COMBAT IS FOREVER: READJUSTMENT TO CIVILIAN LIFE Andrew Pomerantz, MD Chief, Mental Health and Behavioral Sciences WRJ VA Medical Center Associate Professor of Psychiatry Dartmouth Medical School September 23, 2010

Case examples §A 33 year old returnee was evacuated from Ramadi by the Red Cross to tend to his ailing wife. He is brought to treatment for Abusing his wife’s narcotics §A 27 year old man is brought to treatment because he refused to go to a family picnic without a sidearm.

Case Examples §A 47 year old accountant returns to work in the bank after return from Iraq. Previously a good worker, he is unable to concentrate, plays loud music all the time, drives recklessly and always fears the bank is about to be held up. §A 36 year old man, previously engaged in many activities with friends, prefers to hole up in his house and refuses to answer the phone.

§A 65 year old man, working quietly as a teller in a local bank is offered a promotion for the third time. Again, he declines, telling his boss he doesn’t want to be responsible for other people. He is offered the choice between retirement and taking the promotion, “You’ve been at that window your entire career, it’s time for someone else.” §He took his retirement, 5 years earlier than planned and 40 years after his release from a POW camp in Germany.

WHEN IS A SYMPTOM NOT A SYMPTOM? 1.When it’s you or me 2.When it’s not a cause of distress or dysfunction 3.When it’s adaptive 4.Adapting to Baghdad or Saigon is not the same as adapting to Plymouth. Normandy was not a beach resort.

Battlemind courtesy of Walter Reed Army Institute of Research ( §Buddies (cohesion) vs. Withdrawal §Accountability vs. Controlling §Targeted Aggression vs. Inappropriate Aggression §Tactical Awareness vs. Hypervigilance §Lethally Armed vs. Unarmed §Emotional Control vs. Anger/Detachment §Mission Operational Security (OPSEC) vs. Secretiveness §Individual Responsibility vs. Guilt §Non-Defensive (combat) Driving vs. Aggressive Driving §Discipline and Ordering vs. Conflict

Readjustment issues §Where do I fit in? l “Seems that they got along fine without me” §Vigilant – (e.g. driving to the dump) l “I was going to run over that little boy” §Numbness l “There were dead kids everywhere – Now I seem to ignore my own daughter” §Triggers in daily life l “I used to look forward to deer season.”

Readjustment issues §Relationships l “I just want to be left alone” l “Why did they make me come home?” §Occupation l “What happened to my job?” §Social l “Everyone wants the details – I don’t want to talk about it. I’d rather get drunk” l “Who are these people?” §Reexperiencing l “I’m always there. Never here”

A quote from an aging veteran §“Once you’ve been in combat, you are always alone.”

Potential Complications of Deployment on Soldiers & Families §Depression, anxiety, other symptoms §Alcohol and other drug addiction/abuse §Violence, including Suicide/Homicide §Divorce §Job Loss §Homelessness §Poverty §PTSD §Just about anything else that can go wrong

WHAT IS NORMAL? §Resilience following trauma is the norm §Accept “symptoms” as prolonged adaptive mechanisms or expectable reactions to return home §Recurrence of symptoms from previous traumas in some individuals §Problems should gradually improve over time §BUT: Many complications of untreated PTSD for the individual, the family and society

Requirements for clinicians §Professional competency/skill l More training often required §Cultural competency l Veteran/Military §Value clarity l Keeping your own beliefs out of the room §Patient/client centeredness §Wisdom l “First, do no harm”

Trauma across the lifecycle §No one is unaffected by trauma. §Trauma impacts one’s beliefs about safety and justice. §With age, the trauma of others is often personalized. More so in the current era. §Terrorism raises questions of the legacy of generations gone (going) by §Older generations take their responsibility to newer ones seriously but may feel little influence

What about the Aging Veteran? “Old soldiers never die, Never die, never die, Old soldiers never die They just fade away.”

