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How many significant figures of history actually suffered with PTSD? We may never know. The diagnosis, now part of our collective 21st century lexicon, did not exist before 1980. Many historians point to the Civil War with the description of Soldier's Heart as the earliest attempt to describe emotional consequences of war. Jonathan Shay wrote about warriors from Greece who incurred the invisible injuries we now diagnose as PTSD. The earliest medical descriptions of PTSD started in the 1830s during the early era of railroads. Numerous collisions and explosions resulted in a condition called "Railway Spine", something akin to mild traumatic brain injury at first, but later described as a psychiatric condition consistent with PTSD.

Did Clara Barton suffer with PTSD? On the basis of Melinda Henninberg's article, (http://www.washingtonpost.com/lifestyle/magazine/clara-bartons-enemy-depression/2012/04/04/gIQAdryXzS_story.html), I would say it was quite likely. More importantly, what can we learn from Clara Barton's rather extraordinary life? I think there are many lessons applicable to modern observers:

  • Her childhood was filled with fear. She grew up in a chaotic and likely violent family. The article describes pervasive and dramatic mental illness, a sister locked away and a brother who committed suicide; another brother robbed banks. As noted in her diary: "In these later years I have observed that writers of sketches, in a friendly desire to compliment me, have been wont to dwell upon my courage, representing me as personally devoid of fear, not even knowing the feeling. However correct that may have become, it is evident I was not constructed that way, as in the earlier years of my life I remember nothing but fear."

Does growing up in a dysfunctional family better prepare you to survive during war, chaos and/or insanity? There is no absolute answer to this question, but a dysfunctional family may actually help you endure the unmanageable. No exotic constructs needed here; if you grew up having to dissociate to survive, you may simply have "more practice"- the equivalent of early military training. Conversely, some individuals are less prepared for chaos if they grew up in a "crazy" family. A lot depends upon context, types of stressors, etc.

My personal observation is that a dysfunctional family background may make you stronger during a crisis, but in the long term it might make recovery, or at least a balanced recovery, much more difficult. Early studies conducted at the University of Minnesota described a population of "invulnerable children". These were kids who grew up with schizophrenic and alcoholic parents but did not have overt problems as adults. In fact, many were highly adaptive and showed no signs of outward difficulty. When this population was studied more closely, researchers learned that outward coping masked many harsh consequences. They later gave up their quest and decided "invulnerable" was a flawed concept. On the flip side, growing up in a safe and nurturing family is no guarantee you will not develop harsh symptoms. We need to consider multiple variables- including frequency of exposure to trauma, intensity of the trauma, duration of the trauma and age of exposure. Invulnerability is a seductive illusion, but even those who look intact may endure severe suffering.

