NP dealing with PTSD
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WK9videotranscript.docxPTSD & Veterans: A Conversation with Dr. Frank Ochberg
Dedicated to Veterans and their Supporters
Dr. Frank Ochberg is a psychiatrist and former associate director of the National Institute of Mental Health. He is one of the team members who wrote the medical definition for posttraumatic stress disorder. Dr. Ochberg was the editor of the first treatment text in America for PTSD and is a recipient of the lifetime achievement award from the International Society for Traumatic Stress Studies. Dr. Ochberg is the founder of Gift from Within. Acclaimed anchor reporter, Mike Walter, knows of PTSD. After his brother returned from Vietnam, Mike saw firsthand the debilitating effects of PTSD on his brother and the family. And then on that clear autumn day,-
LIVE BREAKING NEWS AMERICA UNDER ATTACK MIKE WALTER CNN
Mike was an eyewitness to the 9/11 attacks on the Pentagon. In the days that followed, he found himself grappling with the same issues that affected his bother. Mike is a Dard Ochberg fellow where he studied PTSD and where he met Dr. Frank Ochberg.
EMOTIONAL WOUNDS OF WAR
MIKE WALTER Frank, you watch the news just like I do and you see all of these stories about returning veterans, the emotional wounds of war, so I'm gonna start with an unusual question. Is this a hopeful situation?
DR. FRANK OCHBERG Well, I think it's hopeful as a therapist. I mean, we have tools of the trade, and we have now, ah, 28 years after inventing the diagnosis, PTSD. We have some concepts that we can work with. And PTSD is actually an encouraging diagnosis. When it's PTSD alone, without a lot of other problems added in, it means were working with a relatively normal person, someone who has a capacity, for relationships, for insight, and for recovery.
MIKE WALTER They do present unique challenges though versus, let, let's say, a civilian coming with PTSD versus, ah, ah, a person in uniform. Talk to me about that.
DR. FRANK OCHBERG Well, this is a new war and this is a new circumstance for young men and women going to war. You know, back in my day the, the Vietnam era, you served a tour. Hopefully you'll live to came out whole. But even if you were wounded and even if you were badly damaged, the tour was over and done within 13 months. Now, people are being sent back again and again. And some are being sent back on psychoactive drugs. So, this isn't necessarily the realm of the therapist, helping a person prepare for yet another tour. In a way that's pre-traumatic stress. But we're talking about advice for colleagues who are good clinicians. They've dealt with a range of issues, and, and they wanna think about how their skills apply to this particular group.
EMOTIONAL WOUNDS OF WAR THIS IS A NEW WAR
MIKE WALTER As a senior therapist who's done this ah, so much, are there simple, concrete coaching tips that you can give to help with this unique population?
DR. FRANK OCHBERG Well, I, this unique population is unique for us in, in, in this part of, ah, 2008. I think it'll be here 2009. That's, ah, it's our war. These are our veterans, and these are our young men and women. And for the most part, they are, uhm, they're in their early 20s. They are different from previous combatants in that many of them are still facing a return call to duty, and that's very unsettling. And I believe a lot of us are finding that if you do go to war long enough and you're not really the professional soldier. Ah, you're going because, you pretty much have to go even though there's not a draft, you have to go. Ah, your, not risk, of, of mental condition goes up considerably. So, it's not an unrealistic fear or dread. It's a sense in the bones that if I keep being called back, ah, I'm gonna hurt.
MIKE WALTER But turning that light switch on and off, transitioning in and out, ah, that presents unique difficulties too.
DR. FRANK OCHBERG And, and, and it does in a, in a range of situations. There are many of us who are therapists have dealt with people who are going through profound transitions. I mean divorce is a profound transition. Escaping an abusive husband is a profound transition. Ah, not all of us are fortunate enough to have jobs that we love and jobs that are stable. And so, I don't think that in itself is a new challenge for a therapist.
MIKE WALTER Should the approaches be different?
DR. FRANK OCHBERG You know, we're who we are. Ah, some of us are so comfortable doing family therapy and some don't we even have an extra chair in the office. So, the approach should be leading to your strength. And if you do find you're working with a returning veteran and the situation feels alien to you and you're not comfortable. Ah, ah, you do have to refer out. Ah, I, I think you really have to be honest with yourself about your limits. But I think the general skills, generalized to this population, and if you're mature and wise and resourceful, you can do so much that's useful.
MIKE WALTER You, you talked about, ah, playing to your strengths. And, ah, a lot of these returning, ah, veterans work with the VA where there's, ah, these people are, are used to seeing this type of, ah, patient. And then, they return to their local hometown. Uhm, I'm the local therapist. Someone like this comes to me, ah, this may not be my strength. What would you like to tell them?
