Traumatic Stress Reactions (TSR)
I am among those who question the story of PTSD as a biologically rooted, chronic disorder to be managed through various drugs and approved talk therapies. There are many problems with this story, but I will outline two important ones here. First, despite billions of research dollars studying the brain from every conceivable perspective, there is no evidence of biological causation. Secondly, when construed as a biological disorder, the best that can be achieved is life-long management. This assertion ignores the reality that many people incorporate the lessons and fully resolve traumatic stress reactions and go on to lead perfectly normal, productive lives. Unfortunately, when military people and others are convinced to accept the idea of compromised brains to access disability remuneration and services, they are also set-up to accept and to live out permanent dysfunction. They and their families are left with few avenues to move on with their lives.
Arguably, medicalizing the experiences of Viet Nam veterans under the DSM (Diagnostic and Statistical Manual) in 1980 gave legitimacy to their struggles and spawned novel interventions that proved helpful to many people. It has also trapped many others in their past experiences. We are beginning to acknowledge the central importance and prevalence of moral injuries, the legacies of developmental abuse and neglect, intergenerational trauma, institutional betrayal, and military sexual trauma. All undermine medical ideas about PTSD as a biological susceptibility among some war heroes. As such, the concept of PTSD has outlived its usefulness as a concept and as an approach to distress.
A more helpful narrative is that chronic emotional avoidance, numbing, substance use, replaying specific memories, and vigilance among traumatized people are learned behaviours in the service of safety and predictability. While these behavioural habits are essential for distressed people who question everything around them, they usually create many other problems. These strategies can be unlearned and replaced with more adaptive habits. And the most helpful habit seems to come down to consistent engagement with other people in re-establishing a needed sense of safety. The solutions to traumatic stress reactions are in the unedited accounts of traumatized men and women. They are not to be found in some, as yet undiscovered corner of the intricate organ sitting on our shoulders.
As said eloquently by others in Canada, there can be no reconciliation without truth.
There can be all sorts of reasons why therapy can seem unhelpful - not having a good fit with your clinician, not believing that talking about military experiences is helpful, or having problems with money and homelife. In addition to these factors, however, there are two others that stand out.
The first involves the use of psychiatric medications. These turn out to be a double-edged sword. They can be necessary initially to help people reset from overwhelming distress but over the long-term they end up blunting emotional functioning. Why is this important? Part of moving forward from distressing events is confronting emotional reactions and learning ways to resolve them. However, for people who cannot feel anything, this work often turns out to be insurmountable. And when we cannot experience the full range of our emotions, including sadness, anger, or joy, life can turn into a daily grind of just going through the motions. In my work, helping people come back to life emotionally is the primary goal of trauma therapy. Even so, it is essential that veterans not just decide to stop on their own. The withdrawal can be very disorienting and is often confused with a return of depression or PTSD symptoms. It is critical to discuss formal protocols for a slow and gradual reduction in medication use with your prescriber to give your mind and body time to adjust.
The second factor comes down to the central importance of supportive social networks in trauma recovery. Somewhat unfortunately, most standard trauma therapies are individual in nature meaning that veterans meet one-on-one on a regular basis to discuss problems. Yet, for many veterans they count their clinician as the only person who they talk to and otherwise spend their lives alone. They do not communicate with their spouses or family members about how they are doing, and they avoid other veterans and community groups. While this may seem safe and predictable, the result is often loneliness and a lack of meaning in life while continually talking privately with therapists about the past. Moving forward comes with the challenge of taking risks of connecting with other people. Meaning and purpose often comes down to believing that we are relevant in bettering the lives of other people by what we do.
Many military veterans released for mental health problems are prescribed psychotropic medications as a 'front-line' treatment. While these drugs can be extremely helpful in managing distress in the short-term - despite well-documented side effects - there is virtually no information about the effects of medications over the long-term.
Emerging research in Canada and the United Kingdom points to possible damage to specific brain regions and raises concerns over addiction and severe withdrawal syndromes among a substantial number of long-term patients. This is of particular concern for the routine, long-term prescribing of benzodiazepines to veterans. In the last several months, both the American FDA and Health Canada have broken a longstanding silence over this drug class by calling for black label warnings alerting prescribers and patients of the high addiction potential even after short-term use. This research and anecdotal accounts from veterans, family members, and clinicians raises questions over possible deleterious effects of long-term reliance on psychiatric medications.
When it comes to successful transition and re-integrating into civilian life for medically released veterans, then, there are crucial questions to be explored. We require a clearer understanding of the possible contributing role of long-term psychiatric medication effects in explaining: (a). reports of lack of progress among veterans undergoing psychosocial treatments; (b). the incidence of family conflicts and dysfunction; (c). the inability of some veterans to transition to civilian life; and (d). the low rates of accessing available post-service program initiatives among medically released veterans.
