PTSD is unending nightmare for vets

The long U.S. wars in Iraq and Afghanistan are winding down, but for many veterans, the anguish continues.

During deployment, many service men and women were on alert around the clock, at constant risk for death or injury. They saw people killed or wounded, and perhaps had to kill or wound others. In some cases, their tours of duty were longer than expected, and many have been deployed several times.

The U.S. Department of Veterans Affairs estimates up to 20 percent of veterans who served in Iraq or Afghanistan have post-traumatic stress disorder. Because not all veterans seek treatment, the numbers could be higher.

Veterans with PTSD may suffer from a range of symptoms including flashbacks, nightmares, emotional numbness, irritability and difficulty sleeping.

The risk of PTSD in service members is higher among those who served longer deployments, experienced more severe combat exposure or physical injury, and those who have family problems, according to the U.S. Department of Veterans Affairs’ National Center for PTSD. Women are more likely to suffer from post-traumatic stress, as are members of the National Guard or Reserve.

For many veterans, the problems start after they’ve been home a while. A spouse or loved one notices that the veteran seems distant and disconnected. Or they might struggle with anger, depression or substance abuse.

The St. Cloud VA Health Care System provides both outpatient and residential mental health treatment for veterans. In 2001, the St. Cloud VA started a 16-bed intensive PTSD treatment track, which is usually full, said Jeremy Maurstad, chief of the VA’s mental health residential rehabilitation treatment program.

The specialized track isn’t for everyone, however. About 60-70 percent of veterans who come in for treatment at the VA have co-occurring disorders such as mental health or substance abuse problems, Maurstad said.

Jeremy Maurstad
(Photo: Kimm Anderson,

“If you have someone who’s really depending on alcohol or some other central nervous system depressant to manage their anxiety, putting them in an arena where they’re going to specifically and extensively talk about traumatic experiences — it’s not going to work,” Maurstad said. “So it’s almost like you’ve got to prepare them to be able to do that.”

Unlike many other facilities, the St. Cloud VA is treating veterans for substance abuse and PTSD concurrently. It’s a rare model, but it works well, Maurstad said.

Too many veterans are getting caught between two systems, Maurstad said. Many mental health professionals don’t want to treat the veteran until his or her substance abuse is treated, while the substance abuse counselors don’t want to treat the patient until the PTSD is taken care of.

“We don’t care,” he said. “Frankly, you’re both, or you’re something. But we’ll figure it out when you’re in the door.”

There’s a very high prevalence of substance abuse among veterans coming in for treatment of PTSD, as high as 80-90 percent, Maurstad said.

Some veterans went into the service with substance problems already, hoping the military would provide structure.

Then there are people who never had an issue with substance abuse before “and when they’re done with their deployment, they’re really struggling,” Maurstad said.

The age of veterans treated for PTSD at the St. Cloud VA ranges from 19 to 91, Maurstad said. The average age is around 50, with many Vietnam-era veterans joined by a growing group of younger veterans. About half served in Operation Iraqi Freedom or Operation Enduring Freedom, he said.

They stay as long as it takes to meet their goals, Maurstad said. The average stay is about seven weeks.

For the special PTSD track, 16 veterans are admitted at one time, and they all leave at the same time. That helps create a feeling of camaraderie like the veterans experienced during their service, Maurstad said.

“Some of them will do some group trauma work, so they have to be very close and trust each other,” he said.

The cohorts can include men and women of any conflict, Maurstad said. One section is reserved for veterans who saw combat, but other than that, there are no restrictions.

In treatment, the patients follow a schedule. That’s helpful for veterans suffering from depression or whose days and nights are mixed up due to substance abuse, Maurstad said.

“They get up every morning at the same time. They have breakfast every morning at the same time,” he said. “If they’re not up and they’re not at breakfast, guess who’s looking for them? Everybody else in that (group). They know somebody’s missing.”

After a treatment plan is created, days are filled with hours of group and individual therapy, as well as specialized treatment such as anger management, relationship counseling or even spiritual treatment.

“They’re pretty busy,” Maurstad said. “Right when they hit the door, they’re being assessed a lot. ... It’s almost like full-time jobs for some of them.”

Part of the treatment is usually cognitive processing therapy, which involves the veteran writing and thinking about their most traumatic experiences. They might be told to reread it 10 times in the evening and then report back on their emotional state the next day.

“It tries to elicit an emotional response,” Maurstad said. “You focus and you talk and discuss it and write about it so much that eventually, that emotional output that you have — that anxiety, that fear — it diminishes over time.”

Still, it’s a very difficult and painful process. Some veterans tolerate it well, but others take a long time to recover from an individual session.

“It’s tough,” Maurstad said. “And they really have to be committed to doing that. You can’t do this halfway. If you do it halfway, you probably could create more damage than you started with.”

