Suicide Prevention for Combat Veterans

“Every day, five U.S. soldiers try to kill themselves”(CNN.com).

HEALING SUICIDAL VETERANS: Recognizing, Supporting and Answering Their Pleas for Help (October 2009, New Horizon Press) is written by Victor Montgomery, III, MAEd., CMAC, RAS, who has worked with thousands of veterans and families as a former crisis intervention therapist at the National Veterans’ Suicide Prevention Lifeline and as an addiction therapist in outpatient clinics.


In HEALING SUICIDAL VETERANS, Montgomery provides,

• Tips and effective strategies for veterans to cope and heal.
• Checklists to identify symptoms of depression, post-traumatic stress disorder, traumatic brain injury and substance abuse.
• Twelve real-life stories featuring veterans from the Iraq, Afghanistan, Gulf, Beirut, Vietnam and Korean wars.
• Resources for veterans to seek the help they need.

HEALING SUICIDAL VETERANS is a vital guide for any veteran struggling with suicidal impulses.

Finding a Therapeutic Framework for Trauma-Based Disorders

I received a comment last night from Jeannie and thought that this would have a wider application to those of us who seek treatment for our trauma-based disorders. Talk therapy is an extremely useful tool when utilizing a proper framework with a trauma-based philosophy, which is beyond the scope of this posting. So, intimacy in a therapeutic framework is where I want to go. Without establishing this environment with a therapist we could run the risk of intellectualizing our trauma and not actually internalizing it. To internalize our trauma and absorb it within our consciousness is to finally find freedom from a foreboding foe.

To all of you who are seeking help with ptsd keep on working at it. My years of sexual abuse hapened over 50 years ago (I'm 62 years old) and I have lived my life with more then my share of ad bad choices, bad decisions and worse choices in relationships.

I would like to mention that finding the right right therapist and the right treatment is like tring to find the right pair of jeans. If the fit between you and your therapist isn't working it's not your fault...the fit just doesn't work. Please don't give up. Seek referrals and don't be hesitant about requesting an informational interview.

PTSD therapy is about as intimate soul bearing as it gets. It is imperative to find the right person to help you through the process.

EMDR - just had my second treatment and I am truly amazed. If the light bothers you then you can close your ears and just listen to the beeps.

My comment,

Jeannie is absolutely correct. It is imperative to find the therapist that you can connect with. The nature and structure; the kernel of trauma-based disorders rest in the most recessed parts of our minds. We will not be able to access this information properly if we do not bond with our treatment provider. To begin the journey of recovery we must find a therapeutic window into our minds substrate. Without developing intimacy between your this would not be possible. This could take several appointments, please be patient you deserve it.

PTSD, The Signature Wound of Modern Warfare

In this reposting I am explaining the split within the combat veteran that allows him or her to be "one person" in a moment and then shift into another completely incompatible individual in the same second. This manifestation of opposing self-states have become a common experience for those of us who have received the "signature wound" of modern warfare.

The leading theorists on the subject recognize that reactions to extreme stress can lead to one or more differing diagnosis, and that inherent in said traumatic reactions is structural dissociation of the personality. Where three types of structural dissociation have been postulated: primary structural dissociation, secondary structural dissociation and tertiary structural dissociation.

Primary structural dissociation involves simple PTSD, and dissociative amnesia, where the Emotional Personality (EP) and the Apparently Normal Personality (ANP) have become disenfranchised or fragmented. The EP "...is fixated in the trauma and associated experiences....[and the ANP]...is fixated in avoidance of the trauma, manifesting detachment, numbing, and partial or complete amnesia" (Steele, van der Hart, and Nijenhuis, n.d., para. 8).

PTSD is not only about personal protection or self preservation but in its essence a mechanism of such endeavors, thus becoming a self-perpetual entity in of itself (the EP can develop into a sub-personality, a component of Dissociative Identity Disorder [DID]). Almost as if it has become self-aware and not only will it steer one away from danger, but also away from its own demise; a seemingly serendipitous supra-intelligent guidance of the subconscious.

The EP has evolutionary roots in defensive mechanisms that propelled us through the traumatic experience(s), an inborn reactionary system that can become entrenched within the mind. The EP's success in our survival leads us to firmly identify with this part of ourselves and engages in obsessive and compulsive rumination of the defensive mechanisms and exhibits as symptomatology.

The ANP has become the mode of operation whereby the individual can engage everyday operational tasks. Such as "...attachment, energy management, reproduction and rearing of children, socialization, play, and exploration" (para. 12). To do so, the ANP’s main function is to avoid the intrusive thoughts and fear potentials.

In a constant threat environment, the evolutionary response system and the benefits of survival further encapsulates the differentiated states of mind. Secondary structural dissociation is a result of this prolonged and saturated state of being. A fluid environment demands that we engage in concerted efforts to survive, to do otherwise means death. Animalistic reflexive defense mechanisms such as the fight or flight response or submissive freezing, delve into the realm of “…complex PTSD or disorders of extreme stress (DES), trauma-induced borderline personality disorder, and dissociative disorders not otherwise specified” (para. 12).

Tertiary structural dissociation results from the complete fragmentation of the EP and the ANP. Whereby numerous ANP’s can develop to engage different aspects of a persons life, such as putting on your “work hat” to enable the separation of a traumatic existence to a work self, the social self, etc. Here we find the diagnosis of DID, where traumatic associations or triggers have inundated the individual and submerges them into a function of constantly changing identities governed by situational exchanges.

Combat Veterans Bring the Monster of War Home: The Story of SGT Travis Triggs

Image via Wikipedia

Welcome home my brothers and sisters, welcome home. Thank you for your service and continuing sacrifices. I pray that you have a blessed Veterans Day. Below I mention Sgt. Travis Triggs who had lost his way home from spiritual and mental wounds of war. Sgt. Triggs is fast becoming the norm when counting the revolving doors and tours of duty. Imagine having lived through the horrors of war and in going home knowing that in all probability you will run with death again.

How would you release the demon raging in your mind?

I was just reading about Sgt. Travis Triggs again, for those that do not know who I am talking about he was the soldier who had 5, yes FIVE tours of combat, that shot himself and his brother in the head after a police car chase. He went to Iraq 4 times and Afghanistan once. He had never been in trouble before that day even though the media had portrayed them both as having violent criminal histories. Sgt. Triggs volunteered for the extra deployments,

My symptoms went away. After all, I was going back to the fight, back to shared adversity, where the tempo is high and our adrenaline pulses through our veins like hot blood (as cited in Times Online, November 23, 2008).

The article gives an account of a lost soul that had left everything over in a far away land where the blood runs thick as the bonds of brotherhood. He had assumed a culture of killing and the persona of a "combat self," a subsumption of the "Soldier's Heart," shedding all of the remnants of his civilian identity and connections to self and home. He had become the perfect soldier, much too perfect.

There is disconnection between everything that is human and the necessities of killing and what has to be done in combat. Imagine being in an unimaginable situation and having to do the unthinkable. How can this be done? A disconnection between everything human and having to do the unimaginable resounds in combat. For we must wholly demonize our adversary and in the process we dehumanize ourselves, whereas the monster must die. A neurological reprogramming engaging dissociative states and a compartmentalization splitting. In doing so some veterans and soldiers lose their way, not only on the inside of our mind but now they become outsiders in society. Everything at home had become foreign to him, he had become lost within a once comfortable environment.

The parallel contrasts to my article on identity and dissociation and Sgt. Triggs? On the night where I had lost myself into psychosis, if the police had shown up, or if someone had confronted me on my abnormal behavior, it would had became real and the psychotic break would have been complete. I was convinced that everyone was out to get me and I would have responded with violence to "protect" myself due to a warped conception of a perceived threat.

I ran out of that house and jumped into my car and drove away; drunk, high and out of my mind. Easily I could have been in an incident that probably would have resulted in a similar outcome. My death, an innocent bystander and possibly the police.

To survive war is not a relief, it is a sentence of grief, guilt, pain and shame from killing and surviving.

Let me ask again, How would you release the demon raging in your mind?

PBS to Air Special on Supporting our Veterans

Tomorrow on Veterans Day PBS will air a special celebrating a group of senior citizens who honor us as a nation when the general public is busy about their lives. I will be representing my service to our country and honoring those who have fallen. I invite you to tune into PBS and watch.



On call 24 hours a day for the past five years, a group of senior citizens has made history by greeting nearly 900,000 American troops at a tiny airport in Bangor,Maine.The Way We Get By is an intimate look at three of these greeters as they confront the universal losses that come with aging and rediscover their reason for living. Bill Knight, Jerry Mundy and Joan Gaudet find the strength to overcome their personal battles and transform their lives through service. This inspirational and surprising story shatters the stereotypes of today's senior citizens as the greeters redefine the meaning of community (copied from email by PBS's Community Engagement and Outreach Assistant).
Our troops deserve every ounce of support.

Soldiers, Guilt, Grief, Killing and Survival

In the last few posts I have been reposting some writings with a central theme. What a combat veteran goes through after returning from the battlefield, what we bring home to our families and communities. Below I discuss an identification with the crippling guilt that had blocked access to fully realizing my memories. Years after combat I could not remember most of what I had witnessed, but wished I could forget the guilt and self-condemnation haunting me. I demonized my enemy and in doing so lost my humanity.

