Healing aftershocks of war, military service ( WOUNDS OF WAR / first of three parts )
Dr. Scott C. Cornelius, PsyD, at the VA Center in Leeds.
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Staff psychologist Scott Cornelius has worked with military veterans for nearly seven years at the Central Western Massachusetts Healthcare System in Leeds, a 25-bed specialized inpatient program for the treatment of post-traumatic stress disorder. The six-week residential program, which opened in 1982, is one of about 30 of its kind at VA’s around the country.
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NORTHAMPTON — At the VA Central Western Massachusetts Healthcare System in Leeds, staff psychologist Scott Cornelius has worked with military veterans for nearly seven years at the hospital’s 25-bed specialized inpatient program for the treatment of post-traumatic stress disorder.
The six-week residential program, which opened in 1982, is one of about 30 of its kind at VAs around the country.
Cornelius says that, as a society, we tend to think about what war can do to soldiers during conflicts, but forget about it afterwards. The reality is that ex-soldiers can struggle for years with the after-effects of military service, he says.
In an interview at the VA, Cornelius talked about what the VA offers those veterans.
QUESTION: Is it hard for vets to ask for help?
ANSWER: It can be. There’s some stigma still against the diagnosis of PTSD. Even with efforts to reduce it, I know it’s still out there.
Q: What’s your sense of how widespread PTSD is? The VA estimates it at between 11 and 20 percent of returning vets.
A: I think the figures are probably higher. I think we’re just seeing the tip of the iceberg now. A veteran who comes back, who’s young and full of energy — you can run from something for a long time. If one thing doesn’t work you can go on to something else — alcohol, drugs, sex, another job, move to a different state. You can go on and on. Sometimes we don’t see them here until their lives have really fallen apart. So the sooner they get in, the less damage there’s going to be in their lives.
Q: Do you find that before coming here some veterans haven’t really talked about their experiences with anyone?
A: That’s very common. But we’re also seeing another phenomenon with others who might have talked about it a lot, in a way that revs them up, gets them jazzed and agitated, like playing a war game. Today, with cameras and cellphones, some are coming back with scores of pictures and they’re constantly reliving this stuff but not in a way that helps them process it. If it makes them revved up and angry, then maybe it’s not a good thing for them to be doing. Brooding on what is wrong with the world can kind of keep them stuck, keep it alive.
Q: Is the residential unit big enough to meet the need?
A: There is a waiting list, though we’ve worked very hard to reduce the waiting time. Veterans come here from around New England and they come through for six weeks. They can come back for a three-week readmission the next year if needed.
Q: Once they’re here, what happens?
A: Mostly it’s a group program. We have three clinicians and each of us has eight vets who come here and stay together for the six weeks. It’s a great thing to see as they start to know each other, they build supportive networks. What we hear again and again is that they start to feel safe, to feel connected, to not be so hypervigilant.
Q: I know many vets are seen on an outpatient basis here. When is admission better for some?
A: First of all, my hope is that most veterans can be helped on an outpatient basis. Many of the same treatments are offered to outpatients. But sometimes younger vets, the ones who are really struggling, have trouble organizing their lives, they’re too unsettled, they’ve been running so much, they can’t keep appointments and so on. So just being here on a unit, this can help them settle, to be in the present, develop plans for the future.
Even by the second week, you can see a tremendous difference. At first, they’d bolt for the door if they could. But a couple of weeks later, even though they’re still working through a lot of pain, you see some laughter, some camaraderie.
Q: What has changed in terms of our understanding of PTSD and how best to treat it?
A: What we’ve offered for years are opportunities for psychotherapy, supportive relationships with therapists that can be very helpful, and education about PTSD so veterans can understand better what they’re facing, what their options are, and how to cope with it.
What’s newer is the growing capacity of therapists to offer evidence-based treatments. There’s now an emphasis on the role that avoidance plays in PTSD — it’s now thought that avoidance itself is the glue that holds PTSD together.
Q: So what does avoidance do to a person?
