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Veterans are not ‘ticking time bombs’
Like all of us, I was very troubled by the recent mass shooting in Thousand Oaks, Calif. This shooting was on top of the massacre at Pittsburgh’s Tree of Life synagogue, the shootings in a yoga studio ... the sickening list goes on and on.
As both a veteran and a psychiatrist with expertise in posttraumatic stress disorder, I was especially dismayed by the assumption that the Thousand Oaks shooter, who had served in the Marine Corps, had PTSD, and that the PTSD had led to the shooting.
The overall effect of these assumptions is to reinforce the stigma against veterans as “ticking time bombs.”
No question, there are plenty of other stereotypes to go around, especially those of Muslims as terrorists. In reality, as reports from the GAO and independent news sources show, most “terrorist” attacks in the United States have been carried out by right-wing extremists, mainly white, and born in this country.
Back to veterans. It is true that there have been several mass shootings by service members and veterans, including the massacre at Fort Hood, Tex., in 2009 by an Army major, the 2017 shooting up of a church in Texas by someone who had served in the Air Force, and this most recent one by a former Marine.
But there have been many other shootings and acts of political violence by numerous others, including those for whom “life is going down the toilet.” When you look at these situations, the driving factors are usually anger, irritability, and a sense of being wronged. Often, delusions and paranoia emerge.
It is true that there are many barriers to treatment for both veterans and nonveterans, including stigma, lack of insurance, and the dearth of mental health providers.
Those factors have nothing to do with being a veteran, who are normally very proud of both their country and their military service.
Let us celebrate those who have given so much to this country, America’s sons and daughters.
Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.
Like all of us, I was very troubled by the recent mass shooting in Thousand Oaks, Calif. This shooting was on top of the massacre at Pittsburgh’s Tree of Life synagogue, the shootings in a yoga studio ... the sickening list goes on and on.
As both a veteran and a psychiatrist with expertise in posttraumatic stress disorder, I was especially dismayed by the assumption that the Thousand Oaks shooter, who had served in the Marine Corps, had PTSD, and that the PTSD had led to the shooting.
The overall effect of these assumptions is to reinforce the stigma against veterans as “ticking time bombs.”
No question, there are plenty of other stereotypes to go around, especially those of Muslims as terrorists. In reality, as reports from the GAO and independent news sources show, most “terrorist” attacks in the United States have been carried out by right-wing extremists, mainly white, and born in this country.
Back to veterans. It is true that there have been several mass shootings by service members and veterans, including the massacre at Fort Hood, Tex., in 2009 by an Army major, the 2017 shooting up of a church in Texas by someone who had served in the Air Force, and this most recent one by a former Marine.
But there have been many other shootings and acts of political violence by numerous others, including those for whom “life is going down the toilet.” When you look at these situations, the driving factors are usually anger, irritability, and a sense of being wronged. Often, delusions and paranoia emerge.
It is true that there are many barriers to treatment for both veterans and nonveterans, including stigma, lack of insurance, and the dearth of mental health providers.
Those factors have nothing to do with being a veteran, who are normally very proud of both their country and their military service.
Let us celebrate those who have given so much to this country, America’s sons and daughters.
Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.
Like all of us, I was very troubled by the recent mass shooting in Thousand Oaks, Calif. This shooting was on top of the massacre at Pittsburgh’s Tree of Life synagogue, the shootings in a yoga studio ... the sickening list goes on and on.
As both a veteran and a psychiatrist with expertise in posttraumatic stress disorder, I was especially dismayed by the assumption that the Thousand Oaks shooter, who had served in the Marine Corps, had PTSD, and that the PTSD had led to the shooting.
The overall effect of these assumptions is to reinforce the stigma against veterans as “ticking time bombs.”
No question, there are plenty of other stereotypes to go around, especially those of Muslims as terrorists. In reality, as reports from the GAO and independent news sources show, most “terrorist” attacks in the United States have been carried out by right-wing extremists, mainly white, and born in this country.