DR. FRANK OCHBERG Well, first of all I think, things have improved in the, close to 30 years now that we have the PTSD diagnosis, I wanna say to you out here who were gonna be treating people who've been traumatized, please be sure you understand PTSD and that you've read some of the basic works and you're comfortable hearing stories that can give you some, some nightmares yourself. I mean, many of us who, who've lived through this work have found times when we inherit the stories of our, of our clients, our patients. We not only have to be comfortable doing that. We, we have to project to the client that we are comfortable; we've been here before. You're not gonna damage me 'coz the returning soldiers and marines are, are really so honorable. They've suffered and, and I wanna be very, very careful that they don't make others suffer.
TREATING PTSD IS A PRIVILEGE
MIKE WALTER Frank, there's a good chance that we've got a therapist in a rural state who, you know, all of a sudden there's an influx of, this population. What advice would you give to them?
DR. FRANK OCHBERG So, all of a sudden they have three, four, six patients?
5MIKE WALTER Exactly.
DR. FRANK OCHBERG And this could happen when a National Guard unit comes back.
MIKE WALTER Exactly.
DR. FRANK OCHBERG And, there in, ah, my state, upstate Michigan, yeah. Well, I guess we've, we've said before, treating this population is a privilege. And I'd say right of the bat and welcome to the group, that's working with PTSD and related issues and that's helping our returning vets, men and women. Ah, it's, ah, it's rewarding, it's gratifying. Most of your clients are gonna do well. There gonna be some difficult situations. You're gonna be able to draw on a lot of skills and experiences that you have from working with incest survivors, ah, bad accident victims, ah, ah, people who've had to deal with shocking news. If, if you have no familiarity whatsoever with PTSD, this, this is not your cup of tea. And, you, you probably need colleagues to do the work, ah, where you need to take some courses. But assuming, that you're, ah, a mid-career therapist, you've seen a range of issues, ah, I, I would say welcome to working on our veterans.
MIKE WALTER Don't feel overwhelmed.
DR. FRANK OCHBERG No, no, no, I, ah, common things are gonna be depression, avoidance, intimacy problems, drinking too much, and adjustment to all the demands of civilian life: new job, new kids, and these are young people who are facing the beginning of adulthood. And in a way they've grown up in a hurry, but in another way you have to remember what the age and stage of life is.
THE BATTLEFIELDS AT HOME
MIKE WALTER Is there a marked difference between civilian PTSD and, and military PTSD?
DR. FRANK OCHBERG No, no, PTSD is PTSD. And when it happens, it means that you can't shake the traumatic memory that comes up at you from the past. Ah, and it means that you've lost something in your full range of human feelings and human capacities, and that means that you're wired. Ah, you're very, very easily distracted, upset, can't sleep well, startle a lot, ah, and, and you can get this condition from exposure on the battlefield or you can get it from civilian life. And the therapist who could treat one should be able to treat the other. And the feelings that's, are veterans now, civilians have, I don't think are foreign to the experience of us therapists. We've been there, we've seen it, and we, we've, like we've, we've taken care of parents of murdered children. We've taken care of incest survivors who have been raped. Ah, we've taken care of people who have walked off the campus on the Virginia attack. We're no strangers to the civilian trauma and tragedy, and the battlefields at home are as just as intense as the battlefields over there.
THE LOSS OF EMOTIONAL TONE TAPPING INTO THE EMOTION
MIKE WALTER I remember af, ah, the first anniversary of September 11th, ah, an interview with a gentleman in New York who just went through this horrific, ah, series of events. And he told the story, but he told them with, ah, without any emotion flat... (crosstalk)
DR. FRANK OCHBERG Hmm.
MIKE WALTER ...delivery, and there are, there are returning vets who tell their stories without tapping into the emotion. How do you get them there, and how important is it to get them there?
DR. FRANK OCHBERG Oh, you wanna get there, Mike, and that is paragraph C of the definition of PTSD. You know, PTSD, the first part is, something happened and it was real. The second part is you have a set of symptoms in which you're haunted by what happened. The third part, the C part is you, you, you're blunted. You, you feel like a shadow of your former self. You, you could be restored to life with people you love, and, and you describe, ah, "I know I love; I, I just don't feel it." And, you sometimes see this in a, in a person's face, ah, a constricted affect. The, there's no direct remedy for that, and there is no pill to restore the range of emotion. If depression is a part of the loss of emotional tone, anti-depressants can help, and it's very common to diagnose PTSD and major depression or dysthymia at the same time. And in that case you treat the depression. But, but to treat the avoidance and the detachment and the loss of, of, of zest, that is part of PTSD, I, I, I think you really treat the whole person, and you watch for that to start coming back.
THE LOSS OF EMOTIONAL TONE PTSD IS NOT A DOWNWARD SPIRAL
MIKE WALTER Uhm, a, a patient comes to you who've got a permanent disability for PTSD, and so as a result, they think, ah, "I'm, I'm permanently messed up. You can't help me. Treatment... (crosstalk)
DR. FRANK OCHBERG Uh hmm.
