
Injuries per year                     2,300,000*       27,600****          70,000**
Deaths per year                      34,000***        2****                   32,000***

So we can regulate cars but not guns just because cars weren’t mentioned
in the Constitution?

Or is it that we regulate guns the same as scooters because they are
 equally dangerous?

For some thoughts on how to combat gun violence see my previous post.

* http://www.cdc.gov/Motorvehiclesafety/index.html
** http://en.wikipedia.org/wiki/Gun_violence_in_the_United_States
*** http://www.cdc.gov/nchs/fastats/injury.htm
**** http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4949a2.htm

Tuesday, April 30, 2013

Combating firearm violence

Responsible Gun Ownership and Combating Firearm Violence

Decreasing gun violence has become a primary concern for me.  As a combat veteran and gun owner, I am concerned about the rising level of gun violence in our society.  Nothing in me is willing to accept this level of carnage, terror, and pain.  The rest of the world shows us this level of killing is not necessary as a price for "freedom" or any rights.  The wholly-to-be-expected-public-concern about this, if it continues to be met by implacable opposition to even the most reasonable efforts to diminish the threat, may   threatens  Here are some thoughts on a strategy for promoting public safety.

1.  I think it is critical for those hoping to decrease gun violence to publicly support the right to firearms for home defense and hunting.  The ability and determination to protect one’s family and obtain food through one’s own efforts far predate both governments and society.  Indeed, it's probably true that society grew out of efforts to protect families.  Acknowledging this right also undercuts the major objection to most gun control measures.

2.  Relentlessly publicize the fact that any/every use of firearms carries the risk of unintended death or injury to innocent bystanders and/or the user.  Thus event the private use of a firearm in the home or outside it inherently creates a risk to PUBLIC safety.  This is the sole basis of efforts by gun control advocates to restrict the caliber, capacity, action, range, etc., of firearms used in home defense and hunting.  It is not a "slippery slope" to siezing all guns, just an attempt to protect us all from the unintended consequences of gun use.

3.  It is also important to publicize the fact that the mere possession of a firearm also creates a threat to public safety.  Because of its lethal power, it is desirable to persons other than the owner for purposes other than intended.  This again constitutes a threat to public safety and is the basis for regulations on how weapons are stored in the home, their design (safeties, etc.), and their traceability.  

Since a firearm is an inherently dangerous device, it should be stored appropriately to prevent unauthorized use and theft.  This is the obvious responsibility of every gun owner.  Unfortunately, the deaths of many toddlers who access guns is grim testimony to the fact that not all gun owners take their responsibilities seriously.  These failures, just like other failures of parenting, authorize public intervention into private matters.  Requiring "smart" guns is one obvious solution.  Gun owners' insurance would also be useful.

Once a firearm is stolen, it becomes a new threat to public safety.  Laws specifying storage, unauthorized use preventing features (smart guns), insurance, and reporting requirements are clearly in the public interest and do not infringe second amendment rights to possess firearms.
4.  We need to develop and publicize objective method of comparing the lethality of various weapons.  This could show how fundamentally different an assault rifle is from a breech-loading musket as well as from knives, etc. But more importantly, it would provide a rational basis for policy decisions on what we do and do not want think is appropriate weapons for different uses.  To state the obvious, a high power rifle useful for hunting big game is not useful for home defense.

I don’t know if a method of calculating lethality of a weapon exists, but I don’t see why it couldn’t be calculated.  For example, imagine a school room filled with manikins representing people.  How many of them could be “killed” in a set time, say 15 minutes, by someone using a knife?  A breech loader?  An assault weapon?  Gathering and using such data puts the arguments on weapons restrictions on a much firmer basis.  Even if absolute comparisons between kinds of weapons is not possible, it is surely possible to quantify relative differences in the lethality of firearms based on their caliber, muzzle velocity, rate of fire, action, projectile weight, etc.  This data could be used to devise standards for specifying acceptable and unacceptable firearms for home protection and hunting.

5.  Recognizing that any possession and/or use of a firearm creates a risk to public health frames the debate regarding concealed and open carry.  In the interest of public safety, concealed carry should be limited to those who have some justifiable need and who can demonstrate they

6. Fund research/advocacy/legal efforts to overturn the idea that “the need for a well regulated militia” constitutes a basis for owning military firearms AND justifies gun ownership to prevent government “tyranny.”  Such an effort is needed to counter the fact that this interpretation is in fact the result of a NRA supported effort to CREATE that interpretation.
Thoughts/comments in support of the above.
1.     Recognizing the right to own arms for specific purposes respects responsible gun ownership, alleviates their fears and makes it far more difficult to portray gun control advocates as “taking away our guns."
2.     Developing data showing the death/injury caused unintentionally by gun usage is absolutely vital.  Document all the injury resulting from accidental discharge, killing/wounding bystanders while hunting, engaged in home defense, firing on firing ranges, showing off, etc.  This is vitally important because this threat to public safety, my safety, our safety, is the sole legitimate basis for our restricting the characteristics of acceptable weapons for home defense and hunting.  It is the basis for prohibiting both 50 cal machine guns and assault weapons.
3.     Publicize all the death/injury caused by unauthorized/illegal/(not sure best word here) use of weapons, i.e., that caused by someone who used a firearm that they wouldn't have been able to obtain if weapons were stored in a manner consistent with their dangerousness.  Think of Sandy Hook:  If guns were required to be stored in an impeccably safe manner, had a user-only safety, or a GPS chip to disable it when removed by other than owner, etc. then many such tragedies could be avoided.  Publicize both owner and non-owner suicides, gun thefts (which puts lethal power in the hands of someone who obviously shouldn’t have it), and injuries/deaths caused by family members/others who used firearms they should not have had access to. Again, this is the fundamental basis for regulations designed to ensure the public safety from this device with extraordinary power by requiring firearms to be safely stored and used.

4.  We must continually highlight how many crimes are committed with illegal firearm, whether bought illegally, or bought legally but transported to places they are illegal, or bought with sham purchasers, or sold by gun stores in violation of state and/or federal law.  At present, efforts to stem the flow of such weapons is hampered by multiple difficulties such as limitations on gun store record keeping, interstate differences in laws, lack of gun registries, etc.