I was writing about the "troop organism" and the squad mentality in my last paper. This line of inquiry took me back to a time when I felt totality, never since have I been more alive. A complete sense of unity, an omnipresence with my squad so whole within my surroundings, including the enemy we snuffed, especially those souls. I carry them today; the weight of such suffering that I now hold within. I have a sense of responsibility to those lives we took, I hold such guilt that at times it overwhelms me to the point of incapacitation.

My surviving has had such an impact on my life that many times I find myself not being worthy of having survived, and I know that this thought is not rational, but at times I cannot shake it. Many times in my life I thought of killing myself because of the crushing guilt, all due to my survival and inability to put behind me these thoughts of incompleteness.

Thinking back now, I feel that the absence of the completeness I felt back in 1991 coupled with the guilt of surviving have combined to form a disorganized attachment to the soldiers that we killed. In losing my attachment to the troop-organism, I unconsciously reformed that attachment on the one thing that I could take home with me, my guilt. In losing my squad-selves and my subsequent identifying with the enemy soldiers, I unwittingly formed a festoon of guilt and hung it upon my soul.

I know that they were the enemy, it was kill or be killed...But my God, when we were shooting and hitting them I saw their tanks and vehicles blowing up in grand fashion, it seemed so beautiful. I remember the sight was so awe inspiring, the turrets flipping end over end, fire spraying upwards to a hundred feet. I could feel in the back of my mind, my humanity, trying to tell me that there were people in those tanks. My mind tried to tell that I could actually see the bodies felling over and over, within the upwelling of fire...no, no that cannot be...I was too far from them to actually see. So I told myself.< The reality set in when we saw the charred remains of the vehicles and realizing that no one could have lived through that. I remember trying not to think of my vehicle getting hit like that. The guilt began to creep up on me when we saw the pitiful encampments of the regular soldiers; we saw their food stocks...rice and rotting tomatoes...nothing more, and little of that. We joked of how we were glad to be on our side, again I felt the little bit of guilt niggling at me to witness and take in what we saw. Today, I carry the guilt of thousands of soldiers who lost their lives to the meat grinder of the US Army by way of the M1A1 Abrams Main Battle tank sabot rounds, of the Apache helicopter hellfire missiles, the 30mm A10 Warthog Gatling guns, multiple launch rocket systems and the 105 mm howitzer to name a few. To find out how bravely the Iraqi Republican Guard units fought against an over whelming foe, follow this link (then click on "correcting myths").

I still chase that sense of totality...I was the driver, on point for the division, so I saw it all.

Precipice of Death, A Soldier's Vista

If you are just now joining us, I am posting overlooked articles that I think can build on an understanding of your combat veteran. In this post I attempt to portray the minds landscape of the veteran or soldier have gone to the brink of death and found the place where others lose theirs and how do we come back from this precipice.

To understand what a person with PTSD goes through "in the moment" we have to think beyond our belief of how we would handle ourselves in a high stress life or death situation. Put self away, go to that place that enables you to kill or be killed.

Forget the theoretical self analyzing the process, but concentrate on the dominating, primeval alpha self that goes beyond rationalizing why or why not, realize that part of you that goes without thinking. This part operates from the law of the wild, the component that keeps you alive when your life becomes threatened to be snatched away. Your will to survive is an entity of its own and will separate from your rationale to preserve itself, self preservation.

We have a filtering mechanism inside of the mind that strains experience looking for the pertinent information needed to navigate stimuli in the environment. The subconscious screens the information through our emotive center which guides us on appropriate actions. When this controller becomes overloaded, the trigger is pulled and the irrational takes over. The flood gate becomes inundated and can no longer hold the storm wind and rain, the dam breaks releasing the rainwater's natural propensity to flow and overwhelm everything in its path.

Once this part of us has been released due to a death threat, it places itself on point and plows the way to safety. That part of us summoned by the heat of anger and the fire of rage and shuts down all thinking and rationalizing to do the deed, the dance of death.

Attachments with Family & Friends Give Way to Squad Cohesion

Again I am reposting past articles to help others in their quest for reasons and rationalities of irrational behavior of a combat veteran.

The question about will a soldier seek out help when they are losing sleep and exhibiting signs of PTSD. Probably not if they are still in the military, because the military has a deep ingrained belief that PTSD is a weakness.

Another thing to consider, soldiers in combat develop a powerful attachment to one another. The strength of this bonding overshadows all others, even family. First of all the degree of familiarity and closeness that extreme survival situations such as combat, brings people together to a height one has never experinced before. People have an instinctual need to feel a belonging such as in a herd where they feel safe.

A small combat squad that has experinced several fire fights develops a sense of oneness with each other, they have become one organism through the forging process of fight or flight. Due to the nature of killing and survival all of their other emotionality has become severed from their environment and channeled into the solidarity that soldiering brings. If one of them gets wounded or killed they all feel it through their connection of unity.

This herdness has supplanted all other attachments while people they once knew intimately have become foreign and strange. The family, friends and soldier feel this estrangement and all involved become unfamiliar and uncomfortable. Family and friends cannot understand what they have been through, so they seek others who do.

Some soldiers will long for that interconnectedness left in the field when they came home and reenlist or volunteer for another tour. Many soldiers find that their PTSD symptoms dissipate or vanish while back in the theater of combat, they have reentered the realm of survival, fight or flight and oneness with soldiering.

A Combat Veteran Struggles with Leaving the Ethics of War Behind

Soldiers and veterans with full blown PTSD usually have low personal self-esteem, a self-constructed foundation of self-affirmations grounded in positive thought, word and deeds, reinforced through values and principles. Esteem manifests in an outward appearance of honor and moral mastery, integrity and humility as others would know a consistency of character established through words, deed and actions. Where all of these principles were meet and mastered in the field of battle they no longer apply to a civilian life or civil society.

The combat schema, a defined preconditioned set of beliefs and values enabling the warrior to navigate efficiently through the adversity of combat without a detailed consideration of consequences. To engage in a mortal fight with the enemy this schema spells out our actions in a given situation as being preoccupied with survivability of the moment can get you killed. The warrior with PTSD has grown accustomed to the value and belief systems of war and feels threatened when they become faced with having to let go of this security to reintegrate back into society.

Without a proper identification of values and a conceptualization of a solid schema we can become lost to the reality of a situation and possibly lose out on our interactions necessary for relationship building. Combat critically changes our value systems, mostly to the detriment of constructing and maintaining significant relationships with family and friends. A disconnect happens between the soldier or veteran that leaves everyone feeling as though an insurmountable wall has been erected.

By an identification of values, along with acknowledging and deconstructing the combat schema one could find the ability to critically analyze in the moment, the validity of said beliefs as required by situational reflection enabling readjustments and disallowing an inflexibility of position. An underpinning of empowering schema and a reevaluation of ethical morality allows one to find plasticity in the moment producing a positive self-efficacy; a confident and self-assured person.

A Solider's Conviction, Why We Fight

Another reposting to bring forth knowledge to those who wish to understand their combat veteran.

My war was in 1991, fought against a invading force foregoing a countries self-determination and rule. A soldier has to believe that their cause has been a just one. For without this belief, war has become an act of tyranny and we amount to mercenaries. King Khalid of Saudia Arabia offered our commander in chief to pay each American soldier in the Gulf War I $1500, he refused as he should have.

I was proud to have served a noble cause of restoring a countries rights, borders and sovereignty. I had been awake fighting for seven days straight without any sleep and was upset when the cease fire had been called. We had engaged in three hard fought campaigns against the Iraqi Republican Guard, Saddam's best armored forces. We had their remaining Division cut off from returning to Iraq in a low lying basin, both opposing forces within firing range.

As we looked upon each other in anticipation, with our trigger fingers itching, we knew that this would be a heavy fought battle with many casualties. Both sides in a bid for life within a surreal cloud of apprehension, waiting for the order to fire.

A soldiers conviction carries them through the inferno of warfare, for a cause linked in faith to higher principles better enables the mind to rest within its self-preservation mode. Engaged by the confidence that our presence will be felt and fueled through our fealty to freedom for everyone. In moments like this, time stands still and listens to the call of the soldiers communion with all and none.

Combat Values Theory and the Veteran: A Marriage of Defensive Mechanisms and Role Switching

My readership has grown pretty steady in the last two years and I want to tell you that I am truly blessed to have people look to me for understanding when not so long ago I seriously lacked such perceptions. Soon I will have my 200th post here at PASP, Thank you for your continued patronage. I would like to bring some attention to some overlooked posts that I think will shed some light on a combat veterans thinking process, feelings, behaviors, reactions and interactions with others. I hope to bring forth an illumination into why we do what we do.

Photo by Scott Lee

Dichotomous Subdivisions Within the Subconscious, an existence without realizing our true nature results in a separation from reality and our connection to one another. An either-or duality dissociates discernment from reason leaving a fractured self. We cut up and separate rationalities in an attempt to preserve our sanity as the mind forms dissections to preserve and protect itself. The defensive mechanism overwhelms our thinking process and compartmentalizes our personality. The split in our mental reflections enables a combat veteran to 'role switch' from a killer instinct with no remorse to a loving and caring father with great capacity for empathy. For the combat vet this can become troublesome to dangerous when these roles begin to blur and wreck havoc.

