Aftermath - A War of Memories

PTSD in HAITI

Perhaps this physical and emotional catastrophe of unimaginable proportions will help the civilized world understand that the traumatic events which cause emotional stress is not a “Disorder” at all. Acute Traumatic Stress, or Post Traumatic Stress, PTSD as it is known today, are conventions of diagnoses that describe symptoms of the natural outcome of exposure to devastation, fright, helplessness, confusion, and the inability of the subjected human to find its equilibrium of body, soul, and mind. Immobilized or frenetic, scattered thoughts run amok and only later refocus until “natural” emotional defenses, our learned and instinctive automatic defenses, take over to provide a clearer direction back from the confusion or apathy. Emotional defenses will be created both consciously and unconsciously to help the afflicted deny, make surreal or mythical, the reality of the trauma so as to lessen the impact or emotional toll on the individual involved in the catastrophic life event. There is no “Disorder” in the symptoms one may experience as a result of catastrophic trauma here. Any symptoms that develop following an emotional insult of this magnitude is part of a automatic process of defensive emotional maneuvering designed to restore the body to its former integrity. It is the process that makes reality, the emotional pain, go away in order to survive. Nothing but death makes reality go away. That is why suicide appeals to some combat soldiers that are unable to overcome certain realities and choose to end their suffering. The reality of a catastrophic event, a holocaust, never actually goes away unless erased by historians. Only the feelings associated with the traumatic event is able to be modified, attenuated, or mollified as memories. Reality needs always to be a reality. Treatment therefore must be administered as an art form that imparts the ability, to the victim of emotional trauma, to find a way to live in harmony between the objective reality of events and subjective passion of ones emotions. Treatment therefore must require that a purging of the buried painful emotional feelings and recollections have a means of expression. It is necessary for a catharsis to be laden with thoughts, expressed in words, and their dreaded consonant feelings. A supportive and understanding human to be there to listen and encourage the egress of the traumatic emotional experience that is stored, partly hidden from consciousness, is all that is needed. Healing is not the province alone of the medical profession. Mothers do it every day! PTSD belongs in the category of non psychiatric disease or disorder. It is a human condition; a natural outcome of exposure to a catastrophic event for the individual or group of people. If you walk away unscathed by the experience of being buried alive under the rabble of an earthquake, or having a building collapse pinning you under your dead buddy in Ramadi, or calling in air strikes that never arrive at the Iron Triangle while your squad is being decimated in Vietnam, you were never there. Yes, medication has its place in the grand scheme of things given for symptom relief until a real emotional therapy can happen. Medication is not the only treatment for Acute Traumatic Stress. We need people who care to be in Haiti to attend to the emotional wounds that need to find expression, verbal and emotional expression together; not an intellectual expression recounting the events. Expression of thoughts and feelings is necessary so that a catharsis can occur to afford momentary emotional decompression. And with some further encouragement just possibly the spontaneous coming together into expression the suppressed thoughts and forbidden feelings of the very traumatic event itself would be released (abreaction). The healing would begin from that point on with successive expressions of thought and feeling so that the delicate equilibrium between thought (objective reality) and feeling (emotional response) find harmony from chaos and conflict over time.