Back to veterans. It is true that there have been several mass shootings by service members and veterans, including the massacre at Fort Hood, Tex., in 2009 by an Army major, the 2017 shooting up of a church in Texas by someone who had served in the Air Force, and this most recent one by a former Marine.
But there have been many other shootings and acts of political violence by numerous others, including those for whom “life is going down the toilet.” When you look at these situations, the driving factors are usually anger, irritability, and a sense of being wronged. Often, delusions and paranoia emerge.
It is true that there are many barriers to treatment for both veterans and nonveterans, including stigma, lack of insurance, and the dearth of mental health providers.
Those factors have nothing to do with being a veteran, who are normally very proud of both their country and their military service.
Let us celebrate those who have given so much to this country, America’s sons and daughters.
Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.
For most veterans with PTSD, helping others is a lifeline
I am a former military psychiatrist who has published extensively about posttraumatic stress disorder and other psychological effects of war. Thus, I got sent the news clips many times about a potential candidate for mayor of Kansas City leaving the race to care for himself, his depression, and posttraumatic stress disorder symptoms.
Like many of our readers who are physicians, I have a very mixed response to the former candidate’s news.
On the one hand, kudos to him that he has decided to 1) get the help he says he needs, and 2) go public. On the other hand, I really wish that he did not have to drop out of the race to do so.
There are some parallels with leaving for severe physical illness, such as getting chemotherapy for cancer. However, for example, when Gov. Larry Hogan of Maryland received treatment for his cancer, he stayed in office.
Why can you stay in a race or office with cancer or heart disease but not with the very common psychiatric and treatable condition of PTSD?
I certainly do not know all the reasons the candidate for Kansas City mayor made this decision. He said he is encouraging other veterans to follow his example and get treatment for PTSD. He also alluded to suicidal ideation.
This got me thinking about the concept of needing to leave work to take care of yourself – a decision that is often lauded as both noble and wise. I will not opine much on nobility, other than saying it is always noble to help fellow veterans. Maybe his decision to go public will help other veterans. Hard to say. But I can on opine on wisdom, based on many years of working with veterans with PTSD. I almost always advise them to keep their jobs, if at all possible.
Taking time off from a job you care for actually might increase suicidal thoughts. That is due to less structure in the day, less socialization, and fewer feelings of self-worth. A consequent lack of funds might not help. I have long called holding a good job one of the best mental health interventions, superior to medicine and therapy alone (OK – I am being doctrinaire; there are no placebo-controlled, double blind trials on the topic. But I am also serious.)
In general, Why is it work or saving oneself? In my opinion, work helps to save oneself. Helping others, for most veterans, is a lifeline.
I wonder why he should have to drop out of work to receive treatment. Perhaps he was placed in a residential Veterans Affairs program, which often are 30-60 days long. It is notoriously hard to maintain a job during such treatment.
I believe that we should structure our PTSD therapy so that one can both work and receive appropriate treatment. We need war veterans, with or without PTSD, to run for office. And win.
Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.
I am a former military psychiatrist who has published extensively about posttraumatic stress disorder and other psychological effects of war. Thus, I got sent the news clips many times about a potential candidate for mayor of Kansas City leaving the race to care for himself, his depression, and posttraumatic stress disorder symptoms.
Like many of our readers who are physicians, I have a very mixed response to the former candidate’s news.
On the one hand, kudos to him that he has decided to 1) get the help he says he needs, and 2) go public. On the other hand, I really wish that he did not have to drop out of the race to do so.
There are some parallels with leaving for severe physical illness, such as getting chemotherapy for cancer. However, for example, when Gov. Larry Hogan of Maryland received treatment for his cancer, he stayed in office.
Why can you stay in a race or office with cancer or heart disease but not with the very common psychiatric and treatable condition of PTSD?
I certainly do not know all the reasons the candidate for Kansas City mayor made this decision. He said he is encouraging other veterans to follow his example and get treatment for PTSD. He also alluded to suicidal ideation.