  • Clara Barton's father may have had PTSD. This may be mere speculation, but as noted in the article: "Her father, Capt. Stephen Barton, had served under "Mad Anthony" Wayne in the French and Indian War, and "his soldier habits and tastes never left him," she wrote. He and Barton's mother, Sarah, "... fought loudly and often." It is not unusual to see multi-generational trauma transmission. This is something rarely studied but worthy of serious consideration. When PTSD rates in current and past wars are sited, we really should include the family unit. Like so many conditions, PTSD becomes a family problem. Nihilism, cynicism, anger and emotional unavailability are features we often see. Overt family violence is not necessarily an outcome. In fact, emotional distance and avoidance is what we most commonly see, along with intermittent outbursts of anger, often directed at others (road rage is a common phenomenon). The likelihood of physical violence seems directly related to the use or non-use of alcohol and other drugs.
  • Clara may have also struggled with the bipolar disorder, a condition that is now known to have strong genetic foundations. Clara's brother committed suicide and her mother displayed possible features consistent with a mood disorder. Kay Jamison excellent book, Touched with Fire describes many figures of history, including Churchill, Lincoln and Hemmingway who probably suffered with the bipolar illness, often mistaken for simple depression. The swings of mood Clara described followed by fits of amazing endurance fit with patterns observed with the bipolar illness. In addition, risk of suicide is also much, much higher with those who so suffer. It is important to note that the bipolar condition increases risk for alcoholism and addictive disorders. It also increases risk for suicide, and the depth of depression is far in excess of situational depressions. Making this more exotic is the fact that PTSD also mirrors the extreme swings in mood we see with PTSD. Emotions and impulse rule, and dramatic shifts are quite common. Finally, alcoholism mimics the swings in mood observed in PTSD and Bipolar Disorder. And one more addition to this complexity: mild brain trauma (mTBI) mimics symptoms of PTSD, mood disorder and alcoholism. The bottom line for readers and diagnosticians: many of these conditions travel the same path and are hard to differentiate, even in the modern era.
  • She likely had problems with trust, attachment and relationships. Not much detail is provided in the article, but Clara never married. Out of the thousands of young men and officers she encountered, she fell in love with a married Union captain who was already married. I cannot speculate as to her actual attachment pattern, but I can say that individuals with early childhood trauma tend to avoid attachments with those who are available and loving, and too often chase the impossible or abusive partner. More of this will be reviewed in subsequent blogs, but for now, problems with core attachments and "recapitulation" of childhood rejection is an almost classic consequence.
  • Working with those injured or dying can produce PTSD. Originally, it was believed that in order to develop PTSD you had to have first-hand exposure to death and violence. If a bullet or rocket did not come toward you, how could you possibly develop PTSD? We now know that direct violence is sufficient but not necessary in the development of PTSD. Many studies show that those who clean up the aftermath of train wrecks, car crashes and fires have a high rate of PTSD. In fact, medics, nurses and physicians have very high rates of PTSD. It is a core principle we now accept: being witness to or part of the aftermath of violence can be as toxic as direct exposure to violence. Those who prepare or transport the dead are also vulnerable, even if they never heard a weapon fired in combat.
  • She found meaning and relief in her work. This is perhaps the most valuable lesson we can discern. As noted in the article "Her diaries (later discovered behind the wall in her former Glen Echo home, now a national historic site) reveal that she self-medicated through service: She used the most intense, bloody work imaginable to keep the "thin black snakes" of sadness from closing in." While sited in the article as an antidote to depression, Clara's dedication to helping others - at first her brother and later countless others - is a great example of "giving back" as a method of healing. I refer the reader to Victor Frankl for a more complete discussion of this potent factor in human survival and transcendence. Finding meaning by helping others is exceptionally effective, but Clara's story demonstrates another vital lesson. Any single strategy applied in excess may leave you exhausted, alone and struggling in isolation. As with all healing factors, helping others and finding meaning should be done as part of the journey of finding or rediscovering balance- emotionally, interpersonally, cognitively and in terms of meaningful action. Even good work can become excessive, unbalanced and perhaps shift from "self-medication", as noted by Clara, to a near addictive pattern depriving you of the satisfaction and balance originally displaced by exposure to trauma.

Clara Barton, the founder of the Red Cross, and her struggle with the "black snakes" of depression, illustrates the complex consequences of exposure to and immersion in trauma. While she lacked comprehension to describe the extent of her suffering, her self-described "depression" was insufficient in capturing the multiple and complex symptoms of what we would now call PTSD and co-occurring disorders. Ironically, Clara Barton"s symptoms propelled her into an excessive, perhaps addictive attraction to violence and war, providing her partial relief and affording comfort and relief to millions as well.

Jerry Boriskin, Ph.D, a Senior Fellow at The Meadows, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness. For more information about Dr. Boriskin, please visit his website at http://www.jerryboriskin.com/.

For more about The Meadows'; innovative treatment program for PTSD and other disorders, see http://www.themeadows.com or call The Meadows at 800-244-4949.

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The Meadows is pleased to announce a contract with TriWest Healthcare Alliance, a sub-contractor of TRICARE health program. Under this agreement, The Meadows has become an approved TriWest provider for behavioral health and substance abuse inpatient services to eligible beneficiaries.

The TriWest Healthcare Alliance is contracted with the Department of Defense to administer the TRICARE West Region program in the 21-state region. As an approved TriWest provider, The Meadows' inpatient substance abuse and psychiatric services are now available to nearly 2.9 million military members, retirees and their families. The convenient location of The Meadows, just 1.5 hours north of the Phoenix airport, offers easy accessibility to soldiers and their families. This could prove to be extremely beneficial to beneficiaries associated with the seven military bases located in the state of Arizona.