REFLECTIONS ON PTSD: THE ROAD TO FT. HOOD

I have been involved with the psychiatric treatment of combat veterans for over 40 years now. It was the tragedy at Ft. Hood that compelled me to express some realities that capture the moment for me. In March, 1968, I entered the Bethesda Naval Medical Center to begin my residency training in psychiatry. It happened that Tet was announced in Vietnam. The air evacuation of casualties had begun from the theaters of combat in Nam. My first patient still smelled from Napalm, fresh off the C-147. I expected to experience a first patient as someone that was having marital problems or was obsessed with a movie star. This never happened. I was met with the rude awakening that some guy was going to talk about death and dying and I had to pry every last word out of his mouth. There was no expectation that following World War II or Korea that battle fatigue or shell shock existed and there was a way to treat it besides R&R. Yes, my mentor was Harold F. Searles, M.D. His insights enabled me to understand combat stress. He understood schizophrenia and I understood the combat veteran in all his disguises. I became creative and designed the first treatment approach to traumatic neurosis at Bethesda Naval Hospital in 1968. I extracted a pound of emotional pus from a group of newly arrived Marines who sat in a group with me for two hours every other day for several months. They had group catharsis and abreactions until they stopped having the symptoms that are now known as PTSD by everyone in the civilized world. When a Chaplain, Capt/USN, asked to observe one of the therapy groups I obliged. After about ½ hour of his sitting there in his dress whites he abruptly ran out clutching a laundered handkerchief to his mouth. I knew I had accomplished my goal with the 14 combat veterans and corpsman seated in that group therapy circle. It was possible to get the suppressed and repressed emotional feelings and thoughts of those combat scenes verbally expressed in a supportive atmosphere of camaraderie with Marines of similar traumatic exposures. As the emotions and thoughts that accompanied the experience of the veteran spewed out the symptoms: fear, numbness, night mares gradually abated in the veterans of the enlisted unit. I learned in later years that this acute phase of trauma was easier to treat because the symptoms were still raw and accessible to retrieval and expression. In 1984 I was recruited to develop programs in PTSD to treat veterans at the Lyons, VAMC in New Jersey. There were no established programs specifically for the combat veteran, The usual individual counseling, group therapy, and medication treatment was the order of the day. Emphasis on issues such as pension, compensation, alcoholism, and drug addiction were the topics of the day. Agent Orange was gathering attention as many Vietnam veterans complained of undiagnosed illnesses and birth defects in their children. The VA system was understaffed at the hospital and there was no way to make any changes to implement a program for the treatment of PTSD. Administrative meeting were called on a daily basis to address problems of drinking and violations of the hospital rules. Veterans acted out their disgruntlements concerning their service in Vietnam, the treatment of their return home without welcome, unemployment and conflicts with the world in general. They were attention seeking at every turn and had no way to voice the collective group experience of combat 10 years after Nam. The administration was pitted against the veteran, the enemy. Few of the staff members were advocates of the Vietnam veteran as they were seen as trouble. There was no compassion for the families of the veterans who suffered as much. There were no resources to treat and limited the motivation to go beyond the burden of every day employment to reach out. When the official designation of traumatic stress or neurosis became PTSD some physicians refused to acknowledge the condition and continued the tradition of viewing the combat veteran as alcoholic, drug addicted, or pension seeking malingerer. The discovery of HIV complicated the treatment picture for veterans that year. It was pretty difficult to treat a single combat veteran that may have suffered PTSD let alone one that had alcoholism, drug addiction, and AIDS all in the same person. The development of a program for PTSD was problematic as to what constituted therapy. It all had to be done as a comprehensive program lest the veteran be divided into 4 parts having to give a piece to one therapist then to another and so forth. Next came the problem of staffing. There was not enough staff to have a program and the budget earmarked for the program never arrived. The hospital administration was insensitive to the problems of the veterans. When the vets became more vociferous about their needs in a newly compassionate milieu the administration retaliated harshly. The staff that was dedicated to the mission of care were intimidated and harassed by the administration that wanted no part of these outrageous veterans. The veterans went out on strike to protest the lack of care and abusive treatment they received over the past 10 years. Professional staff members quit or were forced to retire leaving another void for the veterans. Whistleblowers were treated even more harshly for being advocates of the veterans and being a threat to the System. The proposed PTSD program was disbanded about a year later. Twenty-four years later, in 2008, I was interested in learning how the combat veterans of Iraq and Afghanistan were being treated for PTSD. My first call went to Ft. Bragg where I