This got me thinking about the concept of needing to leave work to take care of yourself – a decision that is often lauded as both noble and wise. I will not opine much on nobility, other than saying it is always noble to help fellow veterans. Maybe his decision to go public will help other veterans. Hard to say. But I can on opine on wisdom, based on many years of working with veterans with PTSD. I almost always advise them to keep their jobs, if at all possible.
Taking time off from a job you care for actually might increase suicidal thoughts. That is due to less structure in the day, less socialization, and fewer feelings of self-worth. A consequent lack of funds might not help. I have long called holding a good job one of the best mental health interventions, superior to medicine and therapy alone (OK – I am being doctrinaire; there are no placebo-controlled, double blind trials on the topic. But I am also serious.)
In general, Why is it work or saving oneself? In my opinion, work helps to save oneself. Helping others, for most veterans, is a lifeline.
I wonder why he should have to drop out of work to receive treatment. Perhaps he was placed in a residential Veterans Affairs program, which often are 30-60 days long. It is notoriously hard to maintain a job during such treatment.
I believe that we should structure our PTSD therapy so that one can both work and receive appropriate treatment. We need war veterans, with or without PTSD, to run for office. And win.
Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.
I am a former military psychiatrist who has published extensively about posttraumatic stress disorder and other psychological effects of war. Thus, I got sent the news clips many times about a potential candidate for mayor of Kansas City leaving the race to care for himself, his depression, and posttraumatic stress disorder symptoms.
Like many of our readers who are physicians, I have a very mixed response to the former candidate’s news.
On the one hand, kudos to him that he has decided to 1) get the help he says he needs, and 2) go public. On the other hand, I really wish that he did not have to drop out of the race to do so.
There are some parallels with leaving for severe physical illness, such as getting chemotherapy for cancer. However, for example, when Gov. Larry Hogan of Maryland received treatment for his cancer, he stayed in office.
Why can you stay in a race or office with cancer or heart disease but not with the very common psychiatric and treatable condition of PTSD?
I certainly do not know all the reasons the candidate for Kansas City mayor made this decision. He said he is encouraging other veterans to follow his example and get treatment for PTSD. He also alluded to suicidal ideation.
This got me thinking about the concept of needing to leave work to take care of yourself – a decision that is often lauded as both noble and wise. I will not opine much on nobility, other than saying it is always noble to help fellow veterans. Maybe his decision to go public will help other veterans. Hard to say. But I can on opine on wisdom, based on many years of working with veterans with PTSD. I almost always advise them to keep their jobs, if at all possible.
Taking time off from a job you care for actually might increase suicidal thoughts. That is due to less structure in the day, less socialization, and fewer feelings of self-worth. A consequent lack of funds might not help. I have long called holding a good job one of the best mental health interventions, superior to medicine and therapy alone (OK – I am being doctrinaire; there are no placebo-controlled, double blind trials on the topic. But I am also serious.)
In general, Why is it work or saving oneself? In my opinion, work helps to save oneself. Helping others, for most veterans, is a lifeline.
I wonder why he should have to drop out of work to receive treatment. Perhaps he was placed in a residential Veterans Affairs program, which often are 30-60 days long. It is notoriously hard to maintain a job during such treatment.
I believe that we should structure our PTSD therapy so that one can both work and receive appropriate treatment. We need war veterans, with or without PTSD, to run for office. And win.
Dr. Ritchie is chief of psychiatry at MedStar Washington Hospital Center.
Talking to military service members and veterans
The following opinions are my own and not those of the Veterans Health Administration.
A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”
There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.
Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”
So start with neutral subjects and their strengths.
I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).
Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.
The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.
What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.
This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.
Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.
Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”
Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.
So again, focus on strengths. “What did you do in the military that you are most proud of?”
A very practical approach about other issues, such as housing and employment, will go a long way.
Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)
I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.
Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.
So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)
The following opinions are my own and not those of the Veterans Health Administration.
A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”
There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.
Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”
So start with neutral subjects and their strengths.
I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).
Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.
The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.
What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.
This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.
Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.
Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”
Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.
So again, focus on strengths. “What did you do in the military that you are most proud of?”
