Navigating Through Smoke, Confusion, Avoidance and Fear (Part 2 of 3)

Capt. Richard Stoltz, commanding officer, Naval Hospital Guantanamo Bay and commander, Joint Medical Group

By Capt. Richard Stoltz, commanding officer, Naval Hospital Guantanamo Bay and commander, Joint Medical Group. Stoltz is a clinical psychologist who began his Navy career in 1986.

(Part 1 of 3 posted on Wednesday, Feb. 15)

 What Continues To Heal

As research continues to help us navigate through all of this confusion, avoidance and fear, it is helpful to remember and understand what fundamentally has to occur for these individuals to experience long term healing. Quite simply, they need to confront, express, and accept the truth of what they experienced and how they truly feel about it.  Just like the patient who could not stop smoking, they need to process through the conflicts they feel inside.

Sometimes the reality of what happened to these service members and their internal reaction to it is very stark and morbid — they might have seen their best efforts fail to prevent their comrades from being killed or even been involved in the accidental deaths of innocent civilians including children. Perhaps they made or believe they made a mistake that led others to die. Avoiding excruciating realities and our internal responses to them will never heal agonizing pain. In fact, avoiding the truth of these traumatic events perpetuates and intensifies our difficulties recovering from them. 

When a patient, I’ll refer to as Tim, was seven years old and at home one night sleeping in a separate bedroom from his younger brother, a fire started. Tim woke up coughing.  His parents were gone. Tim tried to save his younger brother but failed.  

For more than a decade Tim avoided everything related to fires. If he was watching TV and there was any image or scene of a fire, he left the room.   When he enlisted in the service, he could not avoid fire fighting training. In response, early in his career he developed severe post traumatic stress symptoms. Nightmares involving fires increased their intensity and frequency. More and more often he experienced intrusive recollections of what happened when he was seven. He became more irritable and had more difficulty concentrating. On the verge of being separated from the service due to his disorder, he gathered the courage to engage in a comprehensive affective and cognitive review of what happened the night his younger brother died. When it was over, his symptoms greatly decreased and he was able to remain on active duty.

Treatment Methods

The specific methods or treatment techniques that are used to help a person face the truth are far less important than establishing a strong therapeutic relationship with the patient and remembering the direction healing efforts need to go. The best treatment for some may not be the best treatment for others. Whether we utilize social support, education, group therapy, mind-body medicine, virtual reality, hypnosis, spiritual counseling, behavioral techniques, cognitive therapy, mindfulness, meditation, or some other treatment, it is critical that the focus ultimately aim at the truth and processing through to acceptance of that truth. Service members who return from deployments and continue to experience high levels of depression, anxiety, or PTSD symptoms, often need help to achieve this goal. In most cases their journey will not be as simple or as straightforward as it was for Tim and the man who could not stop smoking. But, no matter how difficult it may be to navigate through the chaos and upheaval inside of themselves, facing and accepting the truth is what will set them free. 

Confounding Factors

Often the most severe confounding factors are avoidance and fear.  While post traumatic stress is a highly treatable disorder, post traumatic stress wounds do not automatically heal with time. In many cases, the longer the symptoms are avoided, the worse they become.  Many people live with PTSD until they die.  A common reason why these symptoms persist is fear. It’s an elusive fear that often is not labeled as fear.

There is an inherent irony here: How can our nation’s heroes, who bravely volunteer to enter battle against a ferocious enemy that never wears a uniform and is often unseen, allow fear to thwart their own healing? While service members consistently display great courage and a willingness to risk their lives for others, they respond to painful internal feelings and memories just like most of us do — they quickly aim to avoid them. Their survival in battle depends on blocking troubling emotions and flashbacks; they focus on the immediate task of staying alive and helping their fellow service members. However, when the danger has subsided and they are in safe places, they need to completely change their psychological strategy and unearth what they have blocked and buried. It is important for them to revisit their natural revulsion to horrific events and stop pushing them away when the traumas insidiously re-emerge into consciousness. If they fail to do so, they are at greater risk of developing PTSD and other significant psychological symptoms. To sleep well at night, they need to allow uncomfortable scenes and emotions wash over and through them.   

Another common confounding factor is possible neurological complications from a traumatic brain injury (TBI). Fortunately, such injuries are usually mild and may not lead to long term neurological defects. Nonetheless, ensuring that the service member receives a thorough medical and psychosocial evaluation may be critical to treatment success. Additional complications include the presence of a variety of other physical injuries and a history of various traumas over the course of multiple deployments. Some service members may also develop unhealthy coping responses such as substance abuse and/or somatoform, conversion, and/or dissociative disorders. When these confounding factors are present, it is important to set realistic expectations and pace the treatment process.

(Part 3 of 3 will post on Wednesday, Feb. 29)