Healing the wounds within
Innovative programs at the VA Palo Alto are helping veterans recover from PTSD
U.S. Army veteran Robert Solis was raised in a small, troublesome town rife with substance abuse. He had issues with anger, anxiety, isolation, self-control and depression before he entered the military, he said.
Six years in the war zone of southeast Iraq only boosted his anger.
Returning home, he reacted the way he was trained to do in combat. He was hyper-vigilant, aggressive and on edge.
"In a combat zone, all you know how to be is aggressive," he said.
Solis, now 31, often felt his anxiety levels rising at home and pushed his children away as a result, he said. It was only during a court-appointed program for substance abuse two years ago that he learned he had post-traumatic stress disorder, or PTSD.
Though PTSD is most often thought to be associated with military veterans, anyone can develop the disorder after experiencing a trauma in which the person has witnessed a horrible event, feared for his or her life, or felt extreme helplessness.
Everyday events suddenly unleash unpleasant and frightening feelings, as though the trauma is happening all over again.
Approximately 30 percent of Vietnam War veterans have developed PTSD. Those numbers are expected to rise for Iraq and Afghanistan war veterans, given their multiple tours of duty and the incidence of traumatic brain injury that many now survive, said Joan Smith, a therapist with the VA Palo Alto's PTSD outpatient clinic.
But veterans are finding relief and healing through innovative programs to treat PTSD through the VA system. To gain mastery over their debilitating symptoms, they are training dogs, participating on cycling teams and learning to manage their reactions while driving. Other new treatments include teleconferencing with psychiatrists and mobile-phone applications to help control symptoms. Those recovering from PTSD are also engaging in cognitive behavior therapy and practicing a technique called "prolonged exposure," in which a person becomes desensitized to the trauma by repeatedly remembering aspects of the event.
Solis has been participating in the PAWS for Purple Hearts service-dog training program, which teaches veterans patience and how to feel emotions again.
He and U.S. Air Force veteran Anthony Uzzi are training Ethan and Eldridge, two large and placid golden retrievers, at the VA Palo Alto Menlo Park campus's 41-bed Trauma Recovery facility.
Like Solis, Uzzi is dealing with self-control issues related to PTSD.
Last Thursday, Uzzi was in a VA lounge, trying to get Eldridge to flick on a light switch with his nose. The dog has learned to pick up objects from the floor and to pull open doors with a loop of rope on the handle. He can even open a refrigerator door.
But Eldridge was struggling with the light-switch idea. He got close to a training board with an attached switch — and licked it.
"Light! Light!" Uzzi encouraged the big dog, raising his voice in an excited, friendly manner. Eldridge continued to lick. Prompted by treats, Eldridge finally touched the switch with his nose.
"Good boy!" Uzzi said, giving the dog a treat and vigorously rubbing his neck and head.
Just 60 days ago, that type of disappointment might have frustrated Uzzi, 32, who said he has anger and violence problems. But working with Eldridge has taught him much about patience and the value of positive reinforcement, he said.
Working with Eldridge is improving Uzzi's relationship with his two children, ages 5 and 8. The dogs are good emotional barometers, he said.
"They let you know right away if you are being too harsh on them. It's the way they look at you. Or they back off," he said.
Solis, likewise, is learning to relate to his children because of the training work.
Working with Ethan, who isn't always willing to cooperate on command and makes progress incrementally, has taught him patience, Solis said.
He recalled a recent visit home for his 1-year-old's birthday party. During it, he used cognitive-therapy techniques and lessons learned from Ethan to handle the chaos.
"The kids were all jumping up on me. There was no breathing space. I felt like the anxiety was kicking in," he said.
But he realized that Ethan does that too, jumping up when he's happy to see his trainer. Solis did some deep breathing, and it was all right, he said.