A very practical approach about other issues, such as housing and employment, will go a long way.
Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)
I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.
Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.
So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)
The following opinions are my own and not those of the Veterans Health Administration.
A recurring question at many of the talks I give on posttraumatic stress and related topics is: “How can civilian providers relate to military service members and veterans?”
There are now online and in-person courses on this topic. The Center for Deployment Psychology in Bethesda, Md., and Massachusetts General Hospital in Boston are two of the better sources for these. Here, I would like to offer my condensed version.
Frequently, they are brought in by a spouse or girlfriend who says some version of: “If you do not get help, I am getting a divorce.”
So start with neutral subjects and their strengths.
I usually ask first where they live and who lives with them (which usually tells you a lot about socioeconomic status and relationships).
Then I ask about military history. Their branch of services, when they were/are in the military, and their job (known as MOS, military occupational specialty in the Army), and what rank they were when they left the service.
The answers reveal a lot. The Air Force and part of the Navy have more technical occupations. Marines and some Army specialties are “ground pounders,” often serving in the infantry, who were heavily exposed to combat from the wars in Afghanistan and Iraq.
What conflicts the veterans were in, if any, are very important. Those who have served in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom, Operation New Dawn, etc.) are usually very proud of their military service. However, those veterans may be internally conflicted, usually over friends who were wounded or who died, while they survived.
This latter subject often touches on the theme of moral injury, feelings of shame or guilt that they have returned home, while others have not.
Service members may not want to talk about these issues, as they reawaken those feelings. They often are reluctant to describe traumatic combat events to “someone who has not been there.” So, in my current VA practice, I touch very lightly on these issues, especially in the first meeting.
Usually, the service member or veteran is relieved about not having to talk about having “their friend’s head blown off.” I do say, “We can return to these events when and if you are ready.”
Service members may be reluctant to start medication, especially if they are worried about sexual dysfunction or addiction. They also may be avoidant of traditional trauma therapies, because revisiting the traumas is too painful. Be patient with their reluctance.
So again, focus on strengths. “What did you do in the military that you are most proud of?”
A very practical approach about other issues, such as housing and employment, will go a long way.
Many veterans, unfortunately, have blown through relationships, perhaps because of their posttraumatic stress disorder and related depression and substance abuse. They may be housed, couch surfing, or sleeping in their car. Another practical question is, “Where are you sleeping tonight?” (The VA, by the way, is very good at getting housing for homeless veterans.)
I have often said: “A good job is the best intervention for better mental health.” It adds structure, a paycheck, and a purpose for life.
Finally, I also talk about integrative or complementary medicine. Yoga, meditation, canine or equine therapy, and acupuncture are some of the alternatives that may allow them to modulate their hyperarousal and reconnect with their loved ones.
So, this is the quick version of “how to talk to veterans.” Delve into other resources as needed.
Dr. Ritchie is a forensic psychiatrist with expertise in military and veterans’ issues. She retired from the U.S. Army in 2010 after serving for 24 years and holding many leadership positions, including chief of psychiatry. Currently, Dr. Ritchie is chief of mental health for the community-based outpatient clinics at the Washington, D.C., VA Medical Center. She also serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University and Howard University, both in Washington. Her recent books include “Forensic and Ethical Issues in Military Behavioral Health” (Department of the Army, 2015) and “Posttramatic Stress Disorder and Related Diseases in Combat Veterans (Springer, 2015). Dr. Ritchie’s forthcoming books include “Intimacy Post-Injury: Combat Trauma and Sexual Health (Oxford University Press, 2016) and “Psychiatrists in Combat: Mental Health Clinicians’ Experiences in the War Zone” (Springer, 2017 ed.)
Book Review: Recounting of war, exposure therapy offers lessons
“The Evil Hours: A Biography of Post-Traumatic Stress Disorder” is a marvelous, complex, dark, and gritty book. Well written by David J. Morris, a Marine turned journalist, it examines both old and new ways of understanding the psychological consequences of war.