MIKE WALTER ...isn't gonna help." How do you work with that?
DR. FRANK OCHBERG Ah, let me explain to you. PTSD is not a steady downhill course. It's not a death sentence. This is not something that's going to progress. In fact, episodes of problems are gonna be further and further apart, and you're gonna learn how to tolerate what you had to live through. Ah, dealing with it as a therapist amounts to explaining and interpreting and instructing. Ah, if, if somebody feels that because of PTSD, they are diminished, lessened, hopeless, I also send them to the website, "Gift from Within."
Welcome to Gift From Within An International Nonprofit Organization for Survivors of Trauma and Victimization - Anything that has real and lasting value is always a gift from within. Franz Kafka A Call For True Personal Stories PTSD Etiquette: finding the right words Site Map Dear Friends, We started Gift From Within in 1993 with the intention of giving trauma survivors, their loved ones and supporters a credible online website that was friendly and supportive. PTSD is real and we wanted to explain the condition without being too technical or too superficial. Gift From Within believes that persons with PTSD and related traumatic stress syndromes deserve the same respect and support that individuals and families suffering the impact of cancer, heart disease and stroke receive. At least 10,000,000 Americans have experienced some form of PTSD. Gift From Within was founded to help provide this support. Proceeds from the sale of the materials will be dedicated to accomplishing this mission. You can help with your purchase or donation. Thank you!
DR. FRANK OCHBERG There are, ah, many ways of recovering the poetry of life and the meaning in, in life of, not every therapist and neither I with all my patients have had a chance to get to the later stages where e, enough improvement has occurred and there are enough new stages of life to face together, a person who hasn't had children, who does, a person who hasn't had a civilian child, who does, a person who hasn't been married, and, and is married. So, our patients may not be in a position to look down the road and to savor the next steps of life that are there.
THE LOSS OF EMOTIONAL TONE A SMALL SPECK OF SHRAPNEL
MIKE WALTER You had a story the other day where you used shrapnel as a metaphor. It's a small speck of shrapnel and having to understand the anatomy and that, that the PTSD, go back over that again.
DR. FRANK OCHBERG Oh, yeah, we were thinking about what a PTSD therapist does and has to know about. It isn't that you can't treat PTSD in the abstract as though there's one symptom, and that's like the piece of shrapnel that's in the body and you're gonna get that out and it's all over. And because that piece of shrapnel goes through the lungs and the liver and the kidney and you have to know about each organ now metaphorically, what are those organs? They're your work life. They're your sense of self. Ah, they are your important relationships. Ah, they are your, your faith, ah, your reason for living. So, a trauma therapist, when the therapy goes well, has a chance to help with all of these elements, ah, ah, of life. I, I, I remember the charming story of this old man who goes to the doctor, and says, "Doctor, my bowels aren't moving. My head hurts. I have this itch that I just can't scratch away, and, Doctor, I myself don't feel so good." (laughs) And, and, and every once in a while, there you are, you're working on that sense of self.
PTSD AND DEPRESSION REMITTENT DEPRESSION
MIKE WALTER Talk to me about that another piece that you, you talked about earlier, major depression and... (crosstalk)
DR. FRANK OCHBERG Oh, yeah.
MIKE WALTER ...PTSD.
DR. FRANK OCHBERG Yeah. I, I often see that two together, Mike, and, and I give both diagnoses. And, uhm, when, when I was a resident, which was at Stanford in the '60s, that's a long time ago now, we thought there were two very, very different forms of depression. Well, one was situational. You were in a very tough situation that was hard to cope and felt lousy and you'd rather be in bed. Now, we, we call that exogenous depression. And the other was an inherited, remittent disease, ah, like, ah, ah, psoriasis or, ah, diabetes, something that had flare-ups. And, by the time you became an adolescent or a late adolescent, this disease would show up. You had a strong family history for it. It wasn't necessarily related to bad times and you would spend, ah, the winter with a bad depression. Spring would come and you'd get better. Well, now it turns out that these two conditions overlap very much. If you go through a period of high stress and sadness and, ah, grief and loss, you can come out of it with a remittent depression and major depression, and it's very much alike to the kind that we used to think only happened as a, as a matter of your genotype. So, look for depression, and when PTSD, which is causing a lot of return to scenes of trauma and tragedy and depression co-exist, it means that in addition to the flashback and in addition to the avoidance and the anxiety, you feel helpless, hopeless, worthless. You have, you have very clear suicidal, ah, I wouldn't say wishes, but sometimes the suicidal thought as a form of relief, and, and that's dangerous. That's something we therapists have to be so vigilant about, and particularly with the, with the group that se, seen a lot of death, and ins, instruments of quick death available. So, consider depression. Now, ah, any therapist knows about treating depression, and it's no different in this population and in the other population. You know, you mobilize all that you can and in ways of reframing thinking. You use cognitive behavioral treatment and help someone learn that they have thoughts that come along with bad feelings. And instead of being down on themselves, they learn to recognize a downer thought and figure out where it's coming from and change that thought and the feelings eventually change with it. And medication, and now, now some people, like, have a philosophical aversion to medication, and they don't understand the medication that helps with depression, that, uh, the, there's no black market for Prozac. It doesn't make a normal person feel better. It works when, like diabetes, you don't have enough insulin, ah, your, your brain isn't producing enough neurotransmitter. The Prozac helps your brain use the neurotransmitter that it has more effectively. And if Prozac doesn't work, and there are sometimes some problem for the, one drug, there is another that works well. Ah, the psychiatrist and, well, the internist who has more and more experience with these medications sometimes has to fiddle with the dose and add extra drugs, uhm, but there's no reason for a person to suffer with these week and month long black moods.
