Ongoing Labors of Love: Changing Mental Set about How to Help Wounded Warriors and Others
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Ongoing Labors of Love: Changing Mental Set about How to Help Wounded Warriors and Others By Paula J. Caplan, Ph.D. Created May 12 2011 - 3:06pm ©Copyright Paula J. Caplan All rights reserved
Rethinking what steps we can take to help veterans and other traumatized people
Like many people who become therapists, I went into that kind of work in the hope of being able to help alleviate some human suffering. At some point in my Ph.D. program at Duke University, I became aware that the faculty who were training us were not explicitly addressing this pair of pervasive expectations - that we knew or soon would know how to help and that we knew more about patients than they knew about themselves.
What to do in the face of this daunting pair, combined with the apparent practice of not talking about them and certainly not questioning either assumption? Like most graduate students, I assumed that my teachers and supervisors knew both how to help and how to come to know more about patients than they know about themselves. At that point, I was the kind of student who primarily assumed that the authorities had the answers. In fact, I recall wondering to myself, that first year in graduate school, whether perhaps I was spineless, since I noticed that, almost regardless of who said what in class, I would nod as if in agreement. It took some years to recognize that my default reaction (like a well-socialized woman, of course) was to try to find something to agree with in whatever anyone said, to look for commonalities. And I remember my discomfort when a teacher or other expert said something that did not make sense, did not fit with research with which I was familiar or with the behavior we had just observed in patients or "normal" interviewees, or revealed a lack of attention to and empathy for people's suffering.
It was hard to understand that I had entered a field in which some people's primary intention was to help and their approach was caring, honest, and based on the best principles of clinical practice and critical thinking about the relevant research, but that many did not fit that description. So it took many years, decades even, and a gradual process of disillusionment with many arenas related to clinical work, including both practice and research.
Disappointingly often, when I had to teach about a new topic or became interested in a new area and began to read the clinical and related research literature or to attend continuing education and other lectures, my heart would sink when the absence of standards that mattered became evident. I even reached the point at which I dreaded entering into any new field. Thus, part of the context of this essay is that I have learned that the usual methods in the mental health system often fail to help or to be sufficient, and that it is important to listen to what people tell us about what helps and what does not. We can all be in this together, as we struggle to find ways to alleviate pain.
Although in the rest of this essay, the focus is on ways to help war veterans, much applies also to those who have experienced other kinds of trauma, including but not limited to rape, child sexual abuse, and other kinds of physical or emotional violence. And because this is an essay rather than a book chapter or a book, please keep in mind that I will write here only a fraction of all there is to say about ways to help. [1]
When the Iraq War was about to begin, and Dr. Maureen McHugh at an Association for Women in Psychology conference raised the question of whether there was anything specific that we as psychologists might do, I had for almost a quarter of a century been immersed in waves of disheartening discovery of the unscientific nature of psychiatric diagnosis. During that time, the use of diagnosis had skyrocketed in the United States, as had the use of psychiatric medications about which little was known or had been disclosed by their manufacturers but billions of dollars had been spent on advertising them, while the use of plain, old talk therapy had drastically declined. When Dr. McHugh asked her question, I guessed that as Americans went off to war and then came home, devastated, both we as a nation and mental health professionals in particular would rush to classify the effects of war's horrors as mental illness, whether or not the sufferers should by any stretch of the imagination be called mentally disordered.
That was the first seed of more than seven years of listening to veterans from earlier wars and the new ones, and it was the veterans who taught me part of the answer to the question raised by the Rev. Dr. Roger Ray in a comment in response to one of my earlier essays here. He asked: How can we help these suffering souls?
In the rest of this essay, I offer some ways that I know we can help, but I ask readers to recognize that, when I describe an approach that has been helpful to some veterans - much of which applies to other sufferers of trauma - if it has not been helpful to you, or if you have in addition found other approaches to be helpful, I would not doubt your report of your experience. I will say a bit more about that later.