"We are confident that the impeccable reputation of The Meadows combined with our breathtaking campus and state-of-the-art treatment was a critical factor in choosing The Meadows as a network provider," stated Jim Dredge, CEO of The Meadows. "The Meadows has a commitment to servicing our heroes. We have enormous gratitude to those who protect and defend our freedom. It is a great honor to be a network provider for active duty, families and retired enrollees of the TriWest program."

According to Dr. Jerry Boriskin, a Senior Fellow at The Meadows and a consulting expert to the Veterans Administration, this contract is significant because there is a benefit to having as many options available in the various sectors due to the need for occasionally higher levels of care.

Dr. Boriskin, who has worked with the veteran population for 30 years, commented that "The core challenge is to get the veteran or the civilian, for that matter, to work on acceptance, forgiveness, and most importantly self-forgiveness because things were out of control and they were horrible."

Dr. Stephen Brockway, Chief of Psychiatry at The Meadows, explains that treatment for the veteran allows a move to take place from "It's me against the world" to "There are others like me" to "I'm part of the community again."

To learn more about The Meadows' work with trauma and addiction contact an intake coordinator at (866) 856-1279 or visit www.themeadows.com.

For over 35 years, The Meadows has been a leading trauma and addiction treatment center. In that time, they have helped more than 20,000 patients in one of their three inpatient centers or in national workshops. The Meadows world-class team of Senior Fellows, Psychiatrists, Therapists and Counselors treat the symptoms of addiction and the underlying issues that cause lifelong patterns of self-destructive behavior. The Meadows, with 24 hour nursing and on-site physicians and psychiatrists, is a Level 1 psychiatric hospital that is accredited by the Joint Commission.

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http://www.washingtonpost.com/national/health-science/link-between-ptsd-and-violent-behavior-is-weak/2012/03/31/gIQApYFZnS_story.html

The political and emotional complexities of PTSD (post-traumatic stress disorder) and TBI (traumatic brain injury) can lead to stigmatization and inaccurate attributions. It has long been assumed that soldiers, especially those who have served in combat, are at higher risk for violence. Following WW II several congressmen introduced proposals to send returning combat troops to islands for "retraining" before returning to civilian life. Following Vietnam we had Rambo movies and veterans "going postal". The facts are both simple and confusing: sudden outbursts of violence are rare and very hard to predict.

The article referenced above summarizes some of what is clear: PTSD and TBI can produce shifts in emotional management and changes in "executive brain function" resulting in possible impulsiveness. Complex phenomena like PTSD and TBI are difficult to study and data is scattered, sometimes inconsistent or contaminated by selective sampling or agency agendas. What is clear is that spectacular episodes of sudden violence are extremely rare, despite media attention. There are often multiple factors involved and these include co-occurring disorders, use of drugs or alcohol, lack of sleep, number of tours, severity of symptom or injury, just to name a few. We would love to have instruments that predict these rare outbursts, but they do not exist. We are reduced to the old maxim I learned decades ago: "the best predictor of future behavior is past behavior".

I do not wish to oversimplify; however, I want to reassure readers, especially military readers, that they are not likely to explode in some horrific headline-grabbing fashion. The title of the Washington Post article is generally accurate. Put aside the complexities of multiple tours, diminished capacity, head injury, partial recall, fugue episodes, sleep deprivation, isolation, and alcohol, and let's focus on the reassuring take-away message. There is no data supporting the worst fear carried by many. Most veterans are well trained, restrained, disciplined, highly ethical, and filled with a sense of justice, loyalty and honor. Most veterans I have treated live with the dread that they could lose control of their impulses and inadvertently hurt someone. Newspaper headlines about sudden violence and suicide add to their burden of fear. As a 66 year old combat Marine with severe health and mobility problems recently stated, "I am still afraid of what I could do to others.- That's why I need to stay away from others." The fear of losing control results in isolation, self-medication, avoidance, and a whole host of symptoms we see with PTSD.

I would argue that the most common symptom is not violence but extreme dedication to work or mission. I do not have the statistics, but from my years of experience I see pro-social zealousness- not antisocial outbursts- as the most common coping mechanism. Over dedication to work/mission becomes almost addictive. It is easy to get lost in working excessive hours, and it is rewarded by recognition and increased revenue. Channeling one's anger is difficult, but workaholism is an extreme response rewarded in our culture. However, family members can be angry and confused, and the internal burden remains hidden. Sleepless nights, avoidance, occasional road rage and other symptoms flourish, often visible only to a few. Spectacular outbursts are rare. PTSD tends to be a condition that most often fits the following: "Great souls suffer in silence." (Friedrich Schiller). The articulation of suffering is often the first step toward recovery.