Everyone sets up belief systems, a schema that enable us to react to situations as they arrive. By using this system of rules as a guide in life we can interact in society without having to analyze every aspect of our experience. We can convince ourselves that our ideology is who we are, when in reality living within our dogma cuts us off from a greater understanding and reaching our potentiality. The combat veteran's brain has invoked a divided self to ensure the integrity of the differing internal representations. His or her mind has been subdivided into incompatible subsections to deal with life in the clashing realms of their subconscious.

The Combat Veteran, Detachment and Dissociation

Absence of Prescence and Intimacy
You may or may not know that I am serving an internship in a legal setting. I have been struggling with the opening up and closing down myself along with keeping this separate from my interviews with clients, psychosocial reports and recommendations. Many of the clients I serve have similar backgrounds as myself, that being of course traumatization and retraumatization. The chronically traumatized person can become caught in a whirlwind of triggers, negative emotions and behavior while remaining detached from the environment and the reality of the situation.

When a survivor exhibits detachment from external stimulus and interactions, they have checked out and can remain in this state of mind for long lengths of time. Stressors within the environment that causes distress to the traumatized brain and can trigger the survivors disenfranchised memories, experiences and especially emotions. When this happens we lose a pivotal inner connection with ourselves and significant others. The loved one of a combat veteran can witness this disconnection in them by his or her facial expressions, body language and the absence of presence and intimacy.

Imagine the loss of this connection within yourself, the folding of the self inside out with this other self falling into an abyss. Continuously witnessing your central core falling and never losing site but knowing that, it, will fall forever. While doing this try and pay attention to someone in front of you when your perspective comes from a million miles away.

So, this what I am talking about. I started to write with the intention of explaining the process of opening up of the self to present during interviews and my work as a social work intern. I have trouble with the process of opening up concerning trauma, mine or others; its importance, where, how, when and the emotionality of the process, how to open up and close down. A disconcerted disconnection.

Blast-Related Ear Injury in Modern Warfare

Blast-Related Ear Injury in Modern Warfare
Three years after Gulf War I in 1990-1991, the Army had its first increase in hearing loss since 1974 when new hearing loss tracking methods where adopted (Chandler, 2006; Mcllwain, Gates, and Ciliax, 2008). With a 360 degree battlefield with no defined frontlines, as high as 90% of soldiers have served in a battle zone and 68% have actually engaged in combat. The realities of modern warfare have placed more than 469,095 soldiers on two to three tours of duty, fast becoming the norm. Never before have our combat troops been exposed to more than 200 days of combat in one tour, an operational tempo superior to that of WWII and Vietnam (Lee, 2009).

Further, the survival rate of wounded warriors has risen to 88%, up from 78% from the first Gulf War. About 68% of the wounded have a blast-related injury directly related to the improvised explosive device (IED), the leading weapon in the enemy’s arsenal (Mcllwain, et al., 2008). With new technology and the latest in medical advances, more soldiers survive their wounds (Chandler, 2006). The risk of hearing related injuries have exponentially exploded for the modern warrior.

According to Chandler (2006), of the 257 combat soldiers examined they found that 64% had ear injuries and hearing loss. Mcllwain et al. informs us that 47% of all medical evacuations were blast related injuries, accounting for the majority of battle related wounds. The report makes an exclamatory claim that 51.8% of combat soldiers have “moderately severe hearing loss or worse.” Lew, Jerger, Guillory, Henry (2007) report that 62% of soldiers studied and diagnosed with a blast-related traumatic brain injury (TBI) had self-reported hearing loss while 38% reported tinnitus. The majority of blast-related ear injuries were sensorineural in nature and the soldiers hearing potential will worsen over his or her lifetime (Chandler, 2006, Lew, et al., 2007).

In the coming future the Department of Defense (DoD) and the Veterans Administration (VA) will have increasing difficulties and possibilities of misdiagnosing hearing loss as an affect related to a traumatic brain injury (TBI) and or psychological problems (Chandler, 2006; Fagelson, 2007; Henry et al., 2007). Fagelson (2006) reports that, “34% of the first 300 patients enrolled in the [Veterans Administration Medical Center] VAMC Tinnitus Clinic also carried the diagnosis of [Posttraumatic Stress Disorder] PTSD” (p. 107). Further exacerbating the already precarious situation for our war wounded. Military interdisciplinary teams work together to prevent such misattributions and diagnoses and provide a holistic approach to meeting the needs of the wounded soldiers.

In the last two decades the military has cut funding to hearing conservation programs, even after research has proven the program works. As a result we have seen a marked increase in soldiers and veterans with hearing problems that tend to plague them in later years as most hearing problems increase over the years. A dreary outlook as the increase of blast-related ear injuries will continually add to the already overburdened VA (Chandler, 2006; Mcllwain et al., 2008) .

Insights and Infantry Soldiers Concerns with Hearing Conservation
The modern military Hearing Conservation Program (HCP) has been an evolution of procedures, laws and acts dating back to the General Law of 1862 and the Disability Act of 1890 that recognized hearing loss as a disability. In the first half of the twentieth century little headway was made in the advancement of hearing conservation. In the beginning of the 1900’s it was assumed that hearing loss could be prevented if a solider developed a tolerance to loud noises. This belief in a “tolerance theory” fed the Army attitude that if a soldier avoided loud noises they were considered weak (Mcllwain et al, 2008).

Soldiers in the British Army were largely ignorant of a HCP as late as 2007, fueling increases in hearing related disabilities. With noise levels of 90 decibels (dB) were enough to cause hearing damage. The infantry units were regularly exposed to levels ranging from 145 to 200 dB, enough to cause hearing impairment to a high percentage of soldiers. The report estimates that only 22% knew about a military HCP and the majority (91%) of troops said that their reasons for not wearing hearing protection or use them improperly was due to personal experiences in firearm training and combat. The soldier firing their weapons in many different atmospheres evokes a situation where extreme conditions could foster greater advancement in the research and study of hearing loss, hearing loss prevention and tinnitus (Okapala, 2007).

Tinnitus and Posttraumatic Stress Disorder
Approximately 3 to 4 million veterans have tinnitus with almost 1 million in need of varying levels of interventions (Henry et al., 2007). An avalanche of research finds evidence for a connection between tinnitus and PTSD, suggesting a co-occurring relationship and related neural mechanisms. Similarities in diagnostic criteria for symptoms of increased arousal compared to the diagnostic criteria for tinnitus, such as difficulty in falling asleep, irritability or outburst of anger, difficulty concentrating, hypervigilance and exaggerated startle response. Sleep disorders symptomology and concentration difficulties translate directly to tinnitus screening measures (Fagelson, 2007).

Several neural mechanisms linked to both tinnitus and PTSD affect auditory behaviors. Audiologists should be aware that patients with tinnitus and PTSD will require test protocols and referrals that address these powerful responses (p. 107).

Such misattributed symptoms as hypervigilance and exaggerated startle response have a relational context to irritation and anger and could be associated with tinnitus and or PTSD. The overlap of symptoms suggests that the presence of both diagnoses would exacerbate either condition bi-directionally, of 300 patients studied, 34% had both conditions.

Audiology testing must incorporate sensitivities to patients with diagnosed and undiagnosed PTSD as the startle reflex could be increased with the sudden tones and high pitches related to auditory testing. Many patients self-report the resounding silence within the sound booth as an anxiety stressor, and listed many offending characteristics of the hearing screening regimen. Trauma related disorders and audiology assessments should include screening criteria for both tinnitus and PTSD along with clinical evaluations in mental health primary-care settings.

Recognition from both clinical practices in terms of assessment protocols and treatment modalities would benefit both conditions and clinicians in. By combining a hybrid system of assessment and treatment of best-practices from audiological procedures, mental health practices and primary-care physicians on the psychological effects and the similarities in assessing for PTSD, tinnitus and hearing loss with a central focus on the impact of proper appraisals on effective treatment.

Auditory Dysfunction in Traumatic Brain Injury
“Hearing loss and tinnitus are highly prevalent in the growing population of returning soldiers who have a blast related TBI. Thus we need to develop and implement strategies for diagnosis and management of auditory dysfunction in this population” (Lew et al., 2007, p. 925). Inpatients in the VA’s rehabilitation unit admissions for TBI have increased 47% since the beginning of Operation Iraqi Freedom (OIF). A subgroup of blast related (BR) veterans were reported as having 62% hearing loss with 38% of this group with tinnitus giving a clearer picture of the growing population of veterans with hearing loss attributed to TBI’s.

Forty months before the beginning (group I) of OIF and forty months after (group II), the two groups were compared, and found that group II had a significant amount of younger veterans with BR-TBI and hearing loss. This matter of younger veterans with TBI and hearing loss marks a significant change in the topology and identification of a growing population of veterans who have limited resources within the VA for an ever growing pool of patients. “In light of the high prevalence of hearing loss and tinnitus in this growing population of returning soldiers, we need to develop and implement strategies for diagnosis and management of these conditions” (p. 921).

Hence, while identifying issues with the assessment and services the full exposure and extent of problems within the continuum of care along with the bureaucratic entanglement and a lack of funding impeding effective treatments. With the battlement of statistics and cross-analytics encompassing the VA’s endless study of the problem we will see an insignificant addressing of the quandary in the short term. Endless speculation as to the causes and no end in sight to the ramblings of those that need “proof positive” before treatment remedies can begin to trickle down to the masses of veterans needing services.

