A Discussion on PTSD with Dr. Kari Leiting
Post Traumatic Stress doesn't just affect military veterans. But as a veteran of the USMC, I'm often drawn to conversations that might be of use to those who served and to those who left some part of themselves behind in that service.
The suicide rate among vets is 21 percent higher than among civilians. Veterans with PTSD suffer. Their worlds become smaller. Moments of joy slip away, replaced by moments of pain and guilt and fear.
If there's one thing I've learned from talking with veterans across the state it is this: Help often comes when someone who loves you helps you cross the threshold to the counselor's office. Asking for help takes courage.
If one person finds value in the conversation I had with Dr. Kari Leiting of the VA Medical Center in Sioux Falls . . . then I will have done my job.
What’s the difference between Post-traumatic stress injury and other psychological disorders? Why does this difference matter?
Technically, there's not much of a difference. It's more of a conversation that's been started in the last five or ten years about whether or not to be classified as a disorder or injury, and which one has more of a stigma attached to it. Technically, from the psychiatric disorder standpoint, PTSD, or post-traumatic stress disorder, is the actual name. I liked what Secretary Zimmerman discussed an aspect of awareness, how changing the name or calling it something different doesn't change what we're really trying to get at.
And how long have we been calling it this? You can go back to the beginning of combat and there are different names, people trying to sort things out. Do you have an idea of when it became an official designation as a disorder?
So that actually happened right around Vietnam calling it post-traumatic stress disorder and listing it in the DSMR diagnostic and statistical manual for psychiatric disorders. I think before that we called it things like combat stress and other sorts of names.
Getting it in that manual, why does that matter?
From a practical standpoint, at least we know we're talking about the same thing. When I have to talk to another, they have an idea of what I'm talking about, what sort of symptoms usually fall within that line. It also means we can diagnose it, and we can also provide specific services for it. We can do research that's actually consistent and we're looking at the same thing as opposed to everyone doing something slightly different.
Give me a little background about the research and how we know what we know works today.
Our main research surrounds two kinds of gold standard treatments that started right around the '80s. They actually both originated looking at treatment for rape victims and looking at the post-traumatic stress disorder reaction to that, and essentially doing a lot of research to see if we compare this to treatment as usual, and what happens. Then, when we started to see results from that, we asked, “okay, well how about we compare them to other treatments, and then compare them to each other?”. So, we slowly started building our case over the last 30 plus years of research, now closing in on 40, and consistently finding significant improvements and doing lots of case studies and looking towards doing this via telehealth. Can we look at this with different types of samples? Can we look at this as men versus women? Can we look at this with military samples? Does it matter what type of trauma? And ultimately looking back to our treatments, and making sure that our gold standard treatments are good, and they'll work regardless of what kind of trauma there is. It's nice to know that we can have that and we can offer that to people.
Gold standard treatments. What are they?
What that means is they [treatments] have to meet certain standards with respect to randomized, controlled trials in order to meet that technical standard. Our two gold standard treatments for post-traumatic stress disorder are called prolonged exposure and cognitive processing therapy. They look very different, but study after study finds essentially equivalent results for both of them, so it's nice to be able to offer two kind of different looking treatments to patients and see which ones they gravitate towards.
We're going to talk a little bit about prolonged exposure therapy, and for that we have a little audio clip for you to listen to. You haven't heard this before, this is Hawk Meyer, who's a Vietnam veteran who survived a building collapse during the Tet Offensive. He attended a screening of Ken Burns' upcoming documentary on the Vietnam War in Sioux Falls earlier this month. Afterwards he shared some of his story with South Dakota Public Broadcasting’s Jackie Hendry. It was a story he didn't tell anyone for 40 years, but as is the case with many veterans, the story didn't end with the war. Hawk Meyer shares how he carried his experiences in Vietnam with him when he came back to South Dakota.
“I was in education. I went to college, I got my educational degree and I taught and coached for 14 years and then I was a superintendