Wednesday, April 8, 2009

Post traumatic stress disorder (PTSD)

Post-traumatic Stress Disorder (PTSD)

It has been a while since I blogged regarding PTSD and other mental or emotion distresses. By the way, I prefer the term “distress” instead of “disorder” or “mental illness.” Many mental conditions are perfectly natural responses by the body and the mind to terrible circumstances, and thus I prefer that people do not think of them as “wrong wiring” or “mental imbalance.” PTSD, for those victims of trauma who suffer from it, are the body and the mind’s efforts to deal with something so radical and scarring that a painful set of symptoms occur, but that is not the same as being mentally disordered or biologically or mentally flawed.

I want to address myself to all PTSD sufferers but most especially to those in the military or law enforcement. I am thinking most especially of the Vietnam War veterans who suffer to this day, and now the Afghanistan and Iraq War veterans who must also deal with PTSD in such great numbers. I want to give you two tools to help you when you read this. One is a way to explain PTSD in a way that I believe is much more accurate an analogy or images than you’ve probably heard before. Military people can relate that you must “know the enemy before you can defeat him.” I think this analogy will help you to better understand exactly what PTSD is and how I recommend one can alleviate much of the distress, while never being, of course, able to deny or erase what happened, nor should you. The second tool I want to give to you is a way to work on the PTSD dreams and nightmares that I have found very helpful when I have given sufferers direction in these matters.

The best way to think of PTSD is that you are in the jaws of an alligator or a crocodile. Let’s say crocodile since it’s a global animal that everyone is familiar with. When one has PTSD one can think of one’s self as being firmly in the mouth grip of a crocodile, and each of the croc’s teeth has a hold on you. The crocodile represents the source of the PTSD (such as trauma during war service). In other words, there was nothing wrong with you before you had the trauma. Then something very real happened, where you are bitten by the croc and held in its mouth so you cannot pull free, and the teeth represent the types and severity of the psychological and emotional wounds you have received and the ongoing symptoms.

Now, this is how you can understand the prescription medications that you receive that may or may not help you. The prescription medications do not free you from the croc’s jaws; they only dull the pain so that you can function more gracefully and comfortably as if you were not feeling the pain of the bite. But of course despite what doctors say, the medications cannot erase the cause of the trauma as if it never happened, nor can it restore you to what you were before. This is where the analogy is helpful because each tooth mark leaves a scar, even if one was, using our analogy, completely free of the jaw’s grip.

When one “self medicates” through addictive substances, such as alcohol and drugs, or other addictive behaviors such as risky behavior, compulsive behavior, or other means of “escapism,” one is trying to do the same thing the doctors who prescribe do, which is dull the pain of being bitten by the traumatic event or events. But like the prescribed medications, self medication only attempts to dull the pain of being continually bitten.

So how do I recommend that a PTSD sufferer deal with PTSD, using this analogy? First of all, yes, be sure, of course, to stay on any medication that the doctor prescribes because you cannot work on any sort of remedy or cure if you are in pain and engaging in risky behavior due to the PTSD. Everyone knows that it is harder to heal something like a broken arm if you are in continual pain. So yes, if you have one or more prescriptions that ease your pain and symptoms, be sure to continue to faithfully take what a reputable and conscientious doctor prescribes.

However, I invite you to think about how one actually tackles the PTSD itself. Think of your status as being in the grip of the croc’s jaws and all its teeth. You cannot pull yourself out of the grip, so you are stuck. But are you? What if you had a set of pliers and pulled out the teeth one at a time?

Suppose one of your symptoms is having recurrent traumatic dreams and nightmares. Those dreams represent one of the teeth of the croc. In other words, if you are able to work on alleviating the stress of the dreams, and even reducing their occurrences, that would be as if you pulled out that tooth from the croc. This also helps you to understand why some in distress of PTSD have the bad dreams while others do not. That particular symptom of “tooth” just is not biting down as hard on some folks as it is on others. That is part of how each individual is unique, as is each trauma. You might be someone who was bitten and held by a small croc, with a trauma that, while painful and real, has a smaller “bite mark,” a smaller less severe pattern of symptoms. On the other hand, those who served in the Vietnam War, for example, I have noticed have all been bitten by a huge croc with many deep biting teeth. This is because Vietnam was “not just another war.” It was a shattering experience on so many levels and had few mitigating circumstances of comfort and many simultaneous types of trauma.