As a retired Army psychiatrist, I am well familiar with the history and realities of posttraumatic stress disorder (PTSD). But Mr. Morris recounts them in a new way that is complemented by his personal experiences of being a patient in the maw of the Veterans Affairs system.
The history of psychological reactions to war, from Homer to the present day, is well known to most military mental health practitioners, but less so to the civilian world. Dr. J.M. DaCosta’s term “irritable heart,” from the Civil War, and the term “shell shock” from World War I, are staples of military psychiatry.
Mr. Morris amplifies that discussion. He ascribes the violence in the West following the Civil War to the wandering of battle-scarred soldiers. Jesse James and other outlaws were former Confederates.
The trench warfare–induced torments of soldiers during and after World War I are known through the writings of poets such as Wilfred Owen. His words resonated with Vietnam veterans a half-century later.
David Morris also articulates well the difficulties with reintegration of the warriors back into the home front. His historical review highlights how other warriors who had killed had rituals and cleansing processes as they reunited with their communities. The absence of such rituals may exacerbate the rough transition many of our recent soldiers have struggled with.
The related concept of moral injury is well described, with references to the writings of psychiatrists Jonathan Shay and Bill Nash, and psychologist Brett Litz. I think of moral injury as the corrosive sense of shame and guilt caused by killing, by surviving when one’s buddies have not, or of feeling betrayed by the military that you have devoted yourself to.
What I found much more fascinating, however, was his first-hand description of trying to be a patient at the VA, treated with the so-called evidence-based therapies, such as prolonged exposure (PE) and cognitive processing therapy.
Mr. Morris found that PE made his symptoms much worse and writes: “I began to think of the treatment not as therapy so much as punishment. Penance.”
This is consistent with my experience: I served on an Institute of Medicine committee that sought to evaluate how well the Department of Defense and the VA delivered care to those with PTSD. We found that service members often hated those so-called evidence therapies. Their reluctance was tied to many reasons, including not wanting to talk to a therapist about and relive the traumas over and over.
When Mr. Morris finally ended PE, he wrote that he began to feel better “almost immediately.” “The anxiety I had felt, knowing that I would be forced to mindlessly relive the ambush at Saydia, dissipated in an almost mathematical fashion,” he wrote.
There is much more to savor in “The Evil Hours,” from reflections on cognitive processing therapies, use of medications, to alternative therapies, and posttraumatic growth. The Marine-turned-journalist, functioning as both a patient and recorder of the patient role, holds up an excellent mirror to our psychiatric practice.
Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.
“The Evil Hours: A Biography of Post-Traumatic Stress Disorder” is a marvelous, complex, dark, and gritty book. Well written by David J. Morris, a Marine turned journalist, it examines both old and new ways of understanding the psychological consequences of war.
As a retired Army psychiatrist, I am well familiar with the history and realities of posttraumatic stress disorder (PTSD). But Mr. Morris recounts them in a new way that is complemented by his personal experiences of being a patient in the maw of the Veterans Affairs system.
The history of psychological reactions to war, from Homer to the present day, is well known to most military mental health practitioners, but less so to the civilian world. Dr. J.M. DaCosta’s term “irritable heart,” from the Civil War, and the term “shell shock” from World War I, are staples of military psychiatry.
Mr. Morris amplifies that discussion. He ascribes the violence in the West following the Civil War to the wandering of battle-scarred soldiers. Jesse James and other outlaws were former Confederates.
The trench warfare–induced torments of soldiers during and after World War I are known through the writings of poets such as Wilfred Owen. His words resonated with Vietnam veterans a half-century later.
David Morris also articulates well the difficulties with reintegration of the warriors back into the home front. His historical review highlights how other warriors who had killed had rituals and cleansing processes as they reunited with their communities. The absence of such rituals may exacerbate the rough transition many of our recent soldiers have struggled with.
The related concept of moral injury is well described, with references to the writings of psychiatrists Jonathan Shay and Bill Nash, and psychologist Brett Litz. I think of moral injury as the corrosive sense of shame and guilt caused by killing, by surviving when one’s buddies have not, or of feeling betrayed by the military that you have devoted yourself to.