As I have noted repeatedly, there is a vast system of military and Veterans Affairs mental health programs and providers, the overwhelming majority grounded firmly in the "diagnose, medicate, and maybe listen a bit" tradition. In spite of this, millions of veterans have no homes and/or jobs, are substance abusers, have experienced family breakdown, are serving time in prison for violent conduct, have tried to kill themselves, cannot sleep, and cannot form and maintain good relationships with others. So clearly, the traditional approach is failing.
Yesterday, the head of a VA Vets' Center told me that the average patient in the VA's mental health system is seen once every three months. One might conclude that that is the problem, that the VA is far too understaffed. But since the current wars began, the rapid introductions of new programs and hiring of more staff has not even led to decreases in the numbers of serious problems and suicides. In fact, they only increase steadily, and Pentagon spokespersons have publicly expressed alarm about that.
To listen to veterans is to learn that, for the most part, diagnosis has not been helpful, just made them feel "crazier"; drugs have rarely helped and nearly always caused negative effects such as exacerbation of their troubling emotions and moods, sexual problems, dramatic weight loss or weight gain, and the onset of diabetes and heart problems; and even psychotherapy has not helped, because it has too often been based on the notion that they have individual psychopathology, with little or no attention paid to the mammoth shock of returning from a life focused on strict hierarchies and following of orders aimed at least partly at destruction and killing to civilian life in which structures, ways of interacting, and life aims are utterly different. And too rarely have those in therapy found help in figuring out what to do about the loss of the intense closeness of the relationships they formed with those with whom they served in the military, a closeness that - especially for the men - is unequaled by any relationships they have had with others before or since. And many men have been taught to be uncomfortable if they want close and meaningful friendships with other men in civilian life.
A veteran left this comment in response to an earlier essay on this blog: "Depression made me cry and retreat inward. Therapy sessions made me cry and retreat inward. Antidepressants caused unpleasant side effects. Side effects made life with depression more unpleasant. For me, it was all as counterproductive an experience as it sounds." And one of the veterans I met in the course of writing my book, formerly a vibrant human being, has now been on at least three psychiatric drugs for years, is seen regularly in the VA system, and is clearly experiencing dramatic damage to his brain and major and rapid weight loss, while becoming increasingly despondent and feeling increasingly helpless.
Furthermore, as veteran Rick Lawson wrote to me, "Enduring and returning from combat is not a mental illness! And we shouldn't have to be disabled to obtain compensation and assistance upon our return home." In fact, here is a tragic irony: Robert L. Whitaker has shown in his book, Anatomy of an Epidemic, [2] that the use of psychiatric medication (which virtually never happens unless the patient is given a psychiatric label) dramatically increases the chances that the person will end up on disability as a result of the effects of the medication. (And a reader of this blog left a comment about the ways that both nonpsychiatric and psychiatric drugs can cause what look like symptoms of serious mental illness.) So to call all veterans who are suffering emotionally mentally ill is to increase dramatically the chances that they will end up on disability. In spite of this, the courts are filled with cases of veterans who have received diagnoses but still cannot get the benefits to which they are entitled as veterans, given how slowly the system works and the high frequency with which applications for deserved benefits are rejected. So one way to help is to learn and educate others about these major problems in the systems in which veterans are treated and to support individual veterans and veterans' groups as they struggle to get what is coming to them and to improve the system.
There are other ways to help. To listen to veterans is to hear that even when therapists are helpful, the veterans know the therapists are getting paid to help and are not part of the veterans' world outside the therapists' offices. Time and again, when asked what has helped them regain some calm, some peace, the former servicemembers described incidents in which someone from the wider community, often someone they had never met before, asked to hear their story. It is remarkable how many have said such things as, "When I told a bit of my story and was kicking myself for not having done something I thought I should have handled differently, the person listening said I was being too hard on myself. And that night, I slept for the first time since I got back from Iraq."
