June 17, 2011

Homeless Veteran

A new book says LISTENING helps troubled vets heal. Everyone can do it. Clinical training is unnecessary. Saying they have Post-Traumatic Stress Disorder (PTSD) is harmful.

“A sustained emotional reaction to the horror of war is not a ‘disorder.” What would be a healthy reaction to the horror of war?” psychologist Paula J. Caplan, Ph,D, asks in her new book When Johnny and Jane Come Marching Home: How Each of Us Can Help Veterans.”

Post-Traumatic Stress Disorder (PTSD) is a mental illness listed in the  Diagnostic and Statistical Manual, which lists all mental health disorders, and the observable signs connected with them. We’ve been giving troubled veterans that label since the Vietnam era, Dr. Caplan’s book says.

Why the Label PTSD Harms Veterans

Here are some reasons why she thinks diagnosing troubled war veterans with a mental illness is wrong:

1. A disturbed, lasting emotional reaction to the horror of war is not a disease. Telling a troubled war veteran that his troubles mean he is “mentally ill” makes him more isolated than he already is, and lowers his self-confidence and self-esteem.

2. The term PTSD hides the cause of the trouble – war, Caplan says. The same thing has been called combat fatigue, battle fatigue, and shell shock, In the Civil War, it was called Soldier’s Heart, she says. Each of those names squarely identifies the cause of the person’s suffering.

3. Many veterans think the label PTSD means they’re “sick” or “crazy,” instead of having a normal reaction to something horribly abnormal. They rebel against the idea, and refuse to accept help, often with disastrous, even fatal, results, or they buy into it and become permanent, disabled victims.

4. Since treatment for war shock in the military or Veterans Administration is delivered by mental health professionals in medical settings, the treatment itself reinforces the message that the sufferer is sick or mentally ill.

5. Many in the military view suffering veterans as weak, or cowardly. Many soldiers and veterans think this about themselves. Going for help, or saying they need it, is a sign of weakness that would hurt their careers and relationships with fellow soldiers, they fear.

6. PTSD puts war stress on the same plane with rape or a tsunami. “People do not come to you, like they do after a rape or tsunami, and ask how they can help you heal,” Caplan says. Ordinary people often feel they can’t help a vet with his “illness,” because they do not have clinical training. They might even harm him if they get involved.

Dr. Caplan acknowledged that many veterans liked the “sickness” label. “It was better than being told to buck up and soldier on,” she said, but stood by her contention that veterans are not mentally ill, and should not be told they are.

Dr. Caplan’s Guide to Listening

Dr. Caplan’s book says each of us can help a vet, one on one, by LISTENING. Her book presents advice and guidance for people who want to help by listening, For a troubled vet, telling his story to a person who cares — being listened to without being judged — is part of healing, Cramer says. Clinical training is not necessary.

Start by making a connection with someone distant, not a family member, she suggests. Troubled vets might find it harder to open up to their families. They fear they might damage the relationship, might be misunderstood, or judged, or will place too heavy a burden on people they love.

Give the person all the time he or she needs to say everything they need to say. Don’t rush the person, or try to do it all in one session. Everything will come out in time. Expect some resistance, and come prepared with ways to overcome it. The book lists the most common reasons for resistance, and ways to overcome it..

“I want to thank you for your service. It was a generous sacrifice that took great courage. Do you mind if I ask how you’re doing now?”

If he gives you a perfunctory “I’m fine,” stay engaged, but don’t push, she says.

Establishing trust can take several meetings. Let him know that what he says to you is confidential. You want to know, not gather information to spread to other people. You’ve read about troubled veterans, and want to learn more.

“As an American, I feel it’s my responsibility to learn all I can about how these wars affect Americans who serve, and help if I can, even if all I can do is listen.” If he is not ready to talk about hard stuff right away, talk about easier stuff while he gets used to talking, being listened to, and trusting you.

What was your life like before you joined? Why did you join? What surprised you most when you first arrived in country? What was it like coming home? How are you feeling now?