PTSD AND DEPRESSION WHO IS ON YOUR BOARD OF DIRECTORS?
DR. FRANK OCHBERG Ah, ah, let me go on to something I was, that I find awfully useful with my PTSD and depressed patients. Most of them do say negative things about themselves to themselves. "Oh, I screwed this up," or "Ah, this is just isn't working out," or, and, and, and I'll ask them, consider where that statement comes from. Is, is it like you have a board of directors in your head? And somebody from the past is sitting in that directors chair, and, and, and the people will say, "Yeah, yeah. I, it's my grandmother," or "Ah, it's my father." And he, he always said that you're not gonna amount too much. And, and I ask them, "Well, who else do you have in the room? Who else in your life gives you messages about yourself?" And they'll remember a teacher or the whole, I, I remember (laughs) ah, Maya, who had been badly raped, said, "Arlo(ph), my gay brother. He likes me. I'm gonna put him in the chair and kick my father or mother," I can't remember, "Out." And, and, and he actually have this image of whose in the director's suite. Well, that director's suite is also known as the Super Ego. It's the part of us that judges us. So I, I just had, I, I've had enormous succ, success in helping my patients figure out whose on their board of directors and shoving someone to the back of the board. Unfortunately, you can't kick 'em out forever. And, and, and, you know, all the studies are showing cognitive behavioral treatment and medication together do the job for depression. Depression is a prevalent disease. We have to be on the lookout for depression. Untreated depression can be lethal and it leads to drinking... (crosstalk)
MIKE WALTER Uh hmm.
DR. FRANK OCHBERG ...and it certainly, ah, messes up interpersonal relations.
RESISTANCE MOVING DOWN THE PATH TOGETHER
MIKE WALTER Let's say I have a returning vet and I'm working with them and yet they don't wanna go there. They don't wanna go and talk about, when's the proper time to move in that direction? Ah, ah, do you probe them? How do you, how do you when's the right time to make the move?
DR. FRANK OCHBERG Well, I, I do probe and I'm very cautious about getting there too fast. And in fact, I often say with a traumatized person, ah, "There will come a time when we'll go there. And, and it can feel like and be like elective surgery. I'm not gonna go there before you are ready." Ah, and, and it's not "tell me when you're ready," it's, it's in the conversation lets you know.
MIKE WALTER It, it's just an innate sense, you know, when it's time?
DR. FRANK OCHBERG Let me say two things. First, it's that, early on, I think it's important to let a, a traumatized person know that you're not gonna zero in and try to hear the worst of it to soon, that you've been there before. You, you will have the sense of when it's right, and, and, and both of us will have a sense of when it feels right to go for the issues that hurt. And then as far as knowing when you're there, that's a hard thing to describe in the abstract. I, I guess now after doing this for over thirty years, I, I do have a sense. I sometimes encourage a person by saying, "Well, ah, are we ready to do the counting method?" And then I'll say more about that in a little while. Ah, often I've explained in advance that there will come a time when that flashback that you have, that nightmare that you have, that image that haunts you, ah, you're gonna want to share with me, and, and we'll be there together and here's how I go about helping you have your worst experience with me present. So, just explaining that there will come a time when we'll go for that, help set the stage.
MIKE WALTER It, it, it's really important for them to know that it, it's a partnership, that they're moving down the path with you. Is it important that, ah, ah, as you're outlining this, and, and we'll get to the... (crosstalk)
DR. FRANK OCHBERG Uh hmm.
MIKE WALTER ...counting method in just a minute, is it important early on to kinda set the agenda, say, "Hey, look. At some point we're gonna do this or, or is that a gradual process too?
DR. FRANK OCHBERG I, I think there's a halfway point between having a format and then having your patient or client feel that you're working on a schedule, and maybe not tailoring this to the individual.