Another technique is cognitive behavioral therapy, which involves veterans identifying core beliefs that propel them into mental health disorders — that they are worthless, or don’t deserve to live because of what they did during their service.

Those “stuck points” can keep a veteran from getting better, Maurstad said. He recalls working with a veteran who wouldn’t wear new clothes his wife bought him because he felt like he didn’t deserve them.

Much of the treatment for PTSD includes loved ones. Many veterans numbed themselves emotionally during their deployment and have a difficult time turning those emotions back on after they returned.

The result is usually a downward spiral in the relationship, as the spouse tries to get the veteran to engage more, and the veteran doesn’t know how.

“What happens is your brain just kind of shuts off your feelings just so you can function,” Maurstad said. “Unfortunately, not everybody can turn it back on then. So they come home, and now they’re just kind of this empty shell of who they once were.”

New approaches

Researchers are seeking new methods of treatment for PTSD, with some encouraging results. One of the leading researchers is Barbara Rothbaum, director of the Trauma and Anxiety Recovery Program at Emory University.

“The way I see PTSD is that people are haunted by something that happened to them in the past,” Rothbaum said. “And so a lot of the most effective treatments are ways to help people go back and examine what happened ... and then be able to feel differently about it and think differently about it.”

One of the prime characteristics of PTSD is avoidance, Rothbaum said.

“They don’t want to think about it,” she said. “When you avoid it and you can’t even go there, then we teach ourselves ‘I can’t handle it.’ We can’t even think about it differently if we can’t even go there.”

That’s especially true of war veterans, who don’t want to have a big emotional response while in a combat zone. “You want to stay fairly detached and do what you were trained to do,” she said.

However, what often happens is that when they return, they don’t put the experiences back together with the emotions, Rothbaum said.

“That’s when it kind of comes back to haunt them in different ways,” she said.

During exposure therapy, the patient repeatedly goes back to the traumatic event and describes it as if it’s happening now. Often the session is recorded, and the patient is told to listen to the recording as homework.

Rothbaum also uses some innovative techniques, including using virtual reality technology, to make the experience more real. Patients wear a helmet with a TV-like display so they feel like they’re in a war zone, walking down a street or riding in a Humvee. As they move their head, their view changes. As they describe their experiences, the therapist can reproduce those images.

Going back over the experience again and again helps them change how they think about it, Rothbaum said. It also helps alleviate guilt they might be feeling for failing to spot an improvised explosive device or stopping the incident in some other way.

“When they go back over and over it, they can realize that ‘There’s nothing I could have done,’” she said.

Rothbaum also has investigated medications used to treat PTSD, such as sertraline, commonly sold as Zoloft, and paroxetine, sold as Paxil. While they can help alleviate symptoms, most people would say they aren’t effective enough, she said.

There’s also growing interest in alternative treatments of PTSD, such as yoga and meditation. Rothbaum said she’s looking forward to seeing data from several ongoing studies of these techniques.

She’s also working on a seven-year study following people after a traumatic event to see if it can be predicted who’s at risk for developing PTSD. While 70 percent of people will go through a traumatic event in their lifetime, not all will end up with PTSD, she said.

“If we can predict who’s at risk and then we can focus early interventions ... on them, then I think that’s a good place to focus our efforts,” she said.

These folks have had absolutely life-changing experiences. Their military training is a life-changing experience, certainly their combat deployment. And so when they’re coming back, there can be any number of different kinds of effects. They’ve experienced grief and loss in ways that (we) common civilians are probably never going to experience. They’ve signed up to do a job that, frankly, most of us have not been willing to do. So if someone’s come back from these experiences and it doesn’t affect them, that would be strange, I think. They’re reacting to the experiences that they’ve had.”

Heidi Ampe, program coordinator of the polytrauma support, vision impairment services and spinal cord injury teams at the St. Cloud VA Health Care System

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About the reporters

Kirsti Marohn has been a reporter at the St. Cloud Times since 1998. She has covered local and state government, social issues and the environment. Her father was a U.S. Marine and her husband served in the Minnesota National Guard prior to 9/11.

Marohn became interested in writing about veterans after hearing about the struggles many have faced since returning from Iraq and Afghanistan, and how community resources were not always adequate to help them.

You can follow Marohn on Facebook and on Twitter @kirstimarohn.

David Unze has been a reporter at the St. Cloud Times since 1997. He has covered primarily courts, public safety and higher education.

The problems that Iraq and Afghanistan veterans face came to his attention through the interactions that police and the courts have with veterans in crisis. He also learned about the challenges that vets face when they return home and try to resume their education.

You can follow Unze on Facebook and on Twitter @sctimesunze.