Mental Health Services and Veterans with Auditory Disorders
In stark contrast to Lew et al., Kendall and Rosenheck (2008) declares that, “Although veterans disabled by auditory disorders seem to readily connect with VA mental health services, the reduced frequency or repetition of services use may require intervention” (p. 1357). They hypothesize that veterans with auditory disorders would use the VA mental health facilities less due to communication difficulties. The initial results found that disabled veterans with hearing issues had used VA mental health services at least once. Later the article states that although veterans with auditory disorders were more likely to seek initial mental health care, they were less likely to follow up on subsequent visits. This remains a national problem due to the steadily increasing in this population since 2001 will undoubtedly rise rapidly with our modern wars. In fact the report indicates that in the years 2005 there were 822,413 veterans diagnosed with a service-connected disability, a 176.2% increase in auditory disorders.

There has been some evidence that veterans with posttraumatic stress disorder (PTSD) and tinnitus have a link; it was reported that 34% of veterans seeking mental health care have both disorders. As in the VA means testing system, once you have a diagnosis equal care is given on a scale of service-connection to the medically retired.

Psychometric measures including; audio disorders, mental health disorders and traumatic brain injuries when assessed properly can be maximized through better assessments, best-care practices and joint cooperation among the differing divisions of the VA. “Mental health providers may also benefit from working as a team with other providers such as audiologist, otologists and primary care providers” (p. 1357).

Progressive Audiologic Tinnitus Management
The underlying nascence of this report collocates within the audiologic disorder of tinnitus. Tinnitus pervades and overlaps many of the audiological disorders and weaves its influence on PTSD. As we begin to better understand the nature of the most prevalent of combat injuries we perceive a depth and breadth of understanding what this actually means. PTSD, tinnitus, hearing loss and TBIs intersect into an astounding colloquial arraignment giving new meaning to the walking wounded. To meet this new paradigm we must garner new and improved assessments and treatments encompassing an amalgamation of best-fit practices and effect implementation immediately. Progressive Audiologic Tinnitus Management (PATM) modality fits this description and seeks to raise awareness to a multitude of divisions, service centers, physicians and practitioners from a holistic approach (Henry et al., 2008).

About 20% of veterans suffering from tinnitus require a clinical intervention which necessitates a progressive management approach, providing triage guidelines to facilitate appropriate care for the veteran with tinnitus and other presenting problems such as physical trauma, mental health problems, ear pain or drainage and depending on a categorical fit they would be referred to Ear, Nose and Throat (ENT), the audiology department, mental health or other specialist.

The PATM delineates which level of care the veteran would need based on a few short surveys and gives direction on the next steps such as education, interventions and treatments. The PATM consists of a five level “hierarchical approach [that] minimizes the impact of tinnitus on the patient’s life as efficiently as possible while simultaneously providing cost-effective management” (p. 14). By bringing together a concise and efficient overview of the helping process for the clinician in a generic way highlights and reinforces a collaborative spirit in assessments and treatments. Disseminating standardized direction to the helper that will best serve the veteran, a solution that would benefit from a system wide adoption within the VA system today.

Tinnitus Treatment with Customized Acoustic Neural Stimulus
Various types of treatments can significantly reduce the symptomology of hearing disorders and comorbid PTSD such as the PATM program and the Nueromonics Tinnitus Treatment (NTT) program which combines the use of acoustic stimulus augmented by a clinician and providing a structured counseling program for tinnitus management. The overall success rate of 86% gives ample reason to suspect replication of the new treatment modality and assessments across the VAMC, affecting clinical care settings such as; primary care, mental health, and emergency rooms would bring about much needed systemic change. Clinicians looking to improve the assessment of veterans with auditory disorders with mental health comorbidity would benefit from NTT.

The NTT approach “involves the use of a customized neural stimulus. This stimulus is delivered to the patient in the form of a pleasant acoustic sensation that is spectrally modified according to each patient’s individual audiometric profile” (Davis, Wilde, Steed, and Hanley, 2008, p. 330).

With the ever increasing soldiers joining the walking wounded, we need clear and concise assessment tools and treatment practices that can translate easily across the VAMC so that we can better serve those who served us. Practitioners who become more aware of the culture of the deaf and hard of hearing veterans could better accommodate their needs and help evolve the person-in-environment approach within the VAMC. By becoming aware of the unique needs of our returning soldiers and veterans we will gain an honorable response to their honorable service.

References
Chandler, D. (2006). Blast-related ear injury in current U. S. military operations: Role of audiology on the interdisciplinary team. The ASHA Leader, 11(9), 8-9, 29.

Davis, P. B., Wilde, R. A., Steed, L. G., and Hanley, P. J. (2008). Treatment of tinnitus with a customized acoustic neural stimulus: A controlled clinical study [Abstract]. ENT-Ear, Nose and Throat Journal, 87(6), 330-339.

Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16, 107-117.

Henry, J. A., Zaugg, T. L., Myers, P. J., and Schechter, M. A. (2008). Progressive audiologic tinnitus management. The ASHA Leader, 13(8), 14-17.

Kendall, C. J., and Rosenheck, R. R. (2008). Use of mental health services veterans disabled by auditory disorders. Journal of Rehabilitation Research and Development, 45(9), 1349-1360.

Lee, S. A. (2009). Government and private service providers: Soldiers and veterans stuck in between. Unpublished manuscript, Kent School of Social Work, University of Louisville. http://ptsdasoldiersperspective.blogspot.com/2009/04/government-private-service-providers.html

Lew, H. L., Jerger, J. F., Guillory, S. B., and Henry, J. A. (2007). Auditory dysfunction in traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 921-928.

Mcllwain, D. S., Gates, K. and Ciliax, D. (2008). Heritage of army audiology and the road ahead: The army hearing program. American Journal of Public Health, 98(12), 2167-2172.

Myers, P. J., Henry, J. A., Zaugg, T. L., and Schechter, M. A. (n. d.). Progressive audiologic tinnitus management for veterans [Brochure]. Portland, Oregon, and Tampa, Florida: Veterans Administration (VA) National Center for Rehabilitative Auditory Research, VA Medical Center, Department of Otolaryngology/Head and Neck Surgery, and James A. Haley VA Medical Center.

Okapala, C. E. (2007). Knowledge and attitude of infantry soldiers to hearing conservation. Military Medicine, 172(5), 520-522.

Update on Prazosin for my PTSD

This drug has made a world of difference to me in treating my PTSD. It helps with the major symptoms during the day and affords me a more restful sleep at night. I have been taking Prazosin for about six months now and have had my dosage raised to 6mg, 2mg in the day and up to 4mg at night. Depending on my sleep patterns, stress level and social situations I will either decrease or increase the dosage within the 6mg a day range as needed.

One issue I have experienced with this medication has to do with my memory. When I take the higher doses, I cannot for the life of me remember anything, including names of people I associate with on a daily basis. So, I weigh the costs when taking the larger doses. Am I overly stressed? Did I not sleep well the night before? Do I have to write a paper for school, or have an exam?

Another issue has to do with a dream/wake state. At times I will experince the feeling of dreaming when awake or have a memory that I cannot distinguish from a dream or the waking world. During such times I will remind myself and contribute the symptom to the medication and in doing so the episode expires.

What to Say to Your Soldier While Deployed

I received this comment over at A Soldier's Perspective, on the post "What to Say to Your Solider or Veteran Who Confess to You their Sins of War" from a woman that wanted to know what to say to her boyfriend on his latest tour,

My boyfriend of 6 months poured his heart out to me about his first deployment to Afghanistan back in 2001. It was a very emotional conversation and I just held hi close and listened to every thing he said. I've never felt so helpless before listening to his guilt and his pain. He was deployed to Iraq almost a week ago and I have no idea what to say to him while he's over there. I know not to ask questions abou the situation but is there anything comforting I can say?

My response,

By writing him he will know that you support him, this may seem insignificant to his situation, but has an enormous benefit to his morale. Your sense of helplessness was magnified due to his emotional outpouring, by being present with him you did everything you could do in that moment and the only action needed.

By being present in your writing you will convey your being to him, this can invigorate his day and bring him hope. Write about your day, tell him the funny thing that happened at work or the silly thought you had. Tell him that you had your hair cut and styled or that you had a bad hair day.

The most mundane things to you will be the most significant to him, give him a window into your world.

If you want to follow the conversation here at PASP, click here

Generations of Wounded Spirits, the Heirs of Tomorrow

Generational consequences abound with the wars of today, especially the soldiers, veterans and families, for they have been spiritually wounded.

But, I feel the revival of a movement birthing. One of acceptance and healing, instead of the current paradigm of rejection and exclusivity.

Wife of a Combat Veteran Seeks Guidance

I received this email from a reader which touches on a common situation facing spouses of combat veterans. I have an understanding between myself and my Higher Power that he will send people my way and my part is to point out that they have been chosen to advance the cause of their personal experiences with respect to the dilemmas they face.

We as humans will be surprised at the depths of suffering we can survive and the heights in which we can prevail. I am always telling people, "You will be surprised at what you can do when faced with hardship and how much you can handle when given the right tools to succeed."

