Thomas J. Berger, Ph.D

Family Safety: A Significant Concern for Returning Veterans and Their Families
Capitol Hill, Washington, DC, Cannon Caucus Room (CHOB 345)
October 24, 2008

Remarks submitted by Thomas J. Berger, Ph.D., Chair, PTSD & Substance Abuse Committee, Vietnam Veterans of America

First, as you can see from my bio, I am a combat Vietnam Veteran having served as a Navy Corp man with elements of the third Marine Division, 1966-1968, at different times because of my injuries. I then moved from there to deal with my own mental illness, if you will, PTSD. I completely submerged myself in academia. I'm a recovering academic, as a matter of fact. My last position was Director of the center that dealt with domestic violence and high risk, sexual behaviors. So I have an interest in the subject that we are talking about. For the last decade I have been serving as the Chair for the National PTSD and Substance Abuse Committee for Vietnam Veterans of America. And just recently, two months ago, I accepted a full time position with VVA here in Washington. Our offices are over in Silver Spring and I moved here. I still haven't unpacked but I can find my way around the city pretty well on the Metro. Just one other comment as a recovering academic, I have way too many books that I've been hauling around.

So, with that background, on behalf of Vietnam Veterans of America I'm proud to be here today and I'd like to thank Witness Justice and the Veteran's Initiative Center and Research Institute for providing me with the opportunity to participate in today's briefing on veterans, combat stress, and the family. I should like to say right at the beginning, if any of the things that I say bother you, feel free to get up and walk out and get a drink of water. For those of you who are still addicted, have a smoke downstairs. But I'm going to be pretty frank about some things and, wherever possible, I will use my own experiences as self-disclosure to illustrate some points.

"We'll always have Paris." That's what Humphrey Bogart said as he parted from Ingrid Bergman in Casa Blanca. It's a great movie line and it says a lot about the amazing human gift called memory. Like Bogey, you can keep your favorite places and people with you simply by pulling up your happy memories with them, even if they are miles away or long gone. Without flipping open a scrapbook or putting on a CD you can conjure up your newborn's first smile, first few words. The ecstasy or agony of prom night or even the aroma of mom's baked cookies.

But memories have a dark side also. They can make you feel devastated, furious or humiliated. Did that make you think of your prom night again? Even decades after something bad happened, bad memories seem to stick more than happy ones. And that's especially true for the type of memories like our combat veterans have. While many of us are well aware of the prevalence of combat stress amongst our Vietnam veterans and our returning OIF/OEF veterans, it's my sincere hope that you'll leave today's briefing with a better understanding of the impact of combat stress and the reintegration for our returning troops - how this effects families and how it can potentially lead to family violence.

First, however, a very brief history of combat stress or what we now know today as post traumatic stress disorder - or PTSD. It's a very old malady. Dr. Jonathan Shea, whom I'm proud to say is a colleague and a friend, traces PTSD back, or the first written accounts of PTSD back to Homer's Iliad. It's a very old malady, as I said, and as such, has been called a variety of names. In the 1670's, Swiss military doctors described the symptoms as nostalgia. During the Napoleonic wars, during the 19th century, battlefield surgeons began calling it exhaustion. And by the time of the American Civil War, it had become known as Soldier's Heart and the Effort Symptom. I don't know how many of you know this bit of trivia but the reason we have veteran's homes in this country is because after the Civil War, and there were thousands of veterans from both sides roaming the country. So we set up these institutions for them because the people didn't know what was going on with them.

"Shell shock" became the term commonly used in World War I, and this was succeeded by "combat fatigue" and "battle fatigue" in World War II. By the time the war in Vietnam was winding down in the early 1970s, the term "Post-Vietnam Syndrome" was being used to describe veterans' traumatic stress reactions during and after their military service in Southeast Asia. Finally, in 1980, the term "Post-traumatic Stress Disorder" appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) and is still used today.

Now, PTSD has a lot in common with a normal stress reaction; the big difference is that it's a much more powerful response, and it doesn't go away. PTSD also looks a lot like acute stress disorder – in fact, acute stress disorder becomes PTSD, diagnostically speaking, if symptoms last more than a month, generally speaking.