was told that there was no PTSD treatment there at the base. The cases were sent to the Veterans Administration where programs were supposed to exist. Yet, as it was for the Vietnam combat casualties, there was no psychological exit strategy, no philosophy of treatment for PTSD or comprehensive programs in the military. These soldiers would return to the home base from the theater of combat unlike the Vietnam experience where they flew into California and found their way home in a hostile land, America. The emergence of Cognitive Behavior Therapy, Eye Movement Desensitization Reprocessing, computer simulated warfare exposure therapy, Seroquel, and other pharmaceutical products reflect the lack of consensus, therapeutic understanding, philosophy, and varied styles of treatment. And, still the casualties mount after the return to base with suicides predominating. The emergence of the use of questionnaires to triage for PTSD and Suicidal behavior was testimony that there was insufficient staffing or expertise to treat the numbers affected by PTSD or symptom complexes that were even more deadly to individuals and society. There were no lessons learned from the Vietnam experience. Overwhelmed by the sheer number of those affected by TBI and PTSD, the military retreated to the position that these assets were not going to return to active duty so they were expendable. The military bases did not have the manpower to devote to treating combat veterans en mass. Those cases that needed hospitalization for grave symptoms were placed in the reassignment unit awaiting medical boards for discharge from the military. Other emotional casualties of the war were redeployed a second or third time. Others were retained in a holding unit in uniform pending discharge from the military. The burden of treatment for these combat veterans fell on the weak shoulders of the Veterans Administration or other places that had little or no hands on experience in understanding what was required. The Seroquel shuffle became evident and quickly replaced Thorazine of the Korea and Vietnam Eras. The Veterans Administration Medical Center (VAMC) continued to experience recruitment problems for psychiatrists that had an understanding of PTSD treatment. The ranks of pill-throwing healers swelled as the expedient way to treat symptoms without grasping the underlying dynamic of PTSD. The hand off of veterans from the military to the VAMC was unconscionable and wrong. The VA system was as inadequate and corrupt in the Gen. Shinseki era as it was in 1983. The scandal ridden Veterans Administration was a worthless tool that did more damage than good by setting the standard of care very low. The DVA served best to facilitate pensions and benefits, and it did that poorly too. The National Center for PTSD, underlings to the Veterans Administration, was another failure in recommending a list of sanctioned approaches for the treatment of PTSD without considering the effectiveness, cost of implementing these therapies to large numbers of veterans, or the abilities of the health care providers themselves. Treatment without an understanding of the dynamic formulation in traumatic neurosis*, based on psychoanalytic precepts, would never work in the military or Veteran Administration hospital. *(nosology before PTSD, circa1983). Regarding the Ft. Hood Army base massacre and the psychiatrist that allegedly treated PTSD. A trained psychiatrist learns early in his career about transference issues in treating patients provided his training included psychoanalytic technique or a personal analysis. To avoid transference isssues, i.e. to deal appropriately with one’s own feelings and thoughts toward the patient, counter transference; and not be swept away by the cause or plight of the patient, or his thoughts and feelings about the psychiatrist, requires a neutral distance be taken by the therapist. Identification with the veteran’s cause e.g. death to the infidels, is an issue that a psychiatrist must consider if he himself is Muslim. He must recuse himself if he cannot be objective or identify personal bias, as would a judge in a case broaching conflict of interest. If the basic underlying philosophy of the psychiatrist reflects a negative expression toward the patient, or group he represents, the psychiatrist must evaluate that bias. This doctor had no apparent conflict with the religious mantra or he would have walked away, not treating the patient. To invoke PTSD as the cause of this outrageous act is ludicrous. Hearing the accounts of tragedy on the battle field is the job of a psychiatrist in the military. If the therapeutic distance was lost by the psychiatrist, or the margins were blurred between patient and personal boundary, he was no psychiatrist to begin with. He was an impostor. He may try to excuse his behavior with a plea of dissociation reaction from overwhelming stress of listening to horrific tales of war and atrocities, but then again that was his job to listen. He was never the direct subject of any traumatic event. By that reasoning we are all secondary victims of “media terror.” The only stress that would be evident is the conflict of anti-American sentiment and the psychiatrist’s Islamic roots. His post traumatic stress must have been the witnessing of anti-Islamic expressions coming from combat veterans who voiced in confidence their hatred of the enemy, combatants who killed in the name of Allah and Jihad. These voices echoed an enmity that emboldened this coward to act upon his true feelings and beliefs.

Respectfully submitted,
Ronald M. Chase, M.D.
Author, “Aftermath A War Of Memories” Amazon.com
Tavares, Florida
9172085366