Her email,

I have spent hours reading your blog and trying to understand. I am proud of my husband…for what he did for our country. I am not proud of the hateful man he is now. I love him and will forever stand beside him, but can you give me any idea of where I, as the wife, can go to gain assistance with dealing with the insanity that comes with being married to a man with PTSD. I am at my wits end and tired of crying and trying to be strong and support him.

My response,

I would suggest that you get involved with some organizations that advocate for the family of combat veterans with PTSD. I am certain that women in your area have similar situations to find the support that you need. You cannot go through this alone, it will destroy you and your relationship with your husband. Does he want to seek help, or has he been receiving help? Either way if you want to remain sane throughout the process then get active in your life, find support, advocate for better care for our veterans and support for families. If you have a lack of organizations or support groups in your area then start one.

Think of this as an opportunity to advance the standard of care for our veterans and the support of the families. Keep researching to better understand your husband and to better understand your self in this situation and reactions to his behavior.

I believe that my experiences in life will serve a higher purpose and that I have been chosen by God to prepare myself to become a combat trauma therapist. With my unique insights from both sides of the prism of PTSD, I will be able to empathize and help my clients in such a way as to guide them out of the fog of war and into productive lives. Maybe, you have been chosen to do similar work to advance the cause of increasing awareness and support for spouses and families of combat veterans.

Do not forget that this has completely changed your life, now it is up to you to turn your experiences into a force for change.

• Educate yourself to better understand your internal processes
  
• Review your internal values and belief systems
  
• Reevaluate your life's direction outside of work
  
• Get involved with women of combat veterans
  
• Find the inner warrior to combat the stigma, lack of care and understanding
  
• Evaluate skills you possess and translate them to your life outside work
• Begin to seek out your new path in life

If I left something out or you have more suggestions for our newfound friend, please post a comment.

Round and Round the VA Merrygoround

I am doing the, "Hey not in my backyard" thing with the VA again. I go to one therapist in an attempt to be admitted to the PTSD program and they tell me, no, that I am depressed to go see another therapist. It took me 2 months to see this one, then I get another appointment, and then, they tell me to move on down the road. Now at the VA getting in to see a new therapist. So, now I have to wait to see another therapist and guess what? Yep, you guessed it, another two months, add this up, 5 freaking months.

I know that I am depressed AND I know that my PTSD is kickin. Treat PTSD in one clinic, depression in another.....this is madness! No wonder veterans do not come back to another appointment.

Wait, did I just go into a tangent? I was trying to say that I want to go through EMDR therapy, it might take me another 5 months to receive it, but THEY will not get me to turn away!! Thats all folks a little help here please!!

What to do With a Drug and Alcohol Abuser

Mixed throughout some of my latest articles I have written about events centered around drug use and abuse. Over at A Soldier's Perspective I received a great question on a recent article, by a reader calling herself Susan.

Great story. A memorable milestone in your life. As a mom, I have to ask you how you went from a drug user to a soldier? Was there any defining moment in that change. I ask because I am a mother of a 20 year old young man. A young man I have found to my dismay is using drugs. I am lost as to how to help and live somewhat fearful for him.

Beyond taking a 2×4 across his head I am lost in this struggle. (Please note as a disclaimer that I would use the 2 x 4 with as much unconditional love that I could muster!)

any advice?

My reply to a well timed question,

Susan, I went from a soldier to a drug and alcohol user immediately upon returning home. Although I drank before I deployed, it did not get me into a spectrum of trouble until after combat. It took me 15 years of trouble at home, 2 marriages, alienating my children, problems with the law, violence, anger, 30 jobs, homelessness and landing in a long-term drug and treatment facility before I could come to terms with my addiction and mental illness (PTSD).

Many factors may contribute to your sons using and degree of using. He may be an occasional user, a frequent user or a chronic user. Even if his using is only occasional you could get friends, family and significant others together that love him and tell him of your concerns about his using drugs.

Does he have a mental health diagnosis, or do you suspect he may a mental illness? He could be self medicating, if this is the case then it will probably be harder to get him to quit because he may be seeking and receiving some relief in using.

If his using has caused him legal problems or difficulty holding a job, then he may need further interventions.

Some suggestions, If He Does Not Want Help:

• If he/she does not want help then he will need to reach his "bottom" (12-Step talk for abject demoralization), before they will seek help.
• Enabling an addict will only increase their use and dependence on you (causing you greater stress and safety issues).
• Do not let an addict borrow money.
• Do not trust an addict, they will use it against you.
• Call the police if you fear for your safety (you cannot help him if you are injured or dead).
• You may have to kick the addict out of the house, even if that means they will be homeless. (due to stealing, violence, or other situations that jeopardize the safety of the homes occupants).
• Throughout let him/her know that you are there for them if they want help and spell that help out for him/her.
• Before you help, they must sign into a drug treatment program.
• Unconditional love does not mean that you have to give them everything they "want", only what they "need". What they want will only become relevant to him/her or you if they are the one achieving it.

Live Honoring America's Fallen

By CJ Crisham


As you can tell, I haven't been writing a lot lately. To tell the truth, I haven't really felt like it. But, I've also been busy with a training week. We worked through the past two weekends and I'm REALLY looking forward to this Saturday for my first day off in a few weeks. I'm not complaining though. Guys in Iraq and Afghanistan go months without a day off.

Today, I had my second appointment with my psychologist. Originally, he was going to complete a command assessment, but I have to go to another post in Georgia for that. Not really sure why and neither is my doc. But, I'll do whatever it takes. The road time will be much needed.

What I don't want to turn this blog into is a constant repetition of PTSD issues. There's a lot going in the military and national security world that needs to be talked about – like the release of GITMO detainee Mohammed Jawad to Afghanistan. Jawad is accused of attacking two American soldiers and their Afghani translator in Afghanistan in 2002 by tossing a grenade at them. Instead of getting myself all wrapped up in that, I'll publish what Vets For Freedom Chairman, Pete Hegseth, said about the release since I agree with him on this:

The lives of our troops and the safety of our nation should be of paramount concern to the Obama Administration, not an afterthought. Today’s decision to release yet another trained terrorist shows a lack of consideration for the risks our war-fighters take to help bring insurgents and terrorists to justice.

Jawad’s treatment as a prisoner was unfortunate. However, his treatment does not exonerate him from throwing a grenade at American troops. America cannot afford to have terrorists released back to the battlefield and rejoining the fight to kill Soldiers and Marines, all for the purpose of appeasing a campaign promise.

Having served at Guantanamo Bay and in Iraq, I witnessed the cause of radical Islamists on two vital fronts. I saw how my fellow soldiers risked their lives in battle to capture these terrorists and the hard work and professionalism it took to hold them at Guantanamo Bay. Additional releases such as this will make the continuing mission of our troops far more dangerous and deadly.

Anyway, I've been officially diagnosed with PTSD, something I wasn't exactly happy about. Why? I just want to go on living my life. I've been pretending nothing is wrong with me for years and suddenly there's a name attached to it. I spoke with my doc today about anxiety, anger, stress, and depression. I won't go into all the details, but wanted to focus on something he told me just before we ended.

What is the leading cause of PTSD in civilians in America? It's an interesting question because most people don't think about PTSD as a civilian issue. Yet, it is. The difference is in how civilians deal with it. The number one cause of PTSD in civilians is a car crash. Yet, most people don't exhibit signs of PTSD. Why is that? When a civilian survives a catastrophic event like a violent car wreck, they still need to get places. They get a new or used car to replace the wrecked one and continue on with their lives. It's hard at first, especially when they see similar cars to the one they were driving in or the one with which they crashed. Or when they pass the location where the wreck took place.

However they do it, the fact that they continue to face their fears of driving out of necessity helps them to overcome the root causes of PTSD. Eventually, they learn not to be afraid of driving because they are doing it so much without incident and their symptoms slowly disappear. So, I told him, the answer is simple. I just need to go back to Iraq, right? No. I need to confront those events (or spikes) that have contributed to my PTSD. How can I do that? The same way I did it when I started this blog five years ago – by writing.

I've published an edited version of my journal before, but I've never written about those events in detail and some I didn't publish at all. I'm not sure how I'm going to do that publicly or if I even want to, but I've decided to write my experiences down privately. One day, like my journal, I hope to publish it for others to read and identify or find solace with.

So, CJ, what's with the title? I have a LOT of survivor's guilt that I've lived with for years. I ask that question often about why did I come home? If there is a purpose behind it, have I served that purpose already? If so, then what? That's a lot of pressure I've put on myself. All I can do is follow the advice of the magnet I keep on back of my van: "Live Honoring America's Fallen."

Illuminating our Covenant Selves

I am thankful that God chose to reveal intimacy on a deeper level of meaning and understanding upon me. By honoring and conveying our intimate attachments throughout our day we strengthen this communion between ourselves, significant others and our spirituality. Carrying with us our intimate self and the connections with significant others we become an extension of said selves which allows us to illuminate this covenant.

Seeking Help is Not a Weakness

By CJ Grisham


I guess I could call this part III of my recovery. Earlier, I wrote about how I've been wrestling with inner turmoil for quite some time. I think I've largely been winning, but wrestling nonetheless (I was a wrestler in high school, so that may be helping). Throughout the years, I've learned how to cope with the hardest parts and other parts were no big deal.