Just for one example, the United States had previously fought only open conflicts, never a guerilla war. So while there were vets traumatized by World War II and Korea, Vietnam was a warfare tactic that neither the military institution nor the individuals serving had any experience or preparation for. So being in a guerilla war is, again using that analogy, one tooth of the bite and holding of PTSD that those in other wars did not so much experience (except, for example, those who fought on the ground against dug in Japanese in World War II).

So the individual teeth of the croc are made up of two ways of looking at it: the symptoms that you feel and the reasons that trauma was received. An example of a “symptom tooth” is the bad dreams. An example of the “cause tooth” is being totally unprepared for a guerilla style of warfare.

Military folks who suffer from PTSD tend to be able to list their symptoms, so the “symptom teeth” will probably not be too difficult for you to recognize (though often people do not see how much they have changed until they are home and have difficulties). You’ve probably all had to list the symptoms in the doctor appointments and endless paperwork. But here is what I am suggesting. I have had some very good success at turning it a bit on its head, where instead of the one block being “PTSD” and all the symptoms hanging off of it, to be treated as a whole, try breaking the symptoms down into individual components that you might address one or two at a time. PTSD, like most mental distresses, is not something that one can tend to treat as a whole and people in the profession have become a bit too charmed with that idea, and then are disappointed when they cannot “cure” or alleviate PTSD. It’s not like getting rid of a cold or the flu. But that is a useful comparison so let’s explore it for a minute.

If you have a cold or the flu you have one cause (bacteria or a virus) and many possible symptoms (sneezing, sore throat, fever, runny nose, coughing, sore chest, body aches, nausea, fatigue, etc.) In general when one is dealing with physical illnesses, when the illness passes or is “cured,” all the symptoms go away, obviously, since you are no longer sick with that illness. People for a variety of reasons think of mental and emotional distress the same way: if you treat the overall “type of distress,” such as PTSD, then the symptoms should all together gradually improve. It’s perfectly natural that everyone tends to think of mental illnesses as being just like physical illnesses, except of the mind and nervous system instead of the body. Medical schools, scholars and insurance and medical reimburerses all tend to think that way. We fill out your form with your “diagnosis,” PTSD, list your symptoms as “proof” that you are indeed suffering from PTSD so you can be treated and the provider is reimbursed, and then the “treatment plan” for PTSD is developed, which is usually prescription medications with some group therapy. That is fine and that is the way the system is established, but I believe that it leads to slower, and often nil, results. I believe that in addition to the overall treatment of the overall condition of PTSD that each symptom should be separately addressed using non-prescription drug techniques of counseling, therapy and self help.

The way the medical system is established there is little access, and none of it reimbursable, to what I am suggesting. When I was an intern I was able to treat a number of patients via counseling only because since I was a “free body” (student interns are not paid). Thus while I was there during my nearly nine month internship I was able to provide “talking” treatment to patients who would not have otherwise received it. This is one reason I have spent a fair amount of time thinking about ways that those in distress, such as those with PTSD, and their families and friends, and church groups and others who donate services, can listen to some of my suggestions and try them in addition to their regular treatment. This is why I blog on these types of subjects and would like to be able to help through some future venue.

Suppose that you are a PTSD sufferer with a number of symptoms and you were able to eliminate or control one of those symptoms? I think that would be a relief if, for example, you are troubled by the symptom of bad dreams and you were able to mitigate that one symptom, even if the others remain. It tends to have a mutually beneficial and cascading effect anyways; if you improve one thing you become more at ease and more comforted and when you feel better in that one area you can deal with the other symptoms better, and perhaps address them too, one at a time. So I’m suggesting that while you, of course, continue your medical course of treatment, you draw up an action plan for addressing one of the symptoms as a targeted effort on it and it alone.