Every medical disorder has its own signature, a pattern of symptoms that allows physicians to make a diagnosis and plan a treatment approach. In the case of PTSD, doctors look for three main types of symptoms: 1) re-experiencing the traumatic event or events, which includes intrusive, distressing recollections of the past event, flashbacks, nightmares, exaggerated emotional and sometimes physical reactions to triggers that remind the person of the event(s); 2) avoidance or emotional numbing, which includes avoidance of activities, places, thoughts, feelings, or conversations related to the trauma, and restricted emotions; and 3) increased arousal as indicated by difficulty sleeping, irritability or anger outbursts, difficulty concentrating, hyper vigilance, and an exaggerated startle response.

Normally you can easily brush aside an unpleasant thought. If you have PTSD, however, thoughts and emotions force their way into your mind, leaving you completely at their mercy.

The intrusive thoughts that occur in PTSD almost always cause a strong surge of emotion – anger, fear, humiliation, and helplessness – because the stress response is a total mobilization of the body's physical resources. Powerful neurochemicals flood our brain and body, including epinephrine, Nora epinephrine, serotonin, dopamine, and endogenous opiates and benzodiazepines. Sugars are also mobilized from liver and muscle, the respiratory rate is increased, as is heart rate and blood pressure, and the immune system is activated.

When you're asleep, these intrusive thoughts show up as nightmares. During the daytime, they pull you away from present time, sometimes making you behave in ways that don't make sense to the people around you. The best-known type of these daytime intrusions – although not everyone with PTSD experiences it – is a flashback.

A flashback is a memory from your trauma that intrudes into the here-and-now, making you feel like you're right back in the past. Flashbacks typically contain random bits and pieces of information – a sound, odor, the color of a bystander's umbrella – rather than a full-fledged memory. That's one reason it's hard to make sense of these blasts from the past or gain control over them without help from a therapist.

Flashbacks usually involve sights and sounds as when a veteran sees and hears the sounds of a long-ago battle, but as I said, they can also include smells, tastes, or sensations of touch. Sometimes a flashback just won't go away.

Not all intrusive thoughts, however, involve sensory flashbacks. Often, people with PTSD have other negative thoughts, such as "Other people are out to get me", or Nothing goes right for me" that stems from their trauma.

If you have PTSD, other people around you may mistakenly believe that a flashback or other intrusive thought is "all in your head". What they don't understand is that in reality, your whole body, not just your mind, gets in the game. That's because you're not just thinking about the past, you're actually reliving it.

After a trauma, you desperately want your terrible feelings to go away – but when PTSD strikes, unpleasant emotions just don't pack their bags and leave. In fact, they grow even stronger over time, causing you intense distress. In order to cope, your mind tries to block or avoid these bad feelings with the intention of protecting you from the hurt. These mind games lead you to change your behavior in different ways. For example, you may avoid activities associated with the trauma – if your trauma occurred in a moving convoy in Iraq, when you return home, you may drive faster without regard for other vehicles or directions. Or you may block out key parts of the trauma – this blocking is called psychogenic amnesia, or you may avoid movies or TV shows for fear of seeing scenes that remind you of your trauma; or you may find it hard to fall asleep because you worry that nightmares will dredge up the fears that you're trying to suppress – and of course, when you're awake, all you want to do is sleep as a means of escape from the daytime thoughts that plague you, a real Catch 22.

A related problem that occurs with PTSD is emotional anesthesia, a different trick your mind uses to help you avoid pain. It works to some degree, but it also makes feeling the emotions you want to feel more difficult. For example, people who viewed themselves as outgoing, fun, warm, and loving before a trauma often say that they now have trouble feeling an emotional attachment to others or reacting in a normal way to life events. It hurts relationships; you may find sexual relations and intimacy unpleasant or simply boring; and it steals the joy in your life – you may lose interest in hobbies and recreational activities that you formerly enjoyed. And emotional anesthesia can also make it harder for you to conjure up the emotions or enthusiasm you need to envision your future. The fancy term for this is called "foreshortening", which means that you have difficulty planning ahead and picturing where you'll be in the future, or you lose interest in your personal health – perhaps developing nutritional and substance abuse issues.