Last week, I went to my first appointment with a local psychologist. My intent isn't to necessarily bare my soul here. It was hard enough to do in that office. My intent is to be an example to others that may be dealing with issues related to their combat experiences that they may be hiding.

The Army DOD has made it clear that they are trying to remove the stigma related to PTSD. It's a fundamental shift in attitude and mentality that must occur from the top down in order for it to be effective. A few weeks ago, I spoke with one of the assistants to General Chiarelli who is a LTC. She told me her experiences with PTSD which are encouraging considering that she is a Field Grade officer. She was likewise nervous about "coming out" about her PTSD issues.

I also don't want to get into this stupid debate about "you were only a signal guy or an MI guy, what are you so screwed up about?" Getting shot at, mortared, or having an IED blow up beside your truck doesn't care what MOS you hold. It affects us all differently. And, yes, there are some people simply looking for sympathy or a handout with claims of PTSD, but those will get flushed out in due time. PTSD is not an easy thing to fake, I would think. Maybe I'm wrong.

The bottom line is that I'm a senior NCO in the Army who takes an active role in his Soldiers' and civilians' lives. I impress upon them the importance of taking care of themselves. I've discussed suicide prevention and PTSD with them till I was blue in the face. But, all of that means nothing if I can't lead by example. How can I convince these troops to seek help and not worry about their clearances or jobs while inside I'm ignoring my own advice.

For over six years, my wife has endured uncomfortable nights of sleep while the man next her jerks, flails, tosses, and turns all night long while feeling powerless to help. I've woken up too many nights to an empty bed because it's easier for her to sleep on the couch instead of waking me up from the little sleep I'm able to scrounge up at night.

For over six years, Emily has learned to recognize when my inner temper is flaring up; to pull me aside before I absolutely explode or lash out. I'm not a physically abusive father, but I lose my temper too easily with my kids. The little things that are just the dumbest excuses in the world will set me off. Later, I just feel like the biggest ass because something so small as not closing a door or leaving something on the stairs sets me off.

I struggle with a deep sense of failure that my kids don't feel like they can come to me with their problems because my response is usually "suck it up and deal with it. What doesn't kill you makes you stronger." What a weak response and utter lack of love and compassion for a father to have towards kids who are learning to cope with life! It pierces my very soul when my kids are calling for mom and when she isn't around I ask what they need. Instead of telling me what is bothering them, they say they don't want to tell me because I'll "just get mad at them."

Regardless of whether or not I wanted to set an example for those Soldiers out there reading this that are going through the same thing, I NEED to find my family again. My issues have caused them to adjust their lives as much as mine. They have had to alter how they speak to me or behave around me. The families are just as much affected by PTSD as the Soldier who is afflicted with it. They cannot be forgotten.

Probably one of the factors that helped me cope these past few years is patience and love. The patience and love provided by wife and kids has been met with constant apathy. But, I've made the decision to finally allow that patience to pay off. My family is more important to me than anything in this life except my God. Even if the Army weren't serious about legitimately helping troops and wanted to use this to ruin my career, I simply don't care.

The good news is that the Army IS serious about this. Secretary Gates has put in black and white in no uncertain terms that seeking mental help will NOT affect your clearance. Seeking help with mental issues is NOT a weakness. Walking into that building last week and being surrounded by junior troops was a LOT harder than simply continuing through life hoping I live to see my grandchildren. Baring my soul to a complete stranger wasn't exactly on my list of the funnest things to do in life. But, it had to be done.

So far, I think I've had good command support. I am being given the time I need to navigate this road to recovery and normalcy. They have shown me that they understand the Army's intent. To be honest, I wasn't so sure at first. And only time will tell, but I'm convinced so far that I didn't make the wrong decision, as least as far as my career goes. And I honestly believe the Army wants to help us get through this the best way possible.

One Step at a Time

By CJ Grisham


For those that listen to our You Served Radio Show each Thursday evening, you probably missed an announcement I made at the end. Our interview with General Chiarelli went long so those listening live probably didn't catch it unless they went back and listened to the archives.

I've been noticeably missing the past week or so for a number of reasons. Not the least of which is Army business, but I can't blame it all on work. At the end of the show, I publicly admitted that I'm having issues dealing with life. Not in the sense of ending it, but just coping and interpersonal issues. I consider admitting that I have a problem phase I of my new recovery.

Last week, my company completed Phase II of the Army's Suicide Prevention program. We watched the video, "Shoulder To Shoulder: No Soldier Stands Alone" (I'll have it uploaded later) and then discussed some scenarios afterwords. When the training was complete, I sat down with my Soldiers to talk them face to face about what we had just trained on. I explained to them that NOTHING in this life – nothing in this Army – is worth taking your own life for. Life sucks…a LOT. But, it's never so bad that you should end your life.

I explained that in my experience there is a common thread to people who want to commit suicide. Almost without fail, the inner thought of suicidal people is that "life [for others] would be better without me." Or, "I'm inconsequential." A common goal of suicide is to easy the burden of one's life on other people. What they don't realize is that suicide only compounds the burden's on other people. The only thing it ends is that individual's problems while placing those problems in the hands of someone else. I looked my Soldiers in the eye and told them from the heart that I and the commander are there for them if they EVER feel like life is too burdensome to continue. We will not chastise them, mock them, make light of their situation, or try to convince them that their problems aren't real. We will do everything within our power to help them overcome whatever in their life is causing them pain and anguish.

I then explained that seeking that help, either from us or real professionals, is not a sign of weakness. I talked about my conversation with General Chiarelli and the Army's commitment to ending the stigma that has historically been attached to seeking mental health counseling. To lend credibility to what I had just told them, I entered phase II of my recovery – telling my Soldiers that I am seeking counseling. For far too long since returning from Iraq, people both inside and outside of the military have sort of hinted to me that I should seek help. My lovely wife has mentioned it a few times, sometimes joking for fear of offending me. Even my Command Sergeant Major suggested I seek professional help when he spoke to me about my IG complaint. I met each suggestion with either humor, disinterest, ambivalence, or anger depending on whom was telling me. There's nothing wrong with me. I'm fine. You're crazy for even suggesting such a thing. Haha, that's funny.

As most of you know, I started this blog as self-medication. It worked for a few years, but I'm not sure what's happened in recent months and years. Perhaps it's the physical pain I've been in for more than six years now. Maybe it's the accumulated lack of sleep that is catching up to me. Maybe there really is nothing wrong and I'm just really tired! Whatever it is, my behavior has changed and it sort of scares me.

I am always tired. No matter how long I "sleep," I NEVER wake up rested. I toss and turn throughout the night. I lie awake for hours enjoying the company of the beautiful woman beside, soundly sleeping. Sometimes, I get up and walk around the house or surf the internet. I'm not willing to get specific about the things keeping me awake at night publicly, but it's a combination of bad dreams, everyday stresses, and physical discomfort. I have a prescription to Vicodin for nights that I can't sleep through the pain that I rarely take. I'm afraid to get addicted to the pills if I take them every time I need them. A bottle typically lasts me about six to eight months. But, when I take them I keep Emily awake. Sometimes, they even keep me awake. I'm not in pain, but they make me itch.

I'm not comfortable being around people. I'm not the social butterfly I pretend to be anymore. This year's Milblog Conference was the most uncomfortable I've been in years. I used to love being the center of attention of making an ass out of myself. I don't like doing anything anymore. I hate leaving the house and when I do, I make sure I'm always armed. There's a sense of impending doom just walking out my front door. To at least get me out and about, I've turned to geocaching. It's something I can alone or with my family. It keeps me moving, but I don't have pay for anything or worry about large crowds.  Even when I went to the Tea Parties, I tried to keep mostly to myself and not draw attention.
That is what is so great about the internet. I can have all these friends and be in the company of hundreds of people and I feel perfectly fine. The problem is that I've made a lot of GREAT friends online that I truly love, respect and admire. Yet, I dread the eventuality of being social except with certain people. That tends to push people away or cause them to think that they've somehow done something wrong or that they aren't important to me which is completely untrue. I don't even like hanging out with my own family! My sister just finished a visit and I felt so distant the whole time.

One of the things that keeps me up at night is the fact that I expend a LOT of energy trying to keep my life in order. For many years I've had memory issues and it's gotten much worse lately. I have to write EVERYTHING down or I forget it. I'm not talking about complicated things or detailed things, I'm talking about virtually everything. I forget meetings, appointments, names, faces, promises made, places I've been, things I've done or not done, etc. The list literally goes on and on. It's frustrating because I used to be a virtual encyclopedia of information. Now I have to strain to remember anything.
There's nothing more frustrating than when my commander asks me a question about a Soldier's issue that I know about, but need to check my notes to brief. Hell, I even forget which Soldiers are at which field offices and I've been doing this for nearly two years!! Every day I come into my office, I open up my "go book" that I recently created and read through the list of offices and the troops located there so I don't forget. I used to be able to spout out with ease when someone was ETSing, in their promotion window, having a birthday, etc. I knew their family members' names and had them committed to memory. Now I'm lucky if I can get my own nieces and nephews' names right. I don't know if this is a result of stress or all the wonderful, cool explosions I had the pleasure of sitting through, but it's the one thing that I probably spend the most time trying to combat!

