JS: There are tens of thousands of American men and women who have served in Iraq or Afghanistan, many of whom are finding it difficult to adjust to life back home, particularly life outside the military. Yet spending time in a war zone, and especially in combat, would obviously be stressful for most people. So, how can a veteran who is having trouble adjusting tell whether what he or she is going through is perfectly normal—part of a natural process—or whether they may need to seek help?
FO: Well, it helps to understand this diagnosis. You call it PTSD when the symptoms last more than a month and interfere significantly with life. The PTSD diagnosis certainly isn’t the totality of the adjustment problem faced by soldiers, marines, and combatants who are returning from Iraq and Afghanistan. If you are one of them, or you’re somebody who loves and cares about one of those men and women who are returning, you should know that this syndrome is quite common.
And unfortunately, it is still a source of stigma and shame. The young men I’m dealing with right now, who have returned from Iraq wounded and with PTSD, do not like to talk about this. They make it very clear to me that they do not believe this is the subject for conversation with parents, friends, or marital partners. So, what we’re doing now in explaining it is important for adjusting to civilian life.
We’ll go on in our conversation to talk a bit more about why this happens and what its significance is, but I just want to make the point that not everybody who’s been exposed to trauma in a military setting comes back with post-traumatic stress disorder. It depends on how close you were. It depends on what happened. But I would say that if you’ve been in combat and you’ve been there when a comrade was killed, the percentage of PTSD climbs over 25%. It gets closer to 50% being in a war zone.
JS: If someone feels that they’re possibly dealing with post-traumatic stress disorder rather than the sort of stress response that’s at the milder end of the spectrum, what should they do?
FO: This is a very important point. As I mentioned, there is a difference between post-traumatic stress and general stress. All of us encounter general stress: we’ve got too much on our plate; we’re worried about something; somebody who we care about hasn’t treated us too well. We’re ruffled; we don’t sleep that well that night; we can’t concentrate. It’s hard if you have a difficult job or a lot of responsibility in your life. Just being a parent is a lot of responsibility! In fact, having friends and keeping friends requires being in a good frame of mind. So, all of us know what it’s like, from time-to-time, to be hassled, to be irritated. Sometimes we say, well, we got out of bed on the wrong side. You guys down in New Zealand are always getting out of bed on the wrong side!
One of the things that happens when you’re stressed is that you lose your sense of humor. So, you’re lacking some of the things that keep you feeling good about life and good about yourself. Traumatic stress is something else. It means that if you’re coming back from the theater of war, most likely several times a week you’re back there, seeing things, smelling things, hearing things you don’t want to hear. And sometimes you feel you’re going crazy. You don’t necessarily know the difference between this condition—PTSD—and having a psychosis or being diagnosable with a different major mental illness that can be progressive. So, it’s good to know what PTSD is and to know what it isn’t. PTSD actually has a relatively good prognosis.
JS: How serious can PTSD become? What are the potential consequences for a veteran’s physical and psychological health if PTSD remains undiagnosed or a veteran refuses help?
FO: Right now the most serious problem is suicide. We are seeing a frightening amount of suicide in veterans – people who have been selected for their physical and mental fitness; who have served honorably, and who are having a terribly difficult time adjusting to a lot of things, not just to PTSD. We’re still doing research on the correlation of PTSD and suicide attempts, and PTSD and completed suicides. But we do know that that’s the most tragic of the outcomes, and I think that the higher suicide rate has got to be related to the conditions of re-deployment; to the difficulty of adjusting both to civilian life and to moving back to military engagement for the second, third or fourth time.
There is a lot of controversy about this. In some analyses it looks as though the suicides are occurring not after a fourth or fifth deployment but after the first or second. But that may be related to the pool of people who are being chosen and are being deployed now. There’s a lot more we need to learn about why we’re seeing the psychiatric disability rates we’re seeing in this era of American combat.
But PTSD untreated is a condition in which a person is suffering. They’re having nightmares; they’re having flashbacks. They’re having difficulty feeling like a whole human being, and because of the anxiety cluster they’re easily irritated, and they can be hostile and combative. So, the flip side of the greatest danger, of suicide, is being dangerous to others or being inhumane to others.
JS: You’re talking about domestic violence, as well as violence in general?