So here’s what you do. Make a list of your croc’s teeth. These are both “symptom” teeth and “cause” teeth. The idea of the “cause teeth” may be new to you, but it’s easy to understand once you start thinking about it that way. What made Vietnam so particularly unique and scarring? I gave one example, which is that it was a guerilla war rather than conventional conflict, which the military command and training gave no preparation for, and which shocked the combatants mightily. So while your symptom teeth list what you are suffering from now, your cause teeth list each thing that contributed to the shock, damage and scarring, and many of them will be cultural. I can speak with some experience and authority because I am only a few years younger than many Vietnam veterans, since I was a teenager during the height of the war. Further, my family had extensive World War II experience, in all the theaters, so I observed the differences as they were happening. So let me give you some help in thinking about what some of the “cause teeth” might be in your particular list.

O Being drafted for a war whose purpose was difficult to understand, as the USA was not being invaded, nor was there a clear cut enemy such as Japan (who had bombed Pearl Harbor) or Germany (with Nazi global domination clearly an objective).
O Culture shock, where Vietnam seemed very alien and uncomfortable compared to your upbringing, whereas Europe or even Japan (shipboard) in World War II was less jarring a transition.
O Exposure to vices, such as drugs and prostitution.
O Lack of training and preparation for guerilla warfare, which included devices of terror as booby traps.
O Hostility toward the military, including service men and women, by fellow citizens at home.
O Having a close buddy killed, particularly in a brutal way.
O Witnessing atrocities from either side.
O Inexperienced commanders and chains of command that resulted in errors and losses.
O Tactics and strategies that resulted in battles for which there seemed no point or overall plan.
O Being captured.

I could list more but I think you see my point. So let’s look at two examples of Vietnam veterans with PTSD. I’m just making these two up as examples so you can see that while everyone “shares” the PTSD experience, it is indeed unique to each person and must be treated accordingly.

Example One: Symptom teeth: bad dreams, startles easily, distressed by loud and sudden noises, emotionally withdrawn from loved ones. Cause teeth: many “close calls” in the battlefield, witnessed bad orders causing unnecessary loss of life, close buddy captured, and “social scene” that one was too young to handle.

Example Two: Symptom teeth: bad dreams, addictions (list each one), drawn to conflict and violence, suicidal thoughts. Cause teeth: lack of support from home, found gun was only response to guerilla and cultural violence, forced to give bad orders.

See, these are just with a few words two people that while they share the “PTSD Vietnam vet” label are obviously two very different people with very different experiences. Medicine, like all aspects of our sad culture and society today, try to lump people together into cookie cutter categories and treat them accordingly. PTSD, however, is if anything the example of how individual PTSD distress really is and how customized and unique to the individual that treatment must be.

What I would do if I was counseling one or a group of Vietnam vets with PTSD to apply the technique I’ve introduced them to today is to (and remember, this is in addition to all conventional medical treatment):
1. Draw up your list of symptom and cause teeth. Help each other out in thinking of items to put on the list, but only put them on the list if they really affect you individually.
2. Select one symptom tooth and one cause tooth that you want to specifically gain treatment for.
3. For the symptom tooth, your approach is to work on that one symptom as if it were an illness. For example, when one has a cold one might sneeze or have sore throat. Select “sneeze” or “sore throat” and act as if that is an individual standalone illness. You are going to cure yourself of “sneeze,” to use that example, rather than wait for the sneeze to go away when the cold goes away. Therefore you might select to stop or at least ease the “bad dreams” as if it were a standalone illness, rather than wait for them to go away, if ever, if the PTSD “goes away,” which it rarely does.
4. For the cause tooth you use a different approach, but with the same objective of wanting to cure or at least ease the one “illness” represented by the cause tooth.

Before I explain how to approach 4 in specific detail, let me make a broad point. Vietnam vets, understandably, tend to do one of two things. They either withdraw from talking about their experience, for all the obvious reasons, or they tend to read material or have conversations that validate and revalidate their own experiences. For example, they tend to view movies, read books, or have conversations that parallel and validate their own experiences. That is understandable and seems intuitive to do (as part of “you are not alone” therapy), but it often, as logically as it seems, hinders a cure to one or more symptoms. It tends to reinforce the “what’s done is done” and “it happened to all of us” and it “can’t be changed” mindset. Catharsis and validation of one’s own experience have actually been proven to be among the least effective of techniques used in self or professional therapy. All patients, and the society as a whole, loves “let it all out” and “catharsis,” for example, feeling it is “healthy,” but the literature in group therapy shows that while it gives temporary emotional satisfaction to the client or patient, catharsis is the least helpful of the dozen or so techniques used in therapy. I’m not saying to bottle it up, but I am saying to be more skeptical of one’s own human nature tendency to want to hear one’s own story told time after time, either by one’s self or others, without there being a targeted, curative purpose and technique behind its telling.