MIKE WALTER Uhm, it, you, you're kind of outlining that it, and it's a journey that both are making, ah, a partnership in a sense that both are going down this pathway and, ah, they can feel strength that someone is going there with them. How early on should you outline that to the patient?
DR. FRANK OCHBERG Well, I think by every gesture, by, by the way you greet people, by the, by the way you interact, it's clear that we're going there together. Ah, early on, Mike, I like to teach a little bit about PTSD and I'll sometimes take out the book, you know, with, with the returning group of veterans, then I'm more about PTSD than the early cases that people my age dealt with. Sometimes, I would show the diagnostic manual and a person would say, "I can't believe that's there. This is all about me." Now, with VA and benefits and, and arguing for your benefits, most people know a lot more. Uhm, and, but I, you know, I believe this is a partnership we model and that we're together searching for painful pieces of the past.
RESISTANCE CHINK IN THE ARMOR
MIKE WALTER There's been this stigma attached over time, ah, and, and when you ah, have the sense, these are people that are prepared to go off to war, in, if, in a physical, ah, way and a mental way, and they, they think they got this physical toughness, this mental toughness. And then they come, and this is acknowledging that maybe there's ah, ah, ah, they see it almost as a chink in the armor. How do you get them past that?
DR. FRANK OCHBERG Well, it depends on how deep that chink in the armor is. I mean there are some people that I see who can't go to the job that they've had, whether it's a military job or a train engineer or an airplane pilot, and ah, they usually know. Sometimes their employer isn't that sure and my job is to help affirm the lack of ability to return to a job. Ah, at other times though, it's, it's on the fence or there clearly is capacity. I see capacity, and my, my patient may be very, very reluctant, may feel they'll go back to something important and fail. Now, with ah, military, you can't take risks and were putting people in harms way. Ah, I, I have written "not fit for duty" letters, which means that ah, the job isn't there.
RESISTANCE LIVING IN THE HERE AND NOW
MIKE WALTER Sometimes a patient will come and that's all they want to talk about is the here and now. I've got a drinking problem... (crosstalk)
DR. FRANK OCHBERG Right.
MIKE WALTER ...that I've got, failed relationships. They don't want to go to PTSD, and, and ah, they wanna concentrate on, "How do I fix the relationship?" And yet you know that it's all intertwined. How do you get them to really address that the PTSD may be driving a lot of this?
DR. FRANK OCHBERG Ah, I do talk with people who are taking care of returning vets and I know their feelings are ah, this group doesn't really wanna talk about PTSD, and it can be hard to keep somebody in therapy. There's a lot of pressure on a veteran to get help and there's resistance to that kind of pressure. So sometimes, it's a reluctant, "Oh, I have to see, I have to see you to get benefits. I have to see you 'coz my wife says I have to see you. I don't really wanna be here." Ah, and then, there is interest in talking about trivial things. Ah, Mike, we have to show extra interest in where we wanna help this person get to without being too aggressive about it.
MILITARY SEXUAL TRAUMA A BREACH OF TRUST
MIKE WALTER Let me talk to you about female veterans 'coz we're seeing more and more of them coming back with PTSD, and there are gender differences. How do you approach that differently as a therapist?
DR. FRANK OCHBERG Well, we should be aware that many female veterans of this war have had abusive situations before volunteering. And unfortunately, there is a very high rate of abuse, harassment, and even rape ah, to our female soldiers. Ah, the experts in the field ah, know about this. There are all kinds of prevention programs and awareness programs that you and I spoke with the (inaudible ) of general in the Air Force who, who cares a lot about this situation. But the therapist needs to be aware, and this may not be something that comes out early in, in therapy. Ah, a relationship that is something like an acquaintance rape while in military service is a little bit more like incest than other forms of abuse, 'coz this is your family and there's a lot of pressure to keep things secret. And in some ways, the, the female veteran realizes truthfully that she's damned if she reports and she's damned if she doesn't report. Ah, as a therapist, knowing what you know about working with incest survivors, it can give you some insight and some tools of the thread, even though it's not incest.
MIKE WALTER It might not be top of mind though for lot of therapist... (crosstalk)
DR. FRANK OCHBERG No.
MIKE WALTER ...to approach it that way.
DR. FRANK OCHBERG No, it might not be. So, so, so be aware of that. And, and if you've had ah, good outcomes using some of the workbooks that are there for, for helping an incest survivor, you might actually wanna consider about how to adapt that for your female veteran who's been sexually taken advantage of while in service to her country, and who never would have thought of this like incest. This isn't her father or brother. But in a way, it is.
FIT FOR DUTY THE DUTIES AT HOME
MIKE WALTER What I find interesting about the paramedics, the firefighters, and the police officers, in many cases, the therapist has to assume that role that you were talking about with the, the female returning veteran that ah, an advocate in many ways. Ah, talk to me about some of that ah, that work that you'll do with this type of returning vets.