Jerry Boriskin, Ph.D, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness. For more information about Dr. Boriskin, please visit his website at www.jerryboriskin.com.

For more about The Meadows' innovative treatment program for PTSD and other disorders, see www.themeadows.com or call The Meadows at 800-244-4949.

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Is it possible that trauma is good for you? Is there such a thing as Post-traumatic Growth? Are we supporting soldiers coming forth for assistance or are we engaging in denial when we strip away the "D" (disorder) from PTSD? As a clinician and advocate for those who develop PTSD and its more severe variant, Complex PTSD, I am tortured by the contradictions and questions.

Like many in my profession I have read the research and the controversy associated with resilience training. I am critical of many aspects of these endeavors; they promise more than is reasonable and have been implemented prior to empirical validation. Also, the assessments done during training have resulted in lawsuits due to soldiers objecting to being ordered for additional training on spiritual development (viewed as a resilience booster). Nonetheless, there is such a phenomenon as Post-traumatic Growth. I see it all the time, and in fact have been a strong advocate of this construct for decades. I have always encouraged clients with PTSD to "find meaning from the misery", something much easier said than done. It is no great surprise to observe that like heroes of mythology and bible, adversity is often the precursor of strength. Many soldiers and civilians suffering from PTSD go through a long "dark" period before finding hope, meaning and strength. Some never find the positives and withdraw from life or die from their condition(s). On the other hand, it is possible that some individuals skip the downside and move spontaneously toward "growth".

Whether this is common, rare, or the result of training or genetics is still not known.

The military does an outstanding job in training soldiers to survive in combat. However, is it possible to prevent PTSD? The armed forces would love to be able to select those who are most resilient and train them in all ways to become "immune" to trauma, perhaps even strengthened by trauma. I am reminded by the headline in a recent military newspaper: "Bullet-proof Your Brain". Perhaps this concept can be taken a bit too far. We are already struggling with questions about how many tours someone should have before they "break". I seriously doubt we will be able to precisely predict an individual's breaking point, find a medication that will prevent PTSD, or have cognitive techniques that permit individuals to tolerate the impossible. As cited in the article, "These programs were designed to make people happier and healthier," says George Bonanno, a professor at Columbia University who studies trauma and resilience. "That is not the same thing as inoculating people for serious urinate-in-your-clothing type stress - once-in-a-lifetime stress."

So, how do we make sense of the contradictions: is trauma neutral, negative or a positive? Can we expect resilience, growth or a lifetime of symptoms? Will a mistimed introduction of "the positive" possibility help or hurt someone with active PTSD? I am concerned that the expectation of "Growth" can add burden, perhaps shame to those who have PTSD or Complex PTSD. I recall a very powerful example. My client, a high school teacher who had severe PTSD, was being evaluated by a renowned psychiatrist as part of her lawsuit against the physician who misdiagnosed her near-fatal colon cancer. She lived in dread of a recurrence of her cancer; she had severe anxiety symptoms and was not adjusting well to her colostomy bag. The psychiatrist was representing the defense team and his objective was to gather information to deny the existence of her PTSD. She was expecting critical questions and did very well during the hour, no signs of anxiety or anger at his attempts to undermine the reality of her PTSD. At the very end of the interview the psychiatrist switched tone and tried to display empathy. He was an elderly man, partially blind, and said to her, "I had some health problems myself and medical errors were made. I decided that I had to put my memories and emotions in the attic of my brain and then I was over it. You need to do what I did." Ironically, he was trying to be kind but the result was powerful; my client burst into tears, felt invalidated and humiliated. It took us a full hour to help her recover from the trauma expert's mistimed attempt to validate and encourage. She felt shamed and criticized. In this case, a positive message delivered at the wrong time had unintended consequences.

So, while focusing on the positive results of surviving trauma is empowering, it can be invalidating as well. It is all a matter of context and timing.

Jerry Boriskin, Ph.D, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness.

For more about The Meadows' innovative treatment program for PTSD and other disorders, see www.themeadows.com or call The Meadows at 800-244-4949.