Since fewer than 1% of Americans have served in the military, the only way we can understand what veterans have been through is to ask. Since it is helpful to them and helpful to us, giving us a way to help our nation heal from the emotional wounds of war, asking to hear veterans' stories is one way to provide some help. [3] I have mentioned this several times on this blog but risk being repetitive, because veterans say it is useful for them and because it goes so strongly against the pervasive assumption that only therapists can help.
Another way to help is with the practicalities of life. Whether someone is unemployed because of having been at war or having been traumatized in some other way, as my friend Alan Rauzin wisely said, "Work roots you in the world." It carries some dignity, some sense of mattering. We can help veterans find jobs. And when it comes to having no home or food, how can one begin to heal from emotional trauma while having to worry constantly about where to sleep or find nourishment? Every program I have ever seen that effectively assists people who are suffering from emotional causes provides these kinds of practical assistance.
An anonymous writer commenting on this site speculated about veterans that "The general community isn't going to be able to help the guy who gets intense panic attacks whenever he's in a car, or who constantly feels in danger when in public." Although some therapists can be helpful to some veterans with such problems, veterans report that many have not. But beyond that, one way of helping veterans to feel at least somewhat safer, if not safe, is in fact to ensure that as many people as possible in their communities understand the reasons for the vets' panic and sense of danger and to let them know that they will not be judged or mocked for not having "gotten over it" yet. Does that kind of community education and support solve all of veterans' problems? Certainly not. It is impossible to think of what kind of drilling and events of positive sorts would be powerful to counteract or undo the effects of the months and years of focus on and exposure to mortal danger that they have experienced in the military. No therapist, no layperson, and no community can provide that. What we can do, though, is commit ourselves to the ongoing labor of love, as Veterans Affairs psychologist Dr. David Collier calls it, of taking what steps we can to understand and support veterans, helping them truly come home from war.
[1] See Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press for more about this subject.
[2] Robert L. Whitaker. (2010). Anatomy of an Epidemic. New York: Crown.
[3] In Chapter 6 of Caplan (2011), I offer detailed guidelines for interviewing veterans, as well as suggestions for dealing with some common problems that can arise in these interviews.
Ongoing Labors of Love: Changing Mental Set about How to Help Wounded Warriors and Others By Paula J. Caplan, Ph.D. Created May 12 2011 - 3:06pm ©Copyright Paula J. Caplan All rights reserved
Rethinking what steps we can take to help veterans and other traumatized people
Like many people who become therapists, I went into that kind of work in the hope of being able to help alleviate some human suffering. At some point in my Ph.D. program at Duke University, I became aware that the faculty who were training us were not explicitly addressing this pair of pervasive expectations - that we knew or soon would know how to help and that we knew more about patients than they knew about themselves.
What to do in the face of this daunting pair, combined with the apparent practice of not talking about them and certainly not questioning either assumption? Like most graduate students, I assumed that my teachers and supervisors knew both how to help and how to come to know more about patients than they know about themselves. At that point, I was the kind of student who primarily assumed that the authorities had the answers. In fact, I recall wondering to myself, that first year in graduate school, whether perhaps I was spineless, since I noticed that, almost regardless of who said what in class, I would nod as if in agreement. It took some years to recognize that my default reaction (like a well-socialized woman, of course) was to try to find something to agree with in whatever anyone said, to look for commonalities. And I remember my discomfort when a teacher or other expert said something that did not make sense, did not fit with research with which I was familiar or with the behavior we had just observed in patients or "normal" interviewees, or revealed a lack of attention to and empathy for people's suffering.
It was hard to understand that I had entered a field in which some people's primary intention was to help and their approach was caring, honest, and based on the best principles of clinical practice and critical thinking about the relevant research, but that many did not fit that description. So it took many years, decades even, and a gradual process of disillusionment with many arenas related to clinical work, including both practice and research.