Don’t underestimate silence, she says. Don’t fill every gap in the conversation with words. Sit quietly and reflect with him.

Don’t give advice.

Don’t promise to understand what it was like. Promise to do your best to understand, and promise not to judge, or be scared into stopping the conversation.

Don’t ask if he ever killed someone, or saw a dead body. It’s his decision to talk about that or not.

Let him know it was OK to be scared. Tell him you’d be so scared in that situation you don’t think you could have handled it. Being scared doesn’t mean you’re crazy.

There are many more suggestions and scenarios.tin

Fighting Words

Unfortunately, Caplan does not start telling people how they can help until Page 179. Many people won’t get that far. They’ll become angry and defensive, and stop reading before they get that far.

The people most likely to do that will be military officers, VA officials, and clinicians who counsel troubled vets.

Before she starts telling individuals how they can help, she writes two chapters on what the military and VA are doing wrong. The first ten pages of the “How Individuals Can Help” chapter is a list of all the ways ordinary individuals are better than professionals.

Regardless of how valid these criticisms are, her suggestions about how individuals can help would be more effective without the fighting words.

Even so, the book was still strong enough to motivate me to try to help a vet, convince me I might be able to, and tell me how vitally important it is for ordinary people like me to help.

Dr. Caplan is a clinical and research psychologist at Harvard University’s Kennedy School and Dubois Institure.

SOURCES

Caplan, Paula J., When Johnny and Jane Come Marching Homne: How All of Us Can Help Veteran, 2011, MIT Press, 282 pp.

Keynote Presentation, “Losing Labels to Find Ourselves: Leaving Behind Psychiatric Labels to Learn Who We Really Are,” sponsored by the National Empowerment Center (www.power2u,org), Endicott College Beverly MA, June 10, 2011

Copyright Ken Braiterman. Contact the author to obtain permission for republication.

Moe Armstrong is a Vietnam veteran who says his emotional wounds from the war are still bleeding. Even so, he runs a vets’ center in Massachusetts.  Last year, he received a lifetime achievement award from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) for his decades of support and advocacy for people experiencing emotional problems.
On June 10, after Dr. Caplan’s presentation in Beverly June 10, he wrote on Facebook:

“Forty-two years later, I am still going out of my mind and crawling through my skin.  I am struggling every day of my life to stabilize. Paula better hope that I am working at getting sane and stable and maintaining sobriety. The world and myself are safer,” he said.

‘Post Traumatic Stress Condition is what I will call what I have. We now have 750,000 psychiatric casualties from the current wars and just at my center we do three to five intakes a week of Vietnam veterans.’ 

Across the country, 18 veterans are committing suicide A DAY, he said.

“Mutual support seems to work better than traditional therapies. Just talk to people long enough and everything will be revealed, probably.  [Don’t] get too morbid: how many people did we kill or did we see any dead bodies or the dumb questions that people ask. In time, everything comes out,” Armstrong said.

 

 

4 Comments for this entry

  • I very much appreciated that Ken read the book and wrote a review of it. The main thing is to get the word out to people how much pain vets are in and –regardless of their politics and ours (a point that was not clear from the review, sinc…e one can only provide so much context in a review) — that there are many powerful reasons that it is important for all of us to listen to vets’ stories. Ken must have missed the note at the very beginning of the book, in which I say that readers may wish to skip from the end of Chapter 2 right to Chapter 6, which is about how to do the interviews, if they want to get started right away in doing their part. I am not sure why he would have gotten defensive, as he says, in reading the intervening chapters, because in them I am simply documenting what is being done that it is not helpful, and that is something that many people have wished to understand. Even the people I am in touch with who are top brass dealing with these problems have not gotten defensive but have been acknowledging publicly (as I document in the book) that the current systems of trying to help vets with emotional devastation have not been working for huge numbers of them and that they fully support the Welcome Johnny and Jane Home Project. I can understand if those intervening chapters made Ken angry, as he said, because they ought to make any person who cares about our fellow citizens who are suffering angry that their needs have been so neglected.
    Thank you, Ken, for doing all this work and spreading the word that more help is needed and that each of us can do our part.