There is a bright side to all this. In my quest to deflect the attention I receive, I work hard to draw attention to other, more worthy, individuals. Instead of worrying about myself, I can put all my energy into worrying about my troops and making sure that their achievements are recognized. I try to focus on those injured or killed in combat. They deserve to be recognized for what they've sacrificed for their country.

Why am I writing all of this? Well, for the same reason I started this blog – to get it off my chest. To "tell someone without having to tell anyone." It makes me feel better – a little. The last thing I want/need is sympathy or people feeling sorry for me. I'm no victim here! I don't want special attention, help, or pawing. I don't need pats on the back and I don't want to be a poster child. I don't want money, congressional testimony, or the support of VoteVets or IVAW who want to politicize these issues. I want other Soldiers to realize that the Army is serious about removing the stigma. I have a problem! And I'm still "Army Strong" in spite of it! Don't believe me? Screw up and I'll still nail your arse to the wall and start shooting darts. I'll still put you in the front leaning rest for a decade or "until I get tired." I can still pass my PT test, qualify expert on my weapon, and meet my daily suspenses (thanks to Outlook's "tasks" function).

There's nothing weak about me because I'm having these issues. I can still lead by example, accomplish the mission, and take care of my Soldiers. And if my Soldiers feel like they can't trust me or serve under me, tough! Suck it up until your ETS or call your branch manager and get the hell out of here. Thankfully, I have good Soldiers who embody the Warrior Ethos and Army Values. They see that I'm still very much in control as "Top."

The stigma is hereby dead. I challenge all leaders to understand this and apply it where they can. Our troops need to understand that there is nothing weak about seeking help. I know because it has been much harder to acknowledge these issues than to hide them. It's been a lot harder knowing I may very well be ending my career by admitting that I'm not all there mentally. Talking about this now after 15+ years – and prior to being eligible for retirement benefits – is probably the hardest thing I've ever done. I'd be lying if I said I wasn't worried. I am, but I trust the Army on its word and I'm challenging that mentality. And as I do so, I will be documenting most of my progress here. There are still a great many issues I will probably never feel comfortable talking about, but I owe to others out there that may be trying to hide their problems for fear of losing their jobs or risking their reputation. I need to lead by example. And if I can do it, so can you!

Now, I'm gonna go get some sleep and enjoy the rest of my vacation. I'll be leaving my cell phone in the room tomorrow so I can really relax!

Hey, By the Way I Ran into the Dope Man Today

Yesterday I was running some errands to get ready to spend the weekend with my girlfriend. After I had picked up a prescription from Wal-Mart I was sitting in my car when a guy walks up to me pointing like he had always done. I looked thinking what and was immediately thinking defensively. When I looked up I saw my old dope dealer and was surprised, so to be polite I got out of the car and talked with him for a minute.

We talked about people we used to hang with and if we had seen any of them, I replied no but had actually had seen some of them. I felt guarded with this guy, not wanting to give him to much information about me. He asked where I lived and responded with a general area. He asked me what I was doing today and I was proud to tell him I am in my senior year of college. He seemed surprised, but changed the subject quickly. He did mention that the college campus would be a great money maker, with all the partying going on. I asked him was he working and his reply was "Oh yeah, 7 days a week." He asked me if I still was hustling, code for do you want any drugs to sell and/or use. I was also proud to tell him that, no I do not. But, their was conflicting emotions and the lure of getting high again. The wheels where turning in my head, a voice was seductively saying,

You know he has some weed in his car, all you have to do was ask for it.

Another voice was reminding me of how far I had come, to get high was to give up the esteem that I have earned. I was reminded of the cirlce of frineds I have and how they play a part in my descion making skills today. That my friends today lift me up and inspire me to new heights; they encourage and challenge me. The conflicts I have today with my friends comes from love, not petty resentments from unmet needs and expectations. In that moment I realized a deeper appreciation and understanding of what friendship entails and how it impacts my life. The foundation I have built steadied my course and enabled me to tell myself no, to shut off the negative voices and drive away feeling blessed.

If You Need Help Ask For It

By CJ Grisham


I then explained that seeking that help, either from us or real professionals, is not a sign of weakness. I talked about my conversation with General Chiarelli and the Army's commitment to ending the stigma that has historically been attached to seeking mental health counseling. To lend credibility to what I had just told them, I entered phase II of my recovery – telling my Soldiers that I am seeking counseling. For far too long since returning from Iraq, people both inside and outside of the military have sort of hinted to me that I should seek help. My lovely wife has mentioned it a few times, sometimes joking for fear of offending me. Even my Command Sergeant Major suggested I seek professional help when he spoke to me about my IG complaint. I met each suggestion with either humor, disinterest, ambivalence, or anger depending on whom was telling me. There's nothing wrong with me. I'm fine. You're crazy for even suggesting such a thing. Haha, that's funny.

As most of you know, I started this blog as self-medication. It worked for a few years, but I'm not sure what's happened in recent months and years. Perhaps it's the physical pain I've been in for more than six years now. Maybe it's the accumulated lack of sleep that is catching up to me. Maybe there really is nothing wrong and I'm just really tired! Whatever it is, my behavior has changed and it sort of scares me.

I am always tired. No matter how long I "sleep," I NEVER wake up rested. I toss and turn throughout the night. I lie awake for hours enjoying the company of the beautiful woman beside, soundly sleeping. Sometimes, I get up and walk around the house or surf the internet. I'm not willing to get specific about the things keeping me awake at night publicly, but it's a combination of bad dreams, everyday stresses, and physical discomfort. I have a prescription to Vicodin for nights that I can't sleep through the pain that I rarely take. I'm afraid to get addicted to the pills if I take them every time I need them. A bottle typically lasts me about six to eight months. But, when I take them I keep Emily awake. Sometimes, they even keep me awake. I'm not in pain, but they make me itch.

I'm not comfortable being around people. I'm not the social butterfly I pretend to be anymore. This year's Milblog Conference was the most uncomfortable I've been in years. I used to love being the center of attention of making an ass out of myself. I don't like doing anything anymore. I hate leaving the house and when I do, I make sure I'm always armed. There's a sense of impending doom just walking out my front door. To at least get me out and about, I've turned to geocaching. It's something I can alone or with my family. It keeps me moving, but I don't have pay for anything or worry about large crowds. Even when I went to the Tea Parties, I tried to keep mostly to myself and not draw attention.

Review of Treatment of Tinnitus with a Customized Acoustic neural Stimulus: A Controlled Clinical Study

This study describes a new treatment, the Nueromonics Tinnitus Treatment (NTT), combining the use of acoustic stimulus augmented by a clinician providing a structured counseling program for tinnitus management. The abstract does not go into details as to how the treatment works; it describes the successful testing of this system. An overall success rate of 73% gives ample reason to suspect replications of the studies and possibly providing a new treatment modality and assessments, affecting several clinical care settings, such as primary care, mental health, emergency rooms, and psychiatric wards.

The audience target would be clinicians looking to improve the assessment of veterans with auditory disorders with mental health comorbidity. The abstract is solution oriented and would translate well to the social worker devising a systemic change to patient care from the veteran in the hospital bed to the veteran in the emergency room who may be misdiagnosed due to the fact that she cannot communicate due an auditory disorder. This study would facilitate sound structural changes within the VA system ensuring that our veterans have better care. With this information becoming more prevalent, practitioners could become more aware of the culture of the deaf and hard of hearing veterans and could better accommodate their needs and better round out the person-in-environment approach.

Davis, P. B., Wilde, R. A., Steed, L. G., and Hanley, P. J. (2008). Treatment of tinnitus with a customized acoustic neural stimulus: A controlled clinical study [Abstract]. ENT-Ear, Nose & Throat Journal, 87(6), 330-339.Journal, 87(6), 330-339.

Review of Progressive Audiologic Tinnitus Management

This brochure provides the fundamental principles found in Progressive Audiologic Tinnitus Management (PATM) modality to raise awareness to the practitioner and veteran clients. Only about 20% of veterans suffering from tinnitus require a clinical intervention which necessitates a progressive management approach, providing triage guidelines to facilitate appropriate care for the veteran with tinnitus and other presenting problems such as physical trauma, mental health problems, ear pain or drainage and depending on a categorical fit they would be referred to Ear, Nose and Throat (ENT), the audiology department, mental health or other specialist.

The brochure clearly delineates which level of care the veteran would need based on a few short surveys and gives direction on the next steps, interventions and treatments. The brochure has a concise and efficient overview of the helping process for the clinician in a generic way that could easily bring highlighted points to reinforce educational seminars and lectures within the Veterans Administration (VA) medical and mental health centers. The target audience would be the VA system enabling a more balanced and cultured response to an ever increasing diverse veteran population.

The article could translate well for the social worker as they would benefit the discipline of practitioners ranging from clinical to social services within the VA. The brochure expounds on a solution that pervades the VA system today, veterans with audiologic disorders that have exponentially increased within the last five years.

Myers, P. J., Henry, J. A., Zaugg, T. L., & Schechter, M. A. (n. d.). Progressive audiologic tinnitus management for veterans [Brochure]. Portland, Oregon, and Tampa, Florida: Veterans Administration (VA) National Center for Rehabilitative Auditory Research, VA Medical Center, Department of Otolaryngology/Head and Neck Surgery, and James A. Haley VA Medical Center.