Disappointingly often, when I had to teach about a new topic or became interested in a new area and began to read the clinical and related research literature or to attend continuing education and other lectures, my heart would sink when the absence of standards that mattered became evident. I even reached the point at which I dreaded entering into any new field. Thus, part of the context of this essay is that I have learned that the usual methods in the mental health system often fail to help or to be sufficient, and that it is important to listen to what people tell us about what helps and what does not. We can all be in this together, as we struggle to find ways to alleviate pain.
Although in the rest of this essay, the focus is on ways to help war veterans, much applies also to those who have experienced other kinds of trauma, including but not limited to rape, child sexual abuse, and other kinds of physical or emotional violence. And because this is an essay rather than a book chapter or a book, please keep in mind that I will write here only a fraction of all there is to say about ways to help. [1]
When the Iraq War was about to begin, and Dr. Maureen McHugh at an Association for Women in Psychology conference raised the question of whether there was anything specific that we as psychologists might do, I had for almost a quarter of a century been immersed in waves of disheartening discovery of the unscientific nature of psychiatric diagnosis. During that time, the use of diagnosis had skyrocketed in the United States, as had the use of psychiatric medications about which little was known or had been disclosed by their manufacturers but billions of dollars had been spent on advertising them, while the use of plain, old talk therapy had drastically declined. When Dr. McHugh asked her question, I guessed that as Americans went off to war and then came home, devastated, both we as a nation and mental health professionals in particular would rush to classify the effects of war's horrors as mental illness, whether or not the sufferers should by any stretch of the imagination be called mentally disordered.
That was the first seed of more than seven years of listening to veterans from earlier wars and the new ones, and it was the veterans who taught me part of the answer to the question raised by the Rev. Dr. Roger Ray in a comment in response to one of my earlier essays here. He asked: How can we help these suffering souls?
In the rest of this essay, I offer some ways that I know we can help, but I ask readers to recognize that, when I describe an approach that has been helpful to some veterans - much of which applies to other sufferers of trauma - if it has not been helpful to you, or if you have in addition found other approaches to be helpful, I would not doubt your report of your experience. I will say a bit more about that later.
As I have noted repeatedly, there is a vast system of military and Veterans Affairs mental health programs and providers, the overwhelming majority grounded firmly in the "diagnose, medicate, and maybe listen a bit" tradition. In spite of this, millions of veterans have no homes and/or jobs, are substance abusers, have experienced family breakdown, are serving time in prison for violent conduct, have tried to kill themselves, cannot sleep, and cannot form and maintain good relationships with others. So clearly, the traditional approach is failing.
Yesterday, the head of a VA Vets' Center told me that the average patient in the VA's mental health system is seen once every three months. One might conclude that that is the problem, that the VA is far too understaffed. But since the current wars began, the rapid introductions of new programs and hiring of more staff has not even led to decreases in the numbers of serious problems and suicides. In fact, they only increase steadily, and Pentagon spokespersons have publicly expressed alarm about that.
To listen to veterans is to learn that, for the most part, diagnosis has not been helpful, just made them feel "crazier"; drugs have rarely helped and nearly always caused negative effects such as exacerbation of their troubling emotions and moods, sexual problems, dramatic weight loss or weight gain, and the onset of diabetes and heart problems; and even psychotherapy has not helped, because it has too often been based on the notion that they have individual psychopathology, with little or no attention paid to the mammoth shock of returning from a life focused on strict hierarchies and following of orders aimed at least partly at destruction and killing to civilian life in which structures, ways of interacting, and life aims are utterly different. And too rarely have those in therapy found help in figuring out what to do about the loss of the intense closeness of the relationships they formed with those with whom they served in the military, a closeness that - especially for the men - is unequaled by any relationships they have had with others before or since. And many men have been taught to be uncomfortable if they want close and meaningful friendships with other men in civilian life.
A veteran left this comment in response to an earlier essay on this blog: "Depression made me cry and retreat inward. Therapy sessions made me cry and retreat inward. Antidepressants caused unpleasant side effects. Side effects made life with depression more unpleasant. For me, it was all as counterproductive an experience as it sounds." And one of the veterans I met in the course of writing my book, formerly a vibrant human being, has now been on at least three psychiatric drugs for years, is seen regularly in the VA system, and is clearly experiencing dramatic damage to his brain and major and rapid weight loss, while becoming increasingly despondent and feeling increasingly helpless.