DR. FRANK OCHBERG Well, sometimes, it's advocating for them to stay on the job, have a job, have accommodations for the job. Ah, and it, it could involve writing letters. Ah, I have offered to call an employer on behalf of a client, and it's rare and that someone has wanted me to do that. And I maybe taking things a little bit too far for ah, some this group of, of, uhm, patients and clients. Ah, but Mike ah, there are situations in which a person returns to his civilian job and they can't do it. They don't have the resilience, ah, the capacity to be ah, a firefighter. Or they're, for a period of time, a way too angry to be an effective law enforcement officer. And here, again I, my philosophy is I'm not gonna take damaging information about my patient to some authority. I'm gonna talk it over with my patient. But if my patient reaches the point where he or she says, "I, I really need a different job," it's my job to help them with that transformation.
LIVING WITH PTSD FAMILY, FRIENDS AND SUPPORTERS
MIKE WALTER A veteran comes to see you or any therapist. Ah, it, it's almost like an octopus, there are tentacles that go out. I know the, when my brother returned from Vietnam, as a family it, it, it affects the family dynamic. (crosstalk)
DR. FRANK OCHBERG Uh-huh.
MIKE WALTER My, my mom's concerned about it. You also have returning vets who have spouses and children.
DR. FRANK OCHBERG Yeah.
MIKE WALTER It's all out there. Talk to me about that as a therapist.
DR. FRANK OCHBERG Well, well sometimes, the spouse in particular, really wants to see me. And I have had situations where my patient likes that or doesn't like that. And ah, I, I have to go with what, how I'm instructed. But if I can get a, a loved one to come into the office, sometimes on his or her own, sometimes with my patient, I think I, I'm in a position to make a big difference, a big positive difference. And in fact,-
Living with PTSD Lesson For Partners, Friends and Supporters A Presentation Of Gift From Within 18 minutes www.giftfromwithin.org
DR. FRANK OCHBERG - I've, I've even made instructional tapes and written some things about it, it, the, it, it's written to the partner of the person with PTSD. And it serves very well for the partner of the person with PTSD that came from military service. I mean, in, in essence Mike, it's saying to that partner, you know, you, you can learn a lot about this condition. You should be the smartest one on your block when it comes to understanding PTSD. And, and, and often, I give ah, a course in a therapy hour. Ah, and, and get across a lot of what we've talked about here. This is not a death sentence. In fact, a, a diagnosis is an optimistic diagnosis. It discuss exactly what it means and, and get into the difference between the re-experiencing, the numbing, and, and the anxiety, and point out the implications. I mean, PTSD so often means that a person lacks a language and a desire to talk about and to meet the details. And unfortunately, it can spread from the details of something that's truly horrifying to details about anything personal. So, coaching a spouse, and first of all recognizing that, tolerating it, but having some tools to try to work with it. It isn't only, let's say your wife went off to war, Mike, and she comes back and she's not as communicative. I'm not gonna just be telling you, "Live with it." I'm gonna be trying to collaborate with you. You may actually help me 'coz you may give me some tips on ways that I can help bring her back to the full person that she was.
MIKE WALTER My wife returns.
DR. FRANK OCHBERG Yeah. (crosstalk)
MIKE WALTER She's enveloped to this fog, this fog of war... (crosstalk)
DR. FRANK OCHBERG Yeah.
MIKE WALTER And she's, I want it lifted. I think... (crosstalk)
DR. FRANK OCHBERG Yeah. (crosstalk)
MIKE WALTER ...you're the miracle worker, it's gonna be lifted.
DR. FRANK OCHBERG Yeah.
MIKE WALTER Ah, and, and, a few sessions, I'm like, "Come on!" Ah.
DR. FRANK OCHBERG Oh, that, that, and I think that's something that therapists ah, are quite accustomed to. Ah, ah, that, that expectations of us are awfully hard. I, I wouldn't say that you respond to that by immediately trying to lower expectations. But you respond to that in a collaborative mode. It's a, well, let's see what we can do together. So, when I talked to her, I noticed she brightens up and particularly when we're talking about your girl. Does that happen when, when you talk with her?
MIKE WALTER Uh hmm.
DR. FRANK OCHBERG Are there subjects you find where she is a little bit more, ah, lively ah, her old self? What, what, what are you noticing are the trigger points? And here are some that I noticed. So, that kind of approach puts you on the same page.
DEALING WITH THE TRAUMA MEMORY TRAUMA VS. AUTOBIOGRAPHICAL MEMORY THE COUNTING METHOD
MIKE WALTER You, you talked a little bit about exposure therapy and, and the method that you use. But let's talk about that. Ah, there, there's a lot of workshops on this. AMDR is familiar to some of the folks watching. But just go through this, if you would, and then we'll get into the Counting Method.