Review Use of Mental Health Services by Veterans Disabled by Auditory Disorders

The report hypothesizes that veterans with auditory disorders would use Veterans Administration (VA) mental health facilities less due to communication difficulties. The initial results found that disabled veterans with hearing issues had used VA mental health services at least once. Later the article states that although veterans with auditory disorders were more likely to seek initial mental health care, they were less likely to follow up on subsequent visits. This remains a national problem due to the steadily increasing in this population since 2001 will undoubtedly rise rapidly with our modern wars. In fact the report indicates that in the years 2005 there were 822,413 veterans diagnosed with a service-connected disability, a 176.2% increase in auditory disorders.

There has been some evidence that veterans with posttraumatic stress disorder (PTSD) and tinnitus have a link; it was reported that 34% of veterans seeking mental health care have both disorders. The article seems to be long on words to facilitate the information; although the study was comprehensive I felt that it could be condensed into a smaller package. The level of research involved would indicate that the intended reader were other researchers to offer direction in future studies. The language is sterile and includes terminology indicative of the mental health professions and overcomes the racial and cultural differences in veterans. As in the VA means testing system, once you have a diagnosis equal care is given on a scale of service-connection to the medically retired.

The article gives a perspective that has not been fully realized with protocols and assessment procedures. “Although veterans disabled by auditory disorders seem to readily connect with VA mental health services, the reduced frequency or repetition of services use may require intervention” (Kendall, and Rosenheck, p. 1357, 2008). Since the mental health field has a greater number of social workers they have the necessary skills to implement multidisciplinary approaches to best fit the issues at hand. Psychometric measures can be established maximized through the skill sets of social workers; including better assessments that include audio disorders, mental health disorders and measures taken when assessed properly.

Kendall, C. J., and Rosenheck, R. R. (2008). Use of mental health services veterans disabled by auditory disorders. Journal of Rehabilitation Research and Development, 45(9), 1349-1360.

Review of Auditory Dysfunction in Traumatic Brain Injury

The article was informative with regards to giving a clearer picture of the growing population of veterans with hearing loss attributed to their military service. The report found that admissions for traumatic brain injury (TBI) increased 47% since the beginning of Operation Iraqi Freedom (OIF). A subgroup of blast related (BR) veterans were reported as having 62% hearing loss and 38% of this group with tinnitus. The authors indicated a gap in screening services for veterans as they had inadequate training for the management of tinnitus. The article was well organized and concise in that it gave specific representations of populations and subpopulations. The article does recognize some limitations to the service streams within the Veterans Administration (VA), but falls short in fully recognizing and advocating for the veteran.

One possibility as to the articles soft stance on identifying problems and barriers to care, it appears the target audience was for the VA. Hence, while identifying some issues with assessment and services the full exposure and extent of problems in the continuum of care and the bureaucratic entanglements might impede funding for further research monies for the authors. The article quickly lists the figures for comparisons and draws conclusions delineated from two groups. Forty months before the beginning (group I) of OIF and forty months after (group II), the two groups were compared, and found that group II had a significant amount of younger veterans with BR-TBI and hearing loss. This matter of younger veterans with TBI and hearing loss marks a significant change in the topology and identity of a growing population of veterans who have limited resources for an ever growing pool of patients.

The authors dance around the problems and charging forward with a battlement of statistics and cross analytics encompasses the VA’s endless studying the problem without addressing the quandary. More proof that was suspected and witnessed and now corroborated. Endless speculation as to the causes and no end in sight to the ramblings of those that need “proof positive” before treatment remedies can begin to trickle down to the masses of veterans needing services. A social work perspective and holistic approach would begin to recognize the problem and begin effect treatments in conjunction with research for improving modalities while building on the clients strengths. The most significant piece of information revealed in this endeavor is the low statistical and counter-intuitive expectation in the rupture of the tympanic membrane in percussion blast waves. Even more interesting, this information only covered less than half of a paragraph in the results section and missing in the discussion section.

As far as helping the social worker, this article does little to add to the discussion in helping the veterans. Except that it might add to the growing avalanche of data that the government requires before allocating funding for services and care for the veteran.

Lew, H. L., Jerger, J. F., Guillory, S. B., and Henry, J. A. (2007). Auditory dysfunction in traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 921-928.

Review of The Association Between Tinnitus and Posttraumatic Stress Disorder

The author of this article explains the evidence for connections between tinnitus and Posttraumatic Stress Disorder (PTSD). In the initial paragraph he lists several articles that support a co-occurring relationship and related neural mechanisms. The article jumps back and forth in presenting the information and keeps a central focus on PTSD and its impact on assessment protocols. The article is presented in the Journal of Audiology, so this could explain the emphasis on the psychological aspect of the equation. Audiologists have a unique perspective in their field of practice and would not need a substantial explanation of auditory pathology, hence the concentration on the psychological effects and the similarities in treatments for both PTSD and tinnitus.

The paper details the similarities in diagnostic criteria for symptoms of increased arousal compared to the diagnostic criteria for tinnitus, such as difficulty in falling asleep, irritability or outburst of anger, difficulty concentrating, hypervigilance and exaggerated startle response. The symptoms of sleep disorder and concentration difficulties translate directly to tinnitus screening measures along with hypervigilance and exaggerated startle response as relational to irritation and anger associated with tinnitus. The overlap of symptoms suggests that the presence of both diagnoses would exacerbate either condition bi-directionally. Of 300 patients studied, 34% had both conditions.

The author suggests that clinical evaluations and mental health screenings, when dealing with trauma related disorders and audiology assessments should include screening criteria for both tinnitus and PTSD. He suggests that audiology testing should incorporate sensitivities to patients with diagnosed and undiagnosed PTSD, as the startle responses could be increased with the sudden tones and high pitches related to auditory testing. Many patients self-report of the resounding silence within the sound booth as an anxiety stressor, and listed many offending characteristics of the hearing screening regimen.

One word used throughout the paper that struck me as possibly harmful in translation to the population was the repeated use of the word “complaint” and its many variations. The medical model uses many such words in addressing medicalized “problems” which maintain a distance between the medical profession and patients. With and understanding of comorbid etiology, social workers can better assess the individuals situation and provide a better chance of successful outcomes in treatment and referrals more conducive to the clients best interest. Recognition of treatment modalities that could benefit both conditions, the client can find relief from an efficient use of time and techniques employed by the educated social worker. Treatments indicated to work in both conditions are antidepressants and cognitive-behavioral therapy.

Fagelson, M. A. (2007). The association between tinnitus and posttraumatic stress disorder. American Journal of Audiology, 16, 107-117.

Review of Knowledge and Attitude of Infantry Soldiers to Hearing Conservation

The article presented a clear and concise measure of the attitudes among combat arms soldiers. The message was that soldiers were ignorant of Hearing Conservation Programs (HCP) in the British army. With noise levels of 90 decibels (dB) were enough to cause hearing damage. The infantry units are regularly exposed to levels ranging from 145 to 200 dB, enough to cause hearing impairment to a high percentage of soldiers. The report estimates that only 22% knew about a military hearing conservation program. The majority (91%) of troops said that their reasons for not wearing hearing protection or use them improperly was due to personal experiences in firearm training and in combat. These figures point to an audience of probationers, pointing to the need for a stronger and more ambitions HCP.

The article did not touch on racial or cultural issues; it had to do with a systemic problem related to the inadequacies of the present HCP. The language of the article was general enough in words and efficient in expounding without becoming too cumbersome. This report translates especially well in the promotion and advocacy of awareness within the military community. The problem has a coupling of many issues that engender the social worker in systemic solutions that would be outside the scope of many professions.

The soldier firing their weapons in many different atmospheres evokes a situation where extreme conditions could foster greater advancement in the research and study of hearing loss, hearing loss prevention and tinnitus. This many perspectives enables a person-in-environment look at the complete problem, from the extremes of combat to the monotony of the firing range. The social worker has been trained to look at the issue from a micro to a macro investigation of presenting problems. The article points out glaring inefficiencies within the militaries HCP. A social worker would be able to encompass and envision solutions from a multi-perspective view, enabling holistic approaches from individual treatments, to improved hearing conservation education and revamping the HCP from the inside out.

Deaf and Hard of Hearing Veterans: Auditory Disorders from Combat

I took a class this summer on the Deaf and Hard of Hearing (DHH) population because I wanted to learn about people like me. Today I started posting the first of those reviews, I hope you find some meaning and insight into the veterans mind who has suffered from auditory injuries in combat.

I wear hearing aids and have only 25% of hearing in my left ear and 50% in my right ear. I sustained this injury in Desert Storm from an artillery impact, just far enough out of the kill zone, but close enough to have permanent damage to my hearing. I have been rated 10% service-connection compensation for hearing loss, 10% for tinnitus and 30% for Posttraumatic Stress Disorder (PTSD).

As you will read in a couple of other posts, hearing loss and especially tinnitus can lead to misdiagnosis of mental illnesses and greatly impede coping and functioning. While writing these reviews I was thinking back and had come to realize it took me 7 or 8 years to desenitize to the constant drone of static and auditory garbage. The constant roar, ringing, and pulses triggered my PTSD and I did not realize it until I read these articles. My oh, my how we can forget some of the biggest things to happen in our lives, that is, we who have the blessing of traumatic experinces.