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Outlook: Still a Long Way From Home

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Linda Blum
Clinical Psychologist
Monday, June 30, 2008; 12:00 PM

"Nearly 40,000 U.S. troops [have been] diagnosed by the military with post-traumatic stress disorder after serving in Iraq and Afghanistan from 2003 to 2007; the number of diagnoses increased nearly 50 percent in 2007 over the previous year, the military said this spring. ... What the raw numbers on war trauma can't show are what I see every day in my office: the individual stories of men and women who have sustained emotional trauma as well as physical injury, people who are still fighting an arduous postwar battle to heal, to understand a mysterious psychological condition and re-enter civilian life."

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Clinical psychologist Linda Blum was online Monday, June 30 at noon ET to discuss her Outlook article recounting the stories of the Iraq veterans she met and treated at Fort Dix, N.J., and psychological therapy for the persistent nagging mental trauma of war.

The transcript follows.

Archive: Transcripts of discussions with Outlook article authors

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Linda Blum: Hi, I'm here to discuss "Treating Wounds You Can't See."

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Garden Grove, Calif.: What happens when we don't treat them? Will the symptom go away with time?

Linda Blum: Often symptoms will diminish with time, particularly in milder cases, but treatment very definitely promotes healing.

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San Antonio: What can I say to help my son overcome his sorrow for killing an old Iraqi man who sped through his roadblock? How does he get over carrying dead buddies back to his Humvee after roadside explosions? And there is so much more ... how can I help him? What can I say?

Linda Blum: These are the toughest questions, but your son's communication with you, and your desire to help him, are very positive signs. Too often, soldiers put up a wall in attempting to shield family members from their pain.

I would urge your son to seek counseling -- if he has not already -- to help process these experiences. Group therapy, in which he can get help from other soldiers who have been through similar experiences (and help them, too), is often highly effective.

These traumatic memories will remain with your son, but in time he will move closer to acceptance, and hopefully will be able to extract some meaning from these experiences that can guide his future life. All the best luck; my thoughts are with you.

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Mandatory counseling?: Thank for this article. Do you think all returning military members should have mandatory counseling? On the one hand, it might ferret out men and women in trouble before they fall further, but obviously it also would put an enormous strain on already-scarce resources.

Linda Blum: I don't believe in mandatory counseling, except in those cases when lives are in danger -- both because coercion is rarely effective clinically and for ethical reasons.

We need to ensure that treatment is widely available, let people know that treatment is available, and continue efforts to destigmatize PTSD, so that vets and their families won't be reluctant to seek treatment.

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Ashburn, Va.: I have a minor role in a large study being undertaken by the International Association of Chiefs of Police that is looking at issues surrounding veterans returning to their law enforcement agencies after being deployed to a combat zone. I have two questions: First, our initial observations are that law enforcement officers seem to suffer less from PTSD than other veterans. Have you had any experience in that area? If our observations are valid, could this mean that, in general, police are more stress-inoculated, or that we cover it up better than others? My second question is, if you could implement one requirement for returning veterans that would assist in re-integrating into their pre-deployment jobs, what would it be? Thanks in advance!

Linda Blum: I treated several National Guard vets with long prior careers in law enforcement, suffering from severe PTSD after particularly rough deployments, so I know that law enforcement personnel are not completely immune to PTSD. However, it's possible that the police officers do, over time, develop adaptive, self-protective responses to stress, danger and violence. I would love to see a study of this issue.

Regarding readjustment, I would urge vets to avail themselves of treatment, which is a benefit they have earned, as well as communicate as much as possible with family, friends and supportive colleagues.

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Kensington, Md.: The number quoted in the lead-in to this chat (40,000) low-balls the estimate from the Rand study earlier this year (300,000) by an order of magnitude. Is the 40,000 figure just those who actually have gone in, seen someone and met the diagnosis? In any case, thank you for this compilation of frank vignettes from your patients' lives.

Linda Blum: I believe the 40,000 figure represents diagnosed cases, and the other figure you quote is an estimate.

Thanks for your kind words about my article.

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Millington, Tenn.: Why all the guilty feelings about those you left behind in Iraq? I sure don't want to return, but feel compelled to do so, like I have unfinished business or I've let my comrades down.

Linda Blum: It sounds as if you are experiencing both empathy and guilt.

Empathy for others in difficulty is certainly among of the most admirable aspects of human nature, and guilty feelings, though painful, also can serve important purposes, individually and societally -- but it's important to remember that your individual service cannot in and of itself help the large numbers of soldiers over there now. In that sense, your guilt is irrational.