    • Ken!Brait1 says:

      Thank you, Paula, for commenting. I did not get angry or defensive about your criticism of the system. It made good sense to me, but I don’t know enough about it to comment. Any comments I made on your criticism of the system would have reflected my own bias against huge bureaucracies, and the Psychiatric-Industrial Complex.

      I questioned the wisdom of putting those comments ahead of the suggestions on how people can help. I was afraid people you want to reach would get angry and stop reading before they got to what I thought was the most important part of the book.

  • Ken, I really appreciate the opportunity to write to you again here, because I want to say several things. One is to say how much I appreciate the great detail into which you delved about the book. You really packed so much into the review.

    A second thing is just to clarify something, because the wording might be slightly confusing. One of my concerns about the term “Post-traumatic Stress Disorder” that you mentioned quite correctly is that the very wording masks the presence of war itself as the cause of the veteran’s devastation. Most civilians have little or no sense of what a veteran has been through, and calling their devastation PTSD rather than war trauma, combat fatigue, shell shock, or soldier’s heart, especially when PTSD is applied to victims of rape, tsunami survivors, etc., the term clouds the reality of the sufferer’s experience. But I would not want people to have the impression that I think citizens are likely to ask rape victims about their experiences, any more than they ask war veterans, because they tend to shy away from both.

    Next, what I actually suggest is not thanking the veteran for their service and talking about their having made a sacrifice, because that is evaluative, even though it may seem positive, and I think it is important to be warm and compassionate to the veteran as a person, but we cannot assume until we hear their stories about war and about coming home that we know how _they_ feel about their service, whether they made a sacrifice, etc. It is essential in these interviews to hear what they want to tell us and to avoid shaping what they say. What I actually suggest is making the offer about doing the interview by saying, “As an American whose government sent you to war, I take some responsibility for listening to what it was like for you over there and how it has been for you since you came home. So _if_ you want to talk to me, I will listen for as long as you want to talk, and I will not judge you.”

    Another point is that, although you once in the review used “him or her,” you almost always referred to the veteran with only male pronouns. It is crucial that we recognize that more women than ever before are serving in the military, and due to the nature of current wars, vast numbers of women have been in combat zones, exposed to improvised explosive devices, and so on. I recently learned something so poignant: Because women have not been allowed _officially_ to serve in combat positions, many have simply not been aware that they _are_ veterans, so when they see announcements of services that are offered to vets, they do not think they are relevant to themselves. In the book I discuss some of the similarities and some of the differences between the experiences of veterans depending on their sex.

    Finally, I understand your questioning the wisdom of putting the chapters in which I say why the current approaches to helping vets have failed before the chapter in which I describe how anyone can do these interviews. In fact, at one point I suggested to the publisher that we put those three chapters in a very long appendix. But both the publisher and my agent said they thought those were crucial chapters, because they believed they compellingly revealed why we so badly need civilians to listen to vets’ stories. So I tried to deal with that by my suggestion at the beginning of the book that some people might want to skip Chapters 3, 4, and 5. A number of readers have said that they loved learning in Chapters 3 through 5 why and how we are failing our vets, because they had previously thought that with all the patriotism in this country, surely vets were being well cared for. And a number of other readers said they skipped those chapters but went back and read them after reading Chapter 6 about how to do the interviews and the brief, final chapter.

  • Ken!Brait1 says:

    I think you’re right about not assuming how a veteran feels about his service until you’ve talked a while and know for sure.

    I’m glad to hear you made a conscious decision about where to put the critique of the system and the way things are. I’m glad you did not put it into an appendix. It’s too important for that. I would have made a different editorial decision. Big difference between a disagreement on editorial strategy, and a disagreement on content.

    The distinction between war stress and other trauma was hard for me to write. I tried several ways, and felt that was the least bad in the space I had. It might have been smarter to skip that idea completely.

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