The dogs help the veterans to get away from black-and-white thinking, said Sandra Carson, who teaches the vets to train the dogs. If the dog doesn't do something the trainer wants it to do, the vet might think, "The dog doesn't like me," she said. Instead, she gets the vets to think about what they can modify in themselves to get the dog to listen. It might be the sound of their voice or the way they give a command. The same skill works when vets must handle their children, she said.
Melissa Puckett, recreational therapist and PTSD supervisor in the men's and women's trauma-recovery program, said many vets deal with emotional numbness as part of PTSD. The dogs help them to receive touch and spontaneous affection and to express love — "things they thought they would never have again," she said.
"When the dog does something, and it's not about the treats anymore, it's gratifying and confidence building," she said.
The training program started four years ago, and so far, 13 dogs have been trained. Five of the animals have been placed with disabled vets. Not all dogs graduate; some have too strong of a hunting instinct and are too apt to chase things, Carson said.
Three dogs, including Ethan and Eldridge, are currently in the program. The third dog, Elaine, will be placed in the women's trauma-recovery facility, she said.
Uzzi and Solis will only have the dogs for about 90 days, and then they will turn Ethan and Eldridge over to other vets to continue the training. That's also part of the therapy, Puckett and Carson said.
Loss is something that veterans know well. Many have lost buddies in combat and seen scores of people die.
"Giving up the dog helps process what it means to say goodbye," Puckett said.
Uzzi plans to get involved in service-dog training when he returns home to Santa Cruz, he said. His goal is giving a dog to a disabled vet.
He also wants to improve his relationship with his children. Uzzi said he came back from Iraq an angry man, and it wrecked his home life. He was only diagnosed with PTSD in January.
"It's a lifestyle that we've lived, and we've brought it here. It was a way that we had to live. We were always angry. It's what kept us going," he said. "I got out of the service, and it really hit me."
But the dog-training is changing him.
"My kids are hearing me sound happy and say, 'I love you.' For the past five to six years, they haven't gotten that from me," he said.
For veterans whose job it was to drive vehicles through war zones, returning home is one thing; returning to the roads is another.
These are the vets Marc Samuels works with. Samuels, an occupational therapist and certified driver rehabilitation specialist at the VA Palo Alto, works to help PTSD sufferers get back in the driver's seat.
The VA Palo Alto is at the forefront of innovative driver-therapy and research programs.
One of Samuels' patients was a diesel-truck driver traveling with a convoy to the front lines in Iraq. Every day he anticipated he would be killed by an improvised explosive device, or IED, Samuels' patient told him.
He carried that hyper-vigilance back home. Benign encounters triggered feelings that made driving frightening: A person would unexpectedly come out from behind a corner or a car would get too close.
A person with PTSD might run a stop sign to get away or suddenly pull over by the side of the freeway to cope with the feelings of panic, Samuels said.
"It's all about avoidance. You revert back to combat-driving training. You do all of these things without thinking: You don't stop; you drive in the middle of the road," he said.
Samuels said there are many misconceptions about PTSD.
"People are concerned the veteran driver will go nutso and run somebody down," he said. But "these drivers tend to be significantly defensive drivers. The issue is them stopping in the road" — not threatening others.
Many are self-regulating on such a level that they are not driving anymore, he said.
When that happens, the veteran can't drive his or her kids to school, get to work or sometimes even attend therapy sessions, he said.
The first thing Samuels addresses with patients is how to identify their most potent triggers; then he works with patients to acclimate and to find ways "to ground you in the here and now," he said.
"You experienced a significant life-threat trauma. Yes, it happened and it sucked, but you're not there now" is the message he said he tries to impart to patients.
The process can begin in a simulator designed to set off the patient's triggers. The patient can eventually graduate to getting behind the wheel.
Patients are given two types of treatment. Cognitive behavioral therapy helps them to recognize their triggers, the emotions created and how to circumvent those feelings. Prolonged-exposure therapy repeatedly introduces veterans to their emotional triggers and helps them to work through feelings and to gain the perspective that they are no longer in danger.