Whatever decision you make for the future, remember that you've done your part in serving, and I would like to express my appreciation.

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Richmond, Va.: I have many friends and relatives who have served, and some of them show some signs of a stress disorder, if not PTSD. How is PTSD treated so that people can try to cope with it and return to some normalcy? What kinds of specific coping techniques do you suggest to your patients?

Linda Blum: Really, there are numerous treatments. Even for mild, subclinical PTSD, which seems to be what you are describing, talk therapy can help and medication need not be ruled out. Relaxation exercises and yoga are often helpful.

I would encourage people to minimize life stress as much as possible and work to maintain a positive social support system, even when the tendency is to withdraw from others.

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Philadelphia: In today's newspaper, it states there is a Veterans Administration backlog of 400,000 claims for disability, and that it may take six months until the VA gets to a claim. Does this VA backlog affect the health care that veterans are receiving?

Linda Blum: The delays in obtaining benefits and the arduous process involved certainly add to the stress level for many injured vets, but they can begin psychological treatment through the VA or Veteran's Centers before getting disability.

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Lyme, Conn.: I would like it if you would be able to confirm or explain stories that returning Iraqi veterans have told me. I think if these comments are accurate, it may help the public to better understand the degree to which post-traumatic stress disorders and other mental challenges are even more of an issue than most realize. First, I understand some of the bombs that the soldiers are exposed to cause atmospheric rattling, which literally rattles the brain.

Second, these soldiers go on patrol and face potential fire on such a regular basis that many have faced more days of combat than did soldiers in previous wars. Third, the body gear saves lives but is not protecting limbs, meaning we have a higher survival rate yet a higher severe injury rates. Are all of these points true? These veterans are returning home, and some of them will have very serious issues they are bringing back with them, and we need to be there for them.

Linda Blum: All of the above are true. I would add, though, that soldiers in Iraq and Afghanistan have a very broad array of experiences, with some going out on daily missions with constant exposure to danger, and others more protected on post.

Additionally, some U.S. bases are subject to considerably more incoming mortars and rockets than others.

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Anonymous: My wife is a clinical psychologist working in a VA PTSD clinic and sees a lot of returning vets who come back and get hooked on meth. She theorizes they were given amphetamines in large amounts while in the service. Do you see this, or is it a function of our poor rural populace? Also, when are we going to start hearing about how this war has been retriggering PTSD in the Vietnam guys?

Linda Blum: I haven't heard much about meth abuse in the service. I saw soldiers who tested positive for other illegal substances, but not for meth -- I can't speak more specifically than that. Your wife may know more.

I've read a couple of accounts of the current conflicts reriggering symptoms in Vietnam vets with PTSD, but I'd like to add that the Vietnam vets also often have been a tremendous help to soldiers returning from Iraq and Afghanistan. There is a group of Vietnam vets who visit soldiers on medical hold and have done a tremendous job of boosting morale.

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Silver Spring, Md.: A few years ago, my husband and I dealt with his major depression with the healing nature of Yoga Nidra, which is being offered to returning soldiers at Walter Reed National Medical Center. Can you please address the need for "alternative" healing methods to be introduced to those who might see them as "lite." The healing of the brain, as you point out in the last paragraph of your moving article, requires patience, prayer and restructuring of the actual neurons. I cannot imagine what some of our returning soldiers have had to deal with, and I also think of the medical professionals who are doing their best to patch up these broken bodies. What an extraordinary toll they must carry!

What is the most appropriate way to acknowledge one's gratitude to soldiers when one sees them on the street? We encounter a few amputees at cultural events, and I often feel a great need to thank these young men and women for what they have endured. The fact that they are outdoors with buddies or family seems to be a great stride toward healing, but I think they must often look around at our carefree enjoyment and wonder at our ignorance of what they have had to endure halfway around the world. Thank you so much for your article!

Linda Blum: There is ample empirical evidence of the benefits of yoga, so perhaps we need not even refer to it as an alternative treatment at this point, though it is certainly nontraditional.

"Alternative" suggests that it might replace other forms of treatment -- talk therapy, medication -- rather than be used in conjunction with them. I would urge people to look at the research, and employ whatever treatment works for them personally.

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Washington: When I was in Baghdad (with the government, not the military), many of my career soldier friends told me that counseling was frowned on institutionally, and could result in a black mark on their records. Whether that's true or not, it certainly seemed like a common belief. Is there anything being done to improve the military's perspective on counseling?