The last hallmark of PTSD that I want to mention today is hyper arousal, or when the nervous system stays on red alert all the time, and they can't let their guard down. This situation causes a range of problems that affect their relationships with other people and their general overall well-being such as chronic irritability, difficulty sleeping, other physical reactions triggered by a fight-or-flight reaction whenever a PTSD trigger occurs, and quickness to anger – what I'll call the ride on the adrenaline train...

Anger is one of the most common problems that troops encounter after deployment to the battlefield. This emotion, which stems from the high level of arousal and aggression needed for survival during war, can make re-establishing connections with family and friends a difficult challenge because military training often teaches the use of feelings and emotions for the most rudimentary of purposes, namely differentiation between safe and dangerous situations. Skills required for distinguishing emotional nuances and exploring emotions within interpersonal relationships are not taught by the military. The military's mission requires training our service members to go into dangerous situations, effectively assess the level of danger within the situation, and neutralize that danger using whatever force is necessary, regardless of how personnel feel about the mission.

Combat missions are inherently aggressive and that aggression is reinforced each time a service member is placed in harm's way. Combat veterans have been taught to use aggressive tactics to maneuver safely through issues and problems, and when you add the component of learning how to disconnect from emotions, combat survival skills are nearly useless in creating an emotionally fulfilling relationship in civilian life.

So there are lots of reasons a combat veteran feels angry. First, anger is usually easy to tap into (and therefore accessible at a moments' notice) and is often used to mask underlying feelings that are much more difficult to deal with such as sadness, depression, or guilt. Post-deployment anger can also stem from discouragement or frustration the veteran felt during deployment and even during reintegration.

"Following the rules" is critical while you're in war, and you may become angry if those around you aren't following the rules or doing what they're supposed to be doing at home. This can even start during deployment because while in battle, problems become amplified. This means any fault you find in your comrades or superiors before or during deployment become more obvious during critical situations; just at the moments when you believe the person needs to perform better or at a higher level. Thus, you come to believe that others are not performing their jobs the way they should.

This same anger carries over upon transition, manifesting itself with family and friends or others in the community. For example, you get angry over minor traffic situations or getting cut out of line at the movies...

And because you feel like others aren't doing what they're supposed to be doing, you may try to take over and wind up being over-controlling, and that has serious consequences in personal relationships and with children in particular. Anger can also be easily displaced onto the wrong person or into the wrong situation.

Anger can also be related to issues of trust and betrayal. When service members return from war, they often realize that they're exasperated with the way life works, with the government and military systems, furious about being dragged into a war when war was unexpected in their life, or angry with their "higher power." Anger can be a response to being victimized and can also be directed toward a perpetrator of violence such as an enemy combatant or perpetrator of military sexual violence.

Lastly, anger and irritability can be associated with the fear or loss of control felt at times during deployment. In times of extreme stress, terror, or life threatening situations, such fear may be expressed as fight, flight, or freeze responses. Anger can motivate you, protect your feelings of self-esteem, or make you feel in control. You may feel angry from discouragement or frustration over leaving a job unfinished (such as leaving when the war is not finished) or even at the injustices of the world over which you have little or no control.

In conclusion, our complex brains and powerful memories distinguish us as one of the most intelligent of animals on the planet, and yet this very intelligence that leaves us vulnerable to the intrusive effects of trauma such as flashbacks, body memories, post-traumatic nightmares, and behavioral re-enactments. Exposure to trauma alters people's memories in a number of ways, producing extremes of remembering too much and recalling too little. In my opinion, barriers exist to recognizing the impact of trauma – the reality of traumatic amnesia in individual trauma survivors has repeatedly left our society with a cultural amnesia, especially when the trauma has occurred within marginalized groups such as veterans. In other words, there's a reluctance of both the survivors to dredge up the memories of the trauma and reluctance on the part of the larger audience to listen to the stories. As a result, it's been easy for both survivors and the public to lose the thread of the cause and effect relationships inherent in trauma. It is time to look seriously at how the impact of combat trauma can play in the role of responses - responses which can place the family in a situation that is not safe and one that is often seen as domestic violence.

Thank you, and afterwards I'll be glad to answer any questions you might have.