FO: Yes, I am. I’m very concerned about helping some marines I’m working closely with. They’ll be making the transition from being physically wounded combat marines who’ve seen their fellow marines killed in front of them, to being students and to getting on with worthwhile careers. I have a lot of faith in these men. I like them. There are two of them in particular—I sometimes meet with them one at a time, sometimes with the two of them together. They have a strong bond with one another. They’re both getting out of the service now. One will become a law enforcement officer; I’m not sure what the other will become, but they both have to go to school. Going to school means dealing with students, and these students can say things which can trigger a very hostile feeling in these two patients. I understand that. We talk about it. We try, in various ways, to smooth out and ease the transition from military life to civilian life.
Neither of these marines poses a threat to their domestic partners. They are more likely to over-react to civilians who accost their partners in public. But many returning veterans have difficulty controlling anger and, unfortunately, the spouse can be the target of easily triggered rage. Working with couples to mitigate arguments, to prevent easy access to lethal weapons, to avoid tragic flashbacks and dissociative states in which a partner is confused with an enemy, become objectives in therapy for couples who are at risk of post-deployment domestic violence.
JS: Your mention of the strong bond between your two marines reminds me of something a marine officer in Iraq told me: that there’s no greater love than that between one marine and another. That when you’re in combat all you’ve got is the guy on your right and the guy on your left—that’s your world. That bond is often weakened when a marine (or a soldier) returns to the US, leaves the service, and is set free in a civilian world where, for want of a better word, there’s a lot of alienation; where there are a lot of people who don’t necessarily share a belief in the mission that those marines or soldiers were committed to, and can make comments that might shock or appall a veteran. How do they cope with that? How can veterans deal with that in a healthy way?
FO: I’m so glad we’re talking about this. I think there are a lot of people who think they know what we are talking about. But it’s one thing to appreciate intellectually the challenges that many veterans face, and another to be right there in the room with them as they share them. I guess I feel privileged to have gained a sense of these veterans’ experiences, and, in a way, the bond that exists between them.
In order to help these guys I have to write letters for them. I have to introduce them to professors, to lawyers, to other veterans who know how to deal with the Veterans’ Administration system to get the benefits they deserve. Let’s stick with the marines, because they’re on my mind right now. A lot of these people who are returning have rights: rights to disability payments, to payments for medical and mental health care, to education—rights that they often have to fight for. They’re not easily given to them. So, although I’m a medical doctor, I end up almost being a lawyer, continually helping with the legal fight for rights. These aren’t privileges, they’re rights.
So, in a sense, I almost become part of their team. And as part of the team, I hear about the kind of alienation that you’re talking about. I’m not alienated from students myself. My grandkids are students. I do some work at a university and have a lot of affection for the students. But I really worry about how my marines are going to interact with my students when somebody says something which, from the marines’ point of view, is insensitive.
It’s important for most people to be in an atmosphere of trust and acceptance, but the importance of being around people who you can trust and who accept you is heightened both by a marine’s training and by PTSD. PTSD means that you are hyper-vigilant and on the look-out for things that are a threat or a danger, and insensitive comments can be interpreted as both.
But let me go back to what we do about these men who have to transform themselves from this band of brothers—or sisters, if they’re serving with them—to civilians. What goes on in therapy is going back to challenges that existed and sharing a bit about it, and then working hard to be better at controlling temper, and talking through the nature of a provocation. And reminding this person who’s going through a transformation—having them reminding themselves—that their job, their mission, is now to be a successful civilian.
In the case of the one who’s going into law enforcement, he’s got a dad who’s a distinguished law enforcement leader, and I’m sure this marine will make it. His buddy points out to him, “Well, you know, you have command presence.” And my marine says, “What do you mean by that?” His buddy says, “You know, it’s the way you hold yourself, the way you express yourself; it’s how you look.”
I then add to that, “You don’t need to be menacing. You already have the ingredients for communicating your authority. You just have to refine that, to perfect that.” It’s a lot like athletic coaching: it’s starting with the attributes that the person has, then going through situations—sometimes even going into role-playing—to use strengths of personality, of character, and of logic, to resolve interpersonal problems in a successful way.
Jon Stephenson. (2011). Veterans and Post-Traumatic Stress Disorder: A Conversation with Dr. Frank Ochberg. Psych Central. Retrieved on December 26, 2014, from http://psychcentral.com/lib/veterans-and-post-traumatic-stress-disorder-a-conversation-with-dr-frank-ochberg/0006135
Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
Published on PsychCentral.com. All rights reserved.