DR. FRANK OCHBERG Well, when you're working with someone who's been traumatized, they often have a symptom that just characterizes this whole field. They have a memory that won't quit. And, and when we invented the diagnosis, we didn't realize that we would now have brain scans that show that a trauma pattern, a trauma memory, is different from an autobiographical memory. And, and, and sooner or later, a good therapist has to help somebody deal with that. Now, now, I stumbled on something, decades and decades ago, that is so simple. It, it, it just involves the therapist, you counting out loud to one hundred, while your patient, your client, has their silent memory. And, and you set this up very easily. You explain there'll come a time when we can try this. It, it'll be elective. We, we'll do it when you're ready, when I know you pretty well, when you know me, and when it's comfortable. And then what you'll have is the very memory that haunts you, that comes back and bothers you when you're not with me, but, but, but you'll have it here. You won't be talking. I'll be counting. And, and, and when I as the therapist, count out loud to a hundred, and my client voluntarily plays that awful tape, it could be seeing his best friend blown up in front of him. At least he knows that he'll be with that memory for no more than a hundred seconds, and you give that instruction. And after it's over, after I've counted, my patient has remembered in a traumatic way, then I ask or I gesture for the story that just was remembered. And then I take notes. I, I write down everything that is said as, as fast as I can. And then I go over the notes and, and I say, "Here's what you said and, and oh, When I was counting in the 60's, then you were remembering this awful part. Ah, but when I got up to 90 you were back at a, at a safe place." And then the two of us are together and, and it says, "Though we have both gone through that flashback, that nightmare that, ah, horrifying piece of reality together, words have been put it." There's, there's a certain feeling of mastery. It's very different from telling the story. It's sharing the traumatic memory in this office, which has become a safe place. Yet, ah, I find Mike, I, I sometimes only have to do this once. I don't have to do it over and over. But this is a, a form of re-experiencing and the data shows now that, sooner or later, post-traumatic therapy involves re-experiencing. If, if it doesn't, you've usually missed a piece that's important.
DEALING WITH THE TRAUMA MEMORY PREPARING FOR THE COUNTING METHOD
MIKE WALTER One of the things that you and I have talked about though is setting the parameters just right for that session, to make sure that it works well. That you start the Counting Method at the right time, just a different, talk to me about some of the things that you have to look into before you do it, so you set the table just right.
DR. FRANK OCHBERG Well, I, I've never had a Counting Method that went bad. I, I, I've had some where I didn't feel the person actually generated a trauma memory. Ah, they, they were thinking about bad things, but they didn't really get back into it and, and have a strong emotional reaction. But, but I still worry, Mike, that, that maybe I would stir something up that I hadn't expected. Maybe someone would have to drive home and they'd be so upset, they'd have a car accident. So in, in, in setting it up right, I, I try to be sure a person understands what it's about and what's going to happen in advance. And then we get to it five or ten minutes after the session begins, and I, I, I work with a 50-minute hour. And most people who are gonna be listening to me are also working with a 50-minute hour in their office, where someone drives up and drives away. So, if a minute and forty seconds of that hour are gonna be spent with a, a patient, a client, reliving the worst moment of their life, you wanna get to it quickly, have time to digest it. Ah, I, I, I have a feeling that this has amounted to something and have time to change the subject. So that means early on. I, I actually dim my room, ah, a bit. Ah, I, I have a translucent curtain that could go over the window, and it's kind of a large window in, in my room and I, I, I like to dampen it down somewhat. I, I don't want this to be too hypnotic, but it has relaxed, and, and, and with a changed scene. One, one of the things that you accomplish by dimming a light is that then afterwards, you can put the lights back on. And so you feel, "Oh, I'm back here again." There has been a drift to the, to the past and then back in the present.
MIKE WALTER It's all about setting the right tone.
DR. FRANK OCHBERG It's setting a tone, although, really we, the therapists aren't doing as much as our clients are. And they're the ones who were changing the scene. They're changing the tone. And with the Counting Method, you're usually watching somebody with hands up to their eyes, ah, breathing is, is shifted. I, I, I remember Paul who was a veteran from our first war in Iraq, and he was ordered with night vision goggles to go in and kill Iraqis by his lieutenant and, and he did. And I did the counting with him. And after it was over, he said, "I didn't realize. As I was walking out, I stepped on something. It must have been the body of someone I killed." And that's not all that traumatic. But it, but it was a piece of the reality for Paul. And he pulled it out while he was with me. So, so in a way, he and I experienced that together and, and it was fresh. It, he hadn't been conscious of it. And, and, and yet here it was. And, and, and I think it added an unfortunate element of horror and of intimacy. He was stepping on the body of a man he had killed. That's the sort of thing that we come to. Now, now, part of me, as I'm talking with him, thinks, you know, what a tragedy. What an awful thing that we're sending young men and women to do those kind of jobs. And a part of me is actually, kind of ironically, exhilarated. It, it's that, you use a method, you have a chances of therapist, you get there, with, with your patient, your client, you're there together. And, and, and something is shared that's, that's quite profound.