So suppose that the “cause symptom” that you select to address is the “lack of support from home.” Suppose that your own family had mixed feelings about your service, that you had few friends or buddies back home who could write and support you (younger readers: remember there was no cheap phone calls and this was way before the Internet and email, so traditional letter writing and spotty delivery was one’s only real contact with home, just like in World War II and Korea). And suppose that you were one of those service people who was actually spit on and protested against when you returned home. What if that was a “cause tooth” that aches you still today and contributes to your symptom teeth? How would you address it?

Well, like I said, a lot of people think that is water over the dam and can’t be fixed or undone. And it is true that we cannot go back in time and pretend things went otherwise. But there is an amazing amount of resilience and desire to heal in the human heart and brain, and there is “reprogramming” that one can do to fill in that deficit that was originally created by the lack of support for your service. For example, rather than revisiting through your own memories or the media how bad it was during those times, avoid reinforcement of the feelings of betrayal and abandonment. So do not indulge in “walks down memory lane” of the pain of that “cause tooth.” Here is what you do instead.

You create a “new history” for your brain and your heart in the here and now. For example, you could get a recommendation from someone about a current service member, say in Afghanistan or Iraq, who may not have any family or friends and you become his or her pen pal. In other words, you give today to someone that which you were deprived of. While it does not change time or events, you’ll be surprised at how as far as your brain and heart impulses are concerned, what happens today starts to converge back in time with what had happened to you in the past. In a way it is like you are the new service person today that you start to correspond with. By giving him or her in their need what you did not have, you actually start to put in your heart and memory “bank” what was empty before. Your brain, your heart, and eventually your symptoms will lessen being fueled by what had happened to you, with the lack of support and even hostility that you have received, and instead, the email that you write and receive today with a current service member will be like the support you yourself lacked and that you are now receiving.

It does not have to be, nor can it be, an “exact match.” These are different times where, thankfully, our service people are not being protested against and spat on by anti-war demonstrators. But being lonely and lacking support is universal in all times, and those feelings are the same everywhere. If you find that you can locate a service person who had little or no family or friends, you can make the difference both for him and her and, more importantly for pulling that cause tooth, yourself.

Here’s another idea. Become a self taught “loneliness expert” by reading literature about that condition and studying ways to alleviate it in others, whether military or not. There are two benefits of this kind of approach. One is to learn more about your own condition as you read about it, not in the Vietnam context, but as a general social condition. Rather than reinforcing what you and others experienced in Vietnam, you learn more about why it hurt and scarred by studying the general condition in all aspects of life. That is a lead in to the second benefit which is that it un-bottles the inwardness of the existing PTSD condition and redirects it outward in a productive way. Instead of recycling what has happened to you in your mind, you are now gathering new material in new contexts and could even go so far as to shift from that cause tooth being a scar of Vietnam to a new proactive activity, such as writing articles and blogging about abandonment, loneliness, lack of support, betrayal and ways to cope with them in general. Again, it is not denying what happened to you, but it is a mighty ability to rechannel what was a painful memory into a potentially pleasurable and rewarding here and now activity.

I could give more examples of how to address that particular “cause tooth,” but want to keep this article as an introduction to a technique to get you thinking in these new directions. Now let us discuss my ideas regarding the specific symptom tooth, “bad dreams.”

Remember how I said that humans and societies tend to want to lump things together into one cookie cutter category? Well, people tend to do it to themselves without realizing it. Suppose a Vietnam vet with PTSD is plagued by a particular dream about a specific trauma that he or she endured. They have these dreams “over and over” or at least regularly or, if not too severe, an occasional eruption of that dream. The reaction is, of course, to think “not again” and “it’s that bad dream again.” It is discouraging and thought of as being a repeat of a repeat.