The rest of that song §“Privates they love their beer, 'most every day. Corporals, they love their stripes, that's what they say. Sergeants they love to drill. Guess them bastards always will So we drill and drill until we fade away.”

EACH WAR IS DIFFERENT §WW2: “If we did such a great thing, why am I still in pain?” §Korea: “Will I ever be warm again?” §Viet Nam: “What did I do to deserve this kind of hatred when I got home?” §Somalia/Balkans/Panama: “What do you mean: ‘What war?’” §Iraq/Afghanistan: “There is no safe place.”

Approaches to Understanding §Phenomenology - descriptive §Pathophysiologic § Psychosocial-Developmental §Existential §Psychodynamic §Spiritual §Moral §Western/Eastern §And so on

TRAUMA ACROSS THE AGING CYCLE §Symptoms following acute trauma l May be transient reactions l Readjustment l Some develop PTSD §Chronic PTSD in late life §Late-Life Onset of Symptoms

A CASE WITH MANY THEMES §GG is a 72 year old executive who functioned well for many years. While on a fishing trip, he stood helpless as his best friend drowned. Intrusive recall of events that took place while he was a medic in the Korean War have dominated his daily life since then. He has had no intrusive thoughts of his more recent trauma and continues to fish the same waters regularly.

Geographic cure? §XX is an 71 year old man who retired from his job as a Wall Street stockbroker after having a series of panic attacks on the subway route he had taken for decades. “I would have run over my grandmother to get out of that subway.” “All I could think of was being trapped in a tunnel and I had to escape.” This former POW had not planned to retire but was unable to get to work on time by other routes. After retirement, he moved to a small home in rural New Hampshire. His panic episodes subsided. One day he had a minor problem with the plumbing and decided to go into the crawl space under the house to check out the pipes……..

SEQUELAE OF TRAUMA OVER THE YEARS §PTSD (Management vs cure) §Symptoms wax and wane over lifetime §Exacerbations of well compensated illness in times of stress/disease/loss/inactivity §Late life developmental tasks - integration, wisdom/despair, passing the torch, regrets, survivor pride/guilt

ADULT DEVELOPMENT §Freud §Erikson §Keegan §Piaget §Loevinger §Maslow §Kohlberg

ERIKSON’S EARLY STAGES §1. Basic Trust vs Mistrust §2. Autonomy vs Shame and Doubt §3. Initiative vs Guilt §4. Industry vs Inferiority §5. Identity vs diffusion (confusion)

ERIKSON’S ADULT STAGES §6. Intimacy vs Isolation §7. Generativity vs Stagnation §8. Ego Integrity (Wisdom) vs Despair/Disgust

IMPACT OF TRAUMA ON: §Basic Trust? §Shame? §Industry? §Guilt? §Identity? §Intimacy?

TASKS OF AGING (And often the tasks of therapy with older veterans) §GENERATIVITY Passing the Torch Leaving a mark Leaving the world a better place Providing for heirs §ACHIEVING WISDOM How does this fit

AGING SOLDIERS §WW2, KOREA §VIET NAM §SOMALIA, PANAMA, BALKANS §GULF WAR 1

A FEW MORE QUOTES (Courtesy WW2/Korea group) §“What did we fight for, anyway? Not for this.” §“We’re as bad as the damn Germans ever were.” §“They lied to us. Why else would we blow people to kingdom come?”

A FEW MORE §“We ought to get into the schools and tell them what we know. If no one will fight, then none of the poor bastards is going to get killed.” §“Send me, not my kid. Not his kids either.” §“It’s never going to end, is it? It’s people.”

CONCLUSIONS §No one is unaffected by trauma. §Trauma impacts one’s beliefs about safety and justice. §With age, the trauma of others is often personalized. §Terrorism raises questions of the legacy of generations gone (going) by §Older generations take their responsibility to newer ones seriously but may feel little influence