In the VA Palo Alto's research program, two sets of monitors measure heart rates of veteran drivers with PTSD. As they drive a vehicle, cameras focused on their eyes record and measure the diameter of pupils, and monitors indicate if they are tapping on the brakes.
Often on the course, a driver will become overwhelmed with emotions, Samuels said. When the veteran exits the car, the psychologist works with him or her, offering interventions or specific protocols to help the patient manage anxiety.
Incrementally, the veteran learns to control the knee-jerk response. PTSD isn't cured, but it is mastered, Samuels said.
Therapy has made a huge difference in Archie Stone's life.
For nearly 40 years the former Air Force Airman Second Class kept a secret. Stone, 58, was just 17 years old and only two weeks out of high school when he was raped in a boot -camp shower room on U.S. soil.
The assaults went on for a month, but he never told anyone, he said. To quell the emotional pain, he became addicted to alcohol.
Five years ago, a life-threatening liver transplant brought the trauma back to the surface, heightened by the psychoactive drugs he took as transplant therapy, he said.
"It made me feel like I was 17 again. It brought me back to that time again. I was majorly paranoid," he said.
So Stone took part in a 12-week cognitive-therapy program that helped him identify triggers in everyday life that set off his anxiety. By analyzing how his feelings arise, he has been able to separate false belief —"I am in danger"— from reality. He has also learned how to interrupt the escalating feelings by using skills such as deep breathing and conjuring up a pleasant memory or place.
He also took part in group therapy for other military sexual trauma victims. Such programs did not exist when Stone first came to the VA in the early 1980s. VA Palo Alto's program was innovative, he said.
"It helped me to realize that I wasn't alone in this experience, and I wasn't a freak of nature. It helped me to understand these are things that happen to people; these are things that happen in the course of life," he said.
Paula Weatherby, a licensed clinical social worker on the PTSD clinical team, works with Stone.
"These programs have opened the VA to areas that had been neglected," she said. Asking if a veteran was exposed to military sexual trauma is now a standard question, she said.
Stone is also benefiting from the VA's Telemental Health program, which allows veterans who live long distances away to receive consistent treatment via the Internet, like Skype, increasing the chances that the vet will stay in the program. Stone, who lives in the Santa Cruz Mountains, said he would not be able to make it to all of his visits if he couldn't meet remotely. The program has a high retention rate. Therapist Smith said none of her Telemental Health patients have dropped out.
Stone is now embarking on the most perilous part of his healing journey, prolonged-exposure therapy.
With the triggers that set off his anxiety identified, Weatherby is having him focus on aspects of his trauma, instead of becoming overwhelmed by the whole experience. Stone imagines himself in various situations where he is exposed to the things that trigger his feelings. Weatherby tapes the sessions.
Over and over, he might imagine himself walking into a public restroom or a gym locker room, bringing up the unpleasant feelings, which he can discuss with his therapist. He also goes directly into situations that trigger his feelings. In between sessions, he listens to the tape multiple times.
Through prolonged exposure, the memories have begun to lose their power, he said.
"It makes something not quite as invasive. You know what the memory is. The more detail that comes out of your mind, little things — smells, lighting — suddenly jump out at you. Some were lost to you in the overall experience. You can get lost in the overall story," he said.
Facing the things he was ignoring, the therapy is helping Stone to return to places he previously avoided.
"I would never want to shower in a health club," he recalled. But "now I can go into public restrooms. I don't always have to sit with my back against the wall."
The treatments have moved him away from substance abuse and alcohol, which he used to take his memories and wipe them out of consciousness, he said.
Stone said the trauma "will never, ever, really go away," but he is thankful for the progress he's making.
"I'm blessed. I'm living on bonus time. (PTSD) is very disquieting and very disruptive. The therapy has inspired me to try to reach for something. It matters to my quality of life. I'll be able to function more in normal society. Without this, I would be a bit more of a hermit. I was viewing the world as a dangerous place," he said.
Staff Writer Sue Dremann can be emailed at firstname.lastname@example.org.