Linda Blum: The military recently has changed policy on requiring personnel to report counseling and psychotherapy, and hopefully the new policy both reflects and will encourage a changed mindset.

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Boston: How would approach someone whom you think may need to talk about their experiences in Afghanistan or Iraq, but who doesn't seem keen on discussing anything? In the meanwhile his personal relationships are being destroyed because of his actions.

Linda Blum: I would suggest letting the person know you care and are open to discussion, but not pressuring them. You don't say what your relationship to the person is, and the level of intimacy and trust of course makes a huge difference.

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Vienna, Va.: Everything I've read indicates a strong connection between depression and PTSD. PTSD apparently occurs in civilian life as well. Are people inclined towards depression more susceptible to PTSD? It seems to me that studying this link may lead to better treatments.

Linda Blum: Depression is one of many personality factors found to increase the risk of PTSD.

I would add, though, that exposure to life-threatening events is the most crucial factor, and beyond a certain stress threshold everyone is going to experience symptoms, as the condition is rooted in the basic neurobiology of the human brain.

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Astoria, N.Y.: My father served in World War II, and my brother in Vietnam. My father said Patton wouldn't tolerate this post-traumatic stuff -- he would call you a coward if you try to get out of the military using that as a excuse. My brother -- who just passed away -- used his post traumatic crutch his whole life. It's a bunch of bull, these guys complaining about battle fatigue -- all they need is a kick in the ass and a smack in the face. Get over it already -- life goes on.

Linda Blum: It is certainly true that there are people who exaggerate their symptoms or develop a sense of entitlement as a result of a PTSD diagnosis -- but that is true of any medical condition.

While I did see some malingerers, from my experience there were more people denying or minimizing their symptoms. Someone would come in and say "well, I've had some insomnia," and you soon see that's the tip of the iceberg.

May I say that I doubt that your attitude was helpful to your brother, though I certainly understand your frustration.

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Washington: Thank you for your article. I truly believe that Americans need to pay more attention to our soldiers and become more involved in the sacrifices they are making. What would you suggest to someone who wants to get into a career field assisting our military and their families?

Linda Blum: There are many ways to make a contribution, and I would say only that you should follow your own interests and abilities. You might be interested in working on administrative aspects, might be interested in working with children and families, etc.

Good luck to you.

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Arlington, Va.: Great article addressing a topic I've had on my mind a lot because I have a son doing his first rotation in Iraq. An observation: In some ways it seems a good sign that members of our Armed Forces are so troubled by their experiences in war; it's a sign that they haven't lost empathy or their ability to identify with other people, even if their behavior after returning seems mostly to be withdrawal and lack of willingness to connect with family and friends. I also wonder if vets of past wars found their "talk therapy" informally at the VFW post, and what that experience might teach us now.

Linda Blum: These are very good points, which I would agree with. I have no doubt that the VFW and other veterans' groups have served a crucial therapeutic purpose in giving vets an arena to talk, share experiences, and maintain their bonds with each other (without any conscious awareness of providing "therapy."

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Washington: I was surprised to read about the mandatory holiday party. Have you found many instances such as this, where something supposed to be fun becomes compelled and tortuous? Can you talk to the top officials there to get them to see this point of view?

Linda Blum: I think the purpose of having a mandatory party was to promote socialization and fight the tendency of some vets to withdraw -- but, yes, compulsion/coercion is problematic and in this case it did generate quite a bit of unneeded anxiety.

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San Diego: What can the average person do to help these veterans?

Linda Blum: Your attitude of respect and interest is in and of itself helpful. Beyond that, I would suggest, follow your own interests and background, contact local vets' groups and see what their needs are.

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Tampa, Fla.: Do you know the estimate of Iraqis with PTSD? Also, I hate to sound cold here, but what business did these soldiers think they were in? They are in the killing business. Was their some confusion when they joined the service? That said, I'm not that cold -- they should be treated because they are suffering humans. But somehow I feel that nobody cares much about the Iraqis who have been dragged out of their homes to interrogations, had their doors kicked down in the middle of the night and basically have been terrorized by our troops. Somehow I feel that nobody is going to be tallying the number of PTSD victims in Iraq. Do you?

Linda Blum: I don't know the stats on Iraqis with PTSD, but I imagine it's quite high.

From my experience, many of our soldiers do care a great deal about the Iraqi people.

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Linda Blum: I'll have to sign off, now. Thanks to all.

Linda Blum

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