I have initiated a petition to the Government of Canada to explore these questions by asking veterans and family members that is open for signature until 18 February 2021.
Petition Link: https://petitions.ourcommons.ca/en/Petition/Details?Petition=e-2930&fbclid=IwAR3HW7UmPlJibYXRACYx8kdY8tarDT7A27go_n5ME_EakDsjc2l8P_-IEHU
There is a common belief that chemical brain imbalances and even brain diseases handed down through one's genetics causes addiction and other mental distress problems. We have been told this repeatedly over the past several decades yet the scientific evidence does not support these propositions.
Why is this the case? This story serves polite society in ignoring taboo topics like child sexual abuse, incest, physical violence, poverty, and terrible neglect which are overwhelmingly common among people who struggle with addiction and other forms of mental distress. These men, women, and children are convinced to keep their stories to themselves because of the upset and disbelief that they create for other people; they are taught to be shameful for the things they have experienced. Polite society cannot accept that these things happen.
Dr. Vincent Felitti and colleagues and subsequent research on the ground-breaking Adverse Childhood Experiences (ACE) studies have put into the public domain, knowledge that addiction counselors and mental health clinicians have had to keep confidential for decades. Namely, that unbearable secrets are intimately intertwined with addiction and mental distress, NOT messed up biology. Yet, most mental health professionals and addiction programs continue to ignore the ACE research implications.
So, the question: What if you could tell someone your full story in your own words and be taken seriously; your most closely guarded secrets - the embarrassing ones and especially the taboo ones?
It is just one of those days. I am fed-up with the lip service and hypocrisy when it comes to mental health in Canada. On the heels of tragic events in the United States, the focus has shifted to our own tragedies and arguments over the spectre of endemic racism in Canada.
In the last few days, Ottawa Police Chief Sloly provided a heartfelt commitment to 'fix his own house' even as a young Indigenous woman was shot dead by police in New Brunswick during a wellness check. The Indigenous Minister – Marc Miller – has voiced his outrage, but the question remains: How do we stop the perversion of responding to distressed people, especially marginalized people, through threats of violence? First, we must name these police interactions for what they are – public safety risk assessment and containment interventions. Stop perverting the term wellness checks! There is no universe whereby an armed team of police in paramilitary gear can be construed as agents of care.
I have treated many police officers over the years. Most of them are considerate and good people and I have also seen many others who are misogynistic, openly racist, and discriminatory, and who thrive on the prospect of knocking heads and kicking down doors. In fact, in the interests of veteran welfare, we stopped calling police because they often made matters much worse. When law enforcement members have little regard or awareness of their own mental health, they cannot be expected to respond effectively to the psychological needs of another person in distress.
Police and public safety organizations have been studied extensively in Canada over the past several years. Nearly 45 percent of them have mental health problems resulting from things like workplace intimidation, bullying, threats, micromanagement, and overwork. Officers tell me repeatedly that their organizations are toxic and that their leaders cannot be trusted. It is a fantasy to believe that the effects of these environments on members do not spill over into their interactions with the public.
I am not anti-police by any means. I believe they are placed in an untenable position as both enforcer and social worker. Canada’s longstanding ignorance and indifference towards mental health by federal and provincial politicians means that deferring to law and order mandates to control people outranks any effort to address mental health needs. We have ample research and inquiries telling us that mental distress reaches into histories of childhood abuse, poverty, addiction, family violence, racism and social inequities, and from toxic workplaces. Time to stop the empty platitudes!
Policing, and its paramilitary ethos, centers on taking control from people and reacting with force to perceived threats which is exactly the wrong thing to do in most cases. I agree, Chief Sloly, police agencies must get their own houses in order before they can ever decide they are the ones to put other houses in order. Too many people are dying needlessly!
We are inundated with messages to stay positive, keep busy, learn a new skill, and stay socially connected alongside news and images of tragedies and mounds of flowers heaped at make-shift memorials. Radio and TV ads spin on catch phrases reminding us of ‘unprecedented times’ and ‘difficult times’ as they try to sell us something. Political leaders and public health people keep telling us to stay home, to be vigilant, and to treat this as a marathon as the country slowly tries to re-awaken.
Some health advocates have begun to warn of a possible mental health crisis; that it may not be over when it is over. It can all be emotionally draining. Some people may feel more emotional and want to talk and other people may seem numb to it all. Either way, the reaction of reaching our limits to care about any more of it, is predictable and understandable. There are limits to how much anxiety and sadness we can tolerate without switching off and into a survival mode.