A: For a veteran, crowds may be anxiety provoking, as they marked danger in the war zone. So it’s natural to start avoiding crowds and that does seem to lower anxiety at first.
However, it can easily lead to a whole lifestyle that begins to center around avoidance. A veteran might stop attending his child’s sporting events and other functions where there are lots of people, such as birthday parties or school events. As he starts to realize that he’s missing out on life, he may become depressed, which leads to a whole range of feelings that he also tries to avoid, perhaps by turning to alcohol or by staying in bed. Unchecked, avoidance can escalate into a life that’s lost its meaning and purpose. The good news is that it’s something the veteran can begin reversing, by beginning to make choices about gradually stepping back into life. So treatments target that avoidance.
Q: How do they do that?
A: By looking at a specific traumatic incident and exploring how it has impacted your beliefs. In cognitive processing therapy, you’re looking for the stuck points, the places where the veteran believes, for example, that they’re responsible for what happened, that “if only” they done this, or “what if” they had done that.
In prolonged exposure therapy, we’re literally helping patients approach the very situations they’ve been avoiding, like being in a crowd again. So we’ll go to a mall or a checkout line at a grocery store. It takes repeated exposure, but over time, the idea that this situation is dangerous becomes less prominent.
We also do what’s called imaginal exposure, where the veteran, with a clinician, will talk through a traumatic incident to get in touch with the feelings and sensations that were part of the trauma. We’ll do it repeatedly, maybe 10 times, over and over again. What we find is that the pain is still there but the avoidance starts to be reversed and the memories start to lose their power.
In combat, veterans didn’t have luxury of being able to do this — they had to get on with the mission. So we’re giving them and opportunity to go through it, in a sense to flush this through. It can help develop the flexibility to get on with their lives.
Q: What kind of outcomes do you see?
A: There’s a range, definitely. It depends on the individual, their willingness to take steps forward — and the nature of the environment they’re going back to. Whether it’s toxic or caring and supportive can make a huge difference because this is an ongoing process of recovery. You can’t underestimate the role the veteran’s environment plays. Before I came here, I worked at the Department of Defense, and the soldiers I saw there on active duty who had caring families fared so much better than those that didn’t. I’ve seen people do amazing things — go back to school, get jobs that they dreamed of, get into good relationships, be good parents. And I see people who are taking a longer time to find their way.
Q: How does the life they led before the military figure in?
A: A history of trauma as a child places you at greater risk. If you haven’t had strong support systems as a kid, same thing. So the trauma of war and coming back can amplify problems that were there all along.
Q: Is it true that the severity of the trauma doesn’t necessarily correlate with the severity of the reaction?
A: Absolutely. What one person experiences as a trauma wouldn’t necessarily be a trauma for another.
Q: How do you deal with drug and alcohol abuse?
A: That’s another huge step we’ve taken in the last four years. In the old days, everywhere the thinking was that you need to address the substance abuse first and then get mental heath treatment. What I saw when I first came on the unit was that if we waited, we’d sometimes be waiting 10 years. Now we admit them much sooner in the recovery process. We require that they remain clean and sober on the unit and they go to groups for that — they can’t be detoxing on the unit.
Q: Are the people in the residential program all veterans from Iraq and Afghanistan?
A: No. We still see Vietnam-era vets and we’ve even recently had Korean War vets. When I started five years ago, most were Vietnam-era vets and a trickle of younger ones. Now it’s 50-50, between Vietnam and more recent conflicts.
Q: What do you see with the Vietnam-era vets now?
A: For some, all the news about Iraq has exacerbated symptoms for them and they find they need to come in. And since they’ve had so much life experience, it’s not uncommon for them to have depression superimposed on the PTSD.
For someone who’s been struggling for 40 years, who feels beaten down, depression will likely be a bigger part of picture. The younger vet may be more anxious, agitated and angry that things aren’t working out. Both can have PTSD.
U.S. Department of Veterans Affairs National Center for PTSD
PTSD: Weakness or Wound?
Study links PTSD to Hidden Head Injuries Suffered in Combat
University of Rochester Medical Center