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Monday, 19 March 2012 20:00

What Caused Sgt. Bales to Snap?

A group I facilitate for Vietnam Veterans struggled with this question even before the name of the accused sergeant was released. Violence, injury, death and war stir intense emotions in all, particularly among veterans who have been up close and personal. The issue of atrocity and slaughter of civilians is, naturally, an incredibly intense and sensitive subject.

My group members wrestled with this for 90 minutes; most had extreme empathy for the cumulative damage war has upon warriors. They could not even begin to grasp the immense pressure put upon younger soldiers, some of whom serve three, four, and up to nine tours. They/we are humbled by shocking reports of soldiers committing sudden violence, some of which is toward family, but more often towards self. They embraced the contributing factors that need be considered: alcoholism, traumatic brain injury, post traumatic stress disorder (PTSD), financial problems, issues of unemployment, possible relationship problems, a passed over promotion, an unwanted next tour, recent injury, and experiencing the wounding or killing of fellow warriors.

Reports indicated that Sgt. Bales was suffering from many of these factors; he was also reported to be highly decorated, a model soldier, and has saved lives of civilians and Americans in some of the hottest conflicts in Iraq. How could a highly trained soldier, a member of an elite unit, trained sniper and leader of men possibly commit such an atrocity? Our group struggled with this question and did not come to a clear explanation. They had empathy and contempt; some launched into politics of the current wars, some blamed the military for too many rotations, some defended the military, others discussed the role of combat, loss of recent friends, PTSD, alcohol, and tbi (traumatic brain injury). The discussions were intense and a few favored certain factors, but no consensus or full explanation was derived.

One thing we did derive: in certain situations our usual narratives fall apart. If the conditions are right, we are all capable of sudden violence or extreme behavior. The media will no doubt speculate on which factor(s) were critical in this current horror. Forensic experts will attempt to definitively opine, but we may never fully know why this particular soldier "snapped" in such a dramatic and horrific fashion. Thousands of soldiers carry the burdens of war. Most struggle in silence and harm no one, and if they do injure anyone, they hurt or punish themselves.

We may never know the full explanation of what went wrong. My personal speculation is that alcohol played a large factor. It is the most common variable in violence: domestic, self or toward others. It also works in tandem with PTSD and traumatic brain injury. What will probably emerge is a complex picture of a determined and accomplished soldier worn down by many variables, military and domestic. Early reports suggest Sgt. Bales and others were drinking heavily that evening, against military rules. Those early reports also suggested drinking to levels of blackout. Sgt. Bales allegedly had a drunk driving hit and run episode while stateside. Whereas not the sole factor, alcohol might have been the "tipping point". Alcohol is a common way of "self-medicating" or "de-stressing", but it can have an almost "evil" impact in unleashing primitive emotions. In fact, it is a common but often understated factor in the surging suicide numbers in young soldiers. Alcohol has a long history of violence in so many settings, especially the home. Unfortunately, we continue to deny alcohol's power or even its presence. Mr. Bale's attorney alleged his client had not been drinking.

We will know more as facts emerge, but we may never fully grasp what went wrong or why. We do know that war is ugly; it changes people and distorts mind, body and soul. The results of war can make you feel "untouchable" and unique. My hope is that veterans or military personnel reading this blog will recognize that their worst fears are not reflected in the rare disasters. Most people, even civilians, have a fear of "snapping". Exposure to the horrors of war intensify that fear beyond that which most observers can express or comprehend. The vast majority of those who develop PTSD do not snap. Instead, they suffer quietly and deconstruct their lives. PTSD, especially with co-occurring addiction, is complicated and destructive, but highly treatable. Recovery requires Sleep, Safety and Sobriety, the three "S's" that are the first steps in separating you from the demons of war.

Jerry Boriskin, Ph.D, has been at the forefront of the treatment of PTSD, addiction, and co-occurring disorders for more than 30 years. He is the author of several books, including PTSD and Addiction: A Practical Guide for Clinicians and Counselors and At Wit's End: What Families Need to Know When a Loved One is Diagnosed With Addiction and Mental Illness.

For more about The Meadows' innovative treatment program for PTSD and other disorders, see www.themeadows.com or call The Meadows at 800-244-4949.

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