I was a marathoner runner for years. The toughest part of any run began when the finish line was just coming into sight. Despite the cheering, clapping, and clamouring to keep going, I often just wanted them all to go away and leave me alone. Sometimes, I slowed to a snail’s pace or just walked, placing one foot in front of the other, blocking out pain, and focusing on some point in space – usually my wife’s face just past the finish line. The reality is that we each have limits to our physical and emotional endurance and only find the limit when we are at that line. Acknowledging our limits is important.
Sometimes the experience of exhaustion and wanting it all to end can add another layer of drain and concern because it contradicts the many positivity messages from others. Focusing on the little wins of completing a task or a chore can be essential in getting through to the next minute or the next day; putting one foot in front of the other. Remembering to eat, drink, sleep as much as necessary, getting some physical exercise (might want to leave the races to the young!), or just goofing around with music, gaming, playing with the kids or pets may be all that is possible. That’s enough.
At the risk if overdoing the marathon analogy; Stay at your own pace. Too fast risks burning out while running too slow can leave regrets that you could have done better. This is a different course since nobody is sure where the actual finish line is located. Take the time to walk through the refueling stops, going out when the parks or golf courses are opened, getting a haircut (for those of you so blessed), or going out for a meal when those doors re-open.
As the glimmers of this finish line approaches, instead of feeling excited and positive, we may realize just how drained we are emotionally and physically. This is also normal. Finding places and times to recharge, with others and alone, and staying away from despair may be enough of a goal for the immediate future. Getting over the line does not have to be pretty.
We are in the midst of necessary physical distancing from other people out of fear of spreading infection. Various public health figures and politicians have corrected the earlier misnomer of calling for social distancing - an acceptable oversight given the risks posed to human lives.
When it comes to military veterans, it is assumed that those I speak with must be having a particularly stressful time. This is not the case. They tell me that while everyone around them is trying to manage all the anxiety caused by disruptions to their taken-for-granted social worlds, they are surprisingly calm. One CAF member told me that he felt 20 years younger. "All the normal people out there finally understand a bit of my world." While I don't presume to speak for all veterans, those who are used to physical and social isolation because they are alienated from the world seem to have a peculiar bond with everyday people - however briefly this may be. Others tell me that all the pressure of having to be out in public places to prove to clinicians and family members that they are normal has evaporated over night. Now, vigilance, situational awareness, remaining disciplined and focused on priorities and routines, getting sleep, remembering to eat, staying away from 24-hour news churns filled with talking heads, connecting with buddies and family, playing video games, listening to music, or watching movies, going out only when necessary, and getting some physical exercise are common priorities. For a brief moment in history, before global economic forces and the mindlessness of consumerism push us back to where we were not so long ago, we all seem to be sharing a common reality. We each have to spend time with ourselves, to contend with boredom and figure out how to use our time creatively without resorting to booze or drugs to dull our senses, to reflect, and even reminisce without slipping into rumination over past mistakes. We all share these temporary challenges.
Veterans often believe and are sometimes told that following orders and putting other priorities ahead of themselves is misplaced in the civilian world. And yet, here we are right in the midst of these exact societal needs. This irony is not missed on military or veterans but I don't believe that they gloat over this fact, either. The skills of containing and not over-reacting to emotion, staying focused on facts, being task-oriented, maintaining situational safety, and not anticipating outcomes are hard-wired among most military and veterans. I believe that these learned skills and lessons may be incredibly helpful for family members and other civilian friends to hear as they search for direction.
At the end of this temporary hiatus in 'normal', many of these same people will have lessons to teach veterans about managing the anxiety of re-entering the larger society.
The research is clear: childhood adversity and emotional deprivation can produce significant alterations in the brain's emotional processing system which often extend into adulthood. In my work with people with mental health and addiction issues, these histories are common and the thing that unites them is a belief that they are fundamentally alone. They learn to contain and manage their emotional worlds privately since everything and everyone is a potential threat to them. This self-protective stance is not intentional; it seems to be built right into the brain's hard-wiring from the earliest memories. They learned early on that showing emotional needs were either ignored or displays led to criticisms or put-downs. These things had to be stifled, hidden away and avoided at all costs. These children, turned into adults, learn the essential survival skill of becoming chameleons - blending in by looking and sounding just like everybody else.
This adaptation to survive in a threatening world by suppressing how they actually feel often works to varying degrees and during particular periods in their lives. But many of these same people develop problems with anxiety and depression and often turn to various preoccupations including substances to self-manage. While this is often called addiction (a term nobody can seem to agree on), I view substance reliance as repetitive automatic responses to emotional triggers.
A solution for those who struggle with substance overuse involves slowing down mentally (which can involve mindfulness, spending time without outside distractions) to a point where they begin to recognize the physical cues linked with particular emotional reactions (often termed introception), honestly facing these emotions (naming what they feel, allowing themselves to feel their reactions) and then doing something about them (writing them down, telling someone, engaging in some activity). These activities can literally rewire the brain over the long-run!