What I found much more fascinating, however, was his first-hand description of trying to be a patient at the VA, treated with the so-called evidence-based therapies, such as prolonged exposure (PE) and cognitive processing therapy.
Mr. Morris found that PE made his symptoms much worse and writes: “I began to think of the treatment not as therapy so much as punishment. Penance.”
This is consistent with my experience: I served on an Institute of Medicine committee that sought to evaluate how well the Department of Defense and the VA delivered care to those with PTSD. We found that service members often hated those so-called evidence therapies. Their reluctance was tied to many reasons, including not wanting to talk to a therapist about and relive the traumas over and over.
When Mr. Morris finally ended PE, he wrote that he began to feel better “almost immediately.” “The anxiety I had felt, knowing that I would be forced to mindlessly relive the ambush at Saydia, dissipated in an almost mathematical fashion,” he wrote.
There is much more to savor in “The Evil Hours,” from reflections on cognitive processing therapies, use of medications, to alternative therapies, and posttraumatic growth. The Marine-turned-journalist, functioning as both a patient and recorder of the patient role, holds up an excellent mirror to our psychiatric practice.
Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.
“The Evil Hours: A Biography of Post-Traumatic Stress Disorder” is a marvelous, complex, dark, and gritty book. Well written by David J. Morris, a Marine turned journalist, it examines both old and new ways of understanding the psychological consequences of war.
As a retired Army psychiatrist, I am well familiar with the history and realities of posttraumatic stress disorder (PTSD). But Mr. Morris recounts them in a new way that is complemented by his personal experiences of being a patient in the maw of the Veterans Affairs system.
The history of psychological reactions to war, from Homer to the present day, is well known to most military mental health practitioners, but less so to the civilian world. Dr. J.M. DaCosta’s term “irritable heart,” from the Civil War, and the term “shell shock” from World War I, are staples of military psychiatry.
Mr. Morris amplifies that discussion. He ascribes the violence in the West following the Civil War to the wandering of battle-scarred soldiers. Jesse James and other outlaws were former Confederates.
The trench warfare–induced torments of soldiers during and after World War I are known through the writings of poets such as Wilfred Owen. His words resonated with Vietnam veterans a half-century later.
David Morris also articulates well the difficulties with reintegration of the warriors back into the home front. His historical review highlights how other warriors who had killed had rituals and cleansing processes as they reunited with their communities. The absence of such rituals may exacerbate the rough transition many of our recent soldiers have struggled with.
The related concept of moral injury is well described, with references to the writings of psychiatrists Jonathan Shay and Bill Nash, and psychologist Brett Litz. I think of moral injury as the corrosive sense of shame and guilt caused by killing, by surviving when one’s buddies have not, or of feeling betrayed by the military that you have devoted yourself to.
What I found much more fascinating, however, was his first-hand description of trying to be a patient at the VA, treated with the so-called evidence-based therapies, such as prolonged exposure (PE) and cognitive processing therapy.
Mr. Morris found that PE made his symptoms much worse and writes: “I began to think of the treatment not as therapy so much as punishment. Penance.”
This is consistent with my experience: I served on an Institute of Medicine committee that sought to evaluate how well the Department of Defense and the VA delivered care to those with PTSD. We found that service members often hated those so-called evidence therapies. Their reluctance was tied to many reasons, including not wanting to talk to a therapist about and relive the traumas over and over.
When Mr. Morris finally ended PE, he wrote that he began to feel better “almost immediately.” “The anxiety I had felt, knowing that I would be forced to mindlessly relive the ambush at Saydia, dissipated in an almost mathematical fashion,” he wrote.
There is much more to savor in “The Evil Hours,” from reflections on cognitive processing therapies, use of medications, to alternative therapies, and posttraumatic growth. The Marine-turned-journalist, functioning as both a patient and recorder of the patient role, holds up an excellent mirror to our psychiatric practice.
Dr. Ritchie serves as professor of psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md., and at Georgetown University in Washington.