That is an example of the distressed dreamer, quite understandably, tending to lump all of the occurrences of the dream into the same category, which is a repeat of an unpleasant phenomenon, a bad repeating bad dream. But no dream is exactly the same, even if you think that it is; there is always a subtle difference. So the first thing to do is, even though it is painful to have the dream, as soon as you awake think about one thing different about the dream than the last time that you had it and write it down. Keep a pad of paper and pen by your bed if necessary and as soon as you wake, train yourself to think, before pushing the bad dream from your mind, is there something different about this dream? Look for even subtle differences: longer or shorter in duration? Are there any differences in the setting of the dream, the characters in the dream, and the action of the dream, no matter how small?

For example, suppose that your dream normally involves someone, a buddy for example, being killed. The dream tends to reenact the actual event plus some pattern that your dream takes over and over. But suppose in the actual event your buddy was wearing a helmet, and most dreams show him that way, but one night you dream the same dream except that one time he is not wearing a helmet. Or suppose that it was a daytime attack and you accordingly dream of a daytime attack time each time, but one night you dream that it was nighttime. Or you may even have a shorter or longer version of the dream, or a really subtle difference such as the number of people standing around. Don’t rewrite the whole dream on your pad of paper but make a note each time you have “that dream” to identify just one thing about it that was different from the last time, even if you dreamed it while napping instead of while during your overnight sleep. But trust me, once you get used to observing you will notice at least one subtle, or even large, difference in the dream from one time to the next, even if you’ve automatically thought of it as that “repeat dream.”

Again, it’s beyond the scope of this article to right now to do dream interpretation and explain why the dream changes in even that small way. But it is almost not important to know a full out dream interpretation of the “meaning” of that change as it is to train yourself just to notice it and just to write it down. Here is why.

Dreams are, among other things, a self healing mechanism. Just as when you have a scratch or a cut and the body naturally knits together the skin and heals the injury, dreams, even very bad dreams, are trying to “fix you where it hurts.” That memory hurts you and rather than punishing you, your body is trying to “fix it” and its doctor’s office is your dream. That is why I made the point earlier that bad dreams are not something ‘broken’ or ‘flawed.’ Bad dreams are your body trying to fix what is hurting it, in that case, a specific memory of an experience that you had. I know it seems illogical at first, where you think, how does it fix me to revisit it over and over? But your mind is not trying to revisit it over and over; it is repeating an invitation over and over to go into the doctor’s office about this event. That is why responsible dream interpretation by credible and conservative therapists is a hugely powerful therapeutic tool, because dream interpretation “accepts” the invitation offered by your mind to heal the event that caused the PTSD pattern of dreaming.

Lacking any other input your subconscious mind offers up the invitation, through another reoccurrence of the bad dream, and while the dream looks the same at first glance each time, your subconscious mind is trying a different “dab of medicine” through the subtle change I’ve explained to you to watch for. The subconscious mind is enormously powerful and attempts to be helpful, even when it seems otherwise. But it is limited in how helpful it can be unless you make what it does to be recognized and thought about by you and therefore no longer unconscious but conscious. This is why you can gain benefit even by not knowing, since you have no dream interpreter available perhaps, the meaning of a particular change. Just by noticing the change and thinking about it for a minute or two and writing it down you have moved that unconscious dream “dab of medicine” from the unconscious to the conscious.

You know what it is like? Have you ever gone a long time without having a glass of orange juice or a fruit and then you have a craving? You don’t need to know “why,” which is that your body is alerting you to a vitamin C deficit. You just have the fruit or the glass of orange juice. Likewise you don’t really need to know why your dream always involved the buddy having a helmet on, but one time the dream occurs without the helmet. You just have to notice and record on your notepad that you noticed that this dream differed from previous versions because instead of having his helmet on this time he did not.

Now, I could interpret why your unconscious might try that “dab of medicine,” but if I start writing about the specifics and examples of dream interpretation this will be a long diversion from the point of this article. If readers are interested I’ll of course write more and explain how a responsible and conservative dream interpreter would recognize the healing attempt and meaning of the helmet motif changing, for example. But there is a lot of new information to absorb here and I’d like to keep it manageable. I sincerely hope that you have found this article useful and that this and further work will bring some real relief to those with PTSD and other distresses.