These skills can be difficult to practice since the people who avoid their emotional reactions often believe that this is a silly waste of time or they fear being flooded and overwhelmed. This work (and it is work) often means taking a risk to trust another person and the possibility of being hurt or disappointed. But, in terms of the opportunity to feel the full range of emotions, including things like love, joy, or tenderness, the payoff is often life altering. This process has the power to break the chain of addictive preoccupations. It is a process which has nothing to do with the misguided notion of addiction as a disease, either. People get into difficulties with substances through very human processes and they get out the same way.
Being full awake emotionally is the opposite of addiction.
Time has a way of slipping away unnoticed; it has been several months since my last post on this site. I want to thank those who regularly follow the posts and those new people who drop by to check it out. I have been busy with two separate projects aimed at military veterans. The first is an exciting project based in Ottawa, Canada - Camp Aftermath - aimed at providing groups of military veterans living with PTSD the opportunity to move beyond symptoms by offering help to other people . We are preparing for our third rotation to Costa Rica to participate in several projects in Spring 2020.
The second project is a book I began nearly 15 years ago. I put it aside to publish the books on military mental health. Given the importance of substance abuse and addiction concerns among many veterans, I am writing about the shortcomings of standard medicalized approaches to addiction treatment for military members and veterans (and many other people for that matter).
The Rise of Medicalized Public Workplaces
A soldier / first responder tells his buddy that he is not sleeping and that he is just fed up with things. The friend suggests he may be depressed and that he should come forward and talk to a professional. At first glance, a reasonable suggestion but missing from these cryptic interactions are the contexts. The soldier does not bother to mention that he is not sleeping because he was promised a low tempo posting by his supervisor for agreeing to take on a tough tasking that nobody wanted. His supervisor has reneged on the promise and instead has told him that he is needed for an upcoming deployment and if he refuses he can say good-bye to his career. The soldier’s marriage is already rocky because he has not really been home for the past several years and he does not know what to do. Career or marriage?
These types of scenarios are not unusual. What is new is that any mention of upset/distress in work settings of the 21st century is the rush to medicalize members' problems as part of institutional risk management. Anyone displaying unusual behaviour is a potential liability for organizations. This focus on individual mental health can be helpful to people for sure but we have also come to the realization that many of the ‘evidence-based treatments’ and workplace interventions like mental health first aid, and adoptions of the military’s road to mental readiness (R2MR) initiatives are not producing the expected outcomes of reduced workplace mental health problems (See Carleton et al., 2018). I believe that something fundamental is missing.
What is missing is context. According to the Standing Committee on Veterans Affairs (SCOVA, 2018), 28 percent, nearly one-third of military members, are released annually because of physical and mental health problems. We could attribute these rates to reduced stigma, better detection, and better care for soldiers and maybe even due to leftovers from the Afghanistan War. But, we also must wonder about this seeming upsurge in the numbers of injured men and women. What else has changed?
For starters, beginning in the 1990s most of organizations and public workplaces went through massive downsizing – doing more with less – because of budgetary constraints. Since that time there has been a continual scrutiny for savings and trimming needless fat. This focus on financial bottom lines has impacted personnel and human resource management fronts. In many places, among other demands, this has also meant personnel shortages requiring members to take on multiple roles, time pressures, reduced time away from work settings, and 24-hour access through telephones and social media. Members are required to over-invest to ever-demanding work settings.
A recent investigation of Canadian public safety workplaces showed that a staggering 45 percent of members reported mental health difficulties (See Carleton et al., 2017). Surprisingly, the many public reports of supervisory abuses, sexualized and harassing workplaces, and unreasonable demands are somehow forgotten in efforts to understand worker distress. Instead, there is a predictable call for better resiliency training to address these problems. In our study of resiliency among veteran families (Submitted for publication), we found that resiliency is not an individual quality like hardiness or ‘digging deep’ but a range of problem-solving responses dependent on tangible direct support from the institution and from broader social contexts.
Strikingly, none of our current explanations or interventions into workplace mental health acknowledges or addresses institutional causes of mental distress among members. We are left with the unspoken presumption that our current workforce is somehow lacking in self-management skills or fortitude to meet job demands. We have forgotten the wealth of research from the 1970s to 1990s on occupational burnout (See Maslach). We may have created pressure cooker workplaces and have ended up blaming people for not being able to maintain unreasonable expectations.
If we are intent on creating healthier workplaces, then we must get serious about tackling institutional policies and practices and enshrine employee protections for speaking out about things like supervisory and institutional practices and inconsistencies.
John J. Whelan
John J. Whelan, Ph.D., is the author of Going Crazy in the Green Machine, available now on FriesenPress.