SURVIVOR GUILT PASTORAL CARE
MIKE WALTER Two soldiers on a battlefield ah, for whatever reason, one dies, the other one survives, the survivor's guilt, close bond... (crosstalk)
DR. FRANK OCHBERG Oh, oh yeah.
MIKE WALTER ...getting there. How important is that? And how. (crosstalk)
MIKE WALTER That important word why, you know, it's ah, it's understanding, meaning in your life and, and trying to find the direction in the sense I guess, it's. (crosstalk)
DR. FRANK OCHBERG Yes, and it's, it's a question that I think early on as a therapist, I might have been more vexed by as, as though I needed an answer. I needed to deliver the answer to why. And it wasn't good enough to say, "I don't know." And it would certainly be ah, arrogant to offer the answer. So, it's an open question. It's a pathway. And, and, you, you, you, you place yourself as questioner and seeker also.
SHARING TRAUMATIC IMAGES THE TICKET OF ADMISSION
MIKE WALTER Ah, I, ah, I've gotta ask you, my brother, when he returned from Vietnam. Ah, it, it felt like, and, and I'm perceiving his perception, he couldn't talk to anybody about what he'd gone through, that nobody really understood where he was coming from. The family certainly didn't and he found a veteran, a, a fellow soldier, and the two of them, they would start their drinking at... (crosstalk)
DR. FRANK OCHBERG Uh hmm.
MIKE WALTER ...ten o'clock in the morning and sit out there and talk. And at first uhm, I think the family thought, "Well, this is good. He's got somebody to talk to and stuff." But then ah, there's a fragile state out there when a veteran's talking to another veteran and stuff. Talk to me about that dynamic. Is it a good thing? Is it a bad thing? Group therapy, all of that sort of thing. Uhm, what's good? What's bad?
DR. FRANK OCHBERG Well, just superficially. Let me say, it's not necessarily good to bring a lot of people together to share terrible stories. It's not necessarily good. And there's research that suggests that if you are struggling with your own traumatic images, the last thing you need are, are 20 other trauma images from people who have become instant relatives of yours in a therapy session or a debriefing session. Ah, ah, ah, ah, ah, on the other hand, we all need kinship. Most of us do. And the kinship of, of, of people who have lived in that world, which sometimes feels like it's outside of this world is, is important. Ah, I, I don't know, though, that it means that you have to spend your time, ah, and the only ticket of admission to that kinship is recovering literally war stories. And so, I, I, I think our job as therapists is to indulge the need for kinship and be sure that, that capacity for kinship is created if it's not there, and is facilitated if it's marginally there, but then to try to help somebody normalize, and it's not normal for your only kinship to be a, an alcohol- fueled session of war stories.
MIKE WALTER If, if a therapist thinks a group session is ah, might work or might be helpful. In, in other words, the way I see you outlining this is you have to be very careful on how you manage this and, and put together.
DR. FRANK OCHBERG Well, ah, ah, I mean there, there are very skilled group therapists who are out there and who may have ah, opportunities to pull together groups of returning veterans. Uhm, I would say that this should be undertaken by a newcomer with a lot of caution because of what I said about overdosing on trauma and establishing a society that is bound by uhm, a convention of telling stories. They take you back rather than bring you forward. Uhm, this uhm, in fact I, I participated, and there is a paper that was published not too long ago in the American Journalist Psychiatry in which the architect of the critical incident stress debriefing program, uhm, George Everly, and the critic of that program, Jonathan Bisson, reached agreement, saying that after suffering a trauma, it's better to practice something called psychological first aid than to bring people together for prolonged encounters in which they share their experience. A psychological first aid means you tell a group of people about PTSD. You use a technique of watchful waiting. And we're not talking about people now who absolutely need professional help. We're talking about people we are not sure. They've been to hell and back. They could have a, a few nightmares. They might be ah, under the threshold for giving the diagnosis. And they are advised to have someone to keep an eye on them, to understand what this condition is, to get professional help when they need professional help, and to stay away from forced ah, sessions of this of upping their dose of trauma.
CONCLUSION WE FEW, WE HAPPY FEW, WE BAND OF BROTHERS...
MIKE WALTER Any final suggestions for the people watching this, who are doing this important work?
DR. FRANK OCHBERG (sigh)Well, I think I've said already how, how thrilled we can be for the progress that our patients make and that's why we come to work. We, we can realize that we are all in this together, and whether we're working with military or civilians, or first responders or, or civilians who go through trauma and tragedy we're uhm, I, I don't, remember the lines from Henry V, but, but we put it, that was lucky ones who, who are doing something globally together to help normal people who've suffered, regain their humanity, and pass the privilege of life onto others. What a, what a wonderful place to be.