Furthermore, as veteran Rick Lawson wrote to me, "Enduring and returning from combat is not a mental illness! And we shouldn't have to be disabled to obtain compensation and assistance upon our return home." In fact, here is a tragic irony: Robert L. Whitaker has shown in his book, Anatomy of an Epidemic, [2] that the use of psychiatric medication (which virtually never happens unless the patient is given a psychiatric label) dramatically increases the chances that the person will end up on disability as a result of the effects of the medication. (And a reader of this blog left a comment about the ways that both nonpsychiatric and psychiatric drugs can cause what look like symptoms of serious mental illness.) So to call all veterans who are suffering emotionally mentally ill is to increase dramatically the chances that they will end up on disability. In spite of this, the courts are filled with cases of veterans who have received diagnoses but still cannot get the benefits to which they are entitled as veterans, given how slowly the system works and the high frequency with which applications for deserved benefits are rejected. So one way to help is to learn and educate others about these major problems in the systems in which veterans are treated and to support individual veterans and veterans' groups as they struggle to get what is coming to them and to improve the system.
There are other ways to help. To listen to veterans is to hear that even when therapists are helpful, the veterans know the therapists are getting paid to help and are not part of the veterans' world outside the therapists' offices. Time and again, when asked what has helped them regain some calm, some peace, the former servicemembers described incidents in which someone from the wider community, often someone they had never met before, asked to hear their story. It is remarkable how many have said such things as, "When I told a bit of my story and was kicking myself for not having done something I thought I should have handled differently, the person listening said I was being too hard on myself. And that night, I slept for the first time since I got back from Iraq."
Since fewer than 1% of Americans have served in the military, the only way we can understand what veterans have been through is to ask. Since it is helpful to them and helpful to us, giving us a way to help our nation heal from the emotional wounds of war, asking to hear veterans' stories is one way to provide some help. [3] I have mentioned this several times on this blog but risk being repetitive, because veterans say it is useful for them and because it goes so strongly against the pervasive assumption that only therapists can help.
Another way to help is with the practicalities of life. Whether someone is unemployed because of having been at war or having been traumatized in some other way, as my friend Alan Rauzin wisely said, "Work roots you in the world." It carries some dignity, some sense of mattering. We can help veterans find jobs. And when it comes to having no home or food, how can one begin to heal from emotional trauma while having to worry constantly about where to sleep or find nourishment? Every program I have ever seen that effectively assists people who are suffering from emotional causes provides these kinds of practical assistance.
An anonymous writer commenting on this site speculated about veterans that "The general community isn't going to be able to help the guy who gets intense panic attacks whenever he's in a car, or who constantly feels in danger when in public." Although some therapists can be helpful to some veterans with such problems, veterans report that many have not. But beyond that, one way of helping veterans to feel at least somewhat safer, if not safe, is in fact to ensure that as many people as possible in their communities understand the reasons for the vets' panic and sense of danger and to let them know that they will not be judged or mocked for not having "gotten over it" yet. Does that kind of community education and support solve all of veterans' problems? Certainly not. It is impossible to think of what kind of drilling and events of positive sorts would be powerful to counteract or undo the effects of the months and years of focus on and exposure to mortal danger that they have experienced in the military. No therapist, no layperson, and no community can provide that. What we can do, though, is commit ourselves to the ongoing labor of love, as Veterans Affairs psychologist Dr. David Collier calls it, of taking what steps we can to understand and support veterans, helping them truly come home from war.
[1] See Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press for more about this subject.
[2] Robert L. Whitaker. (2010). Anatomy of an Epidemic. New York: Crown.
[3] In Chapter 6 of Caplan (2011), I offer detailed guidelines for interviewing veterans, as well as suggestions for dealing with some common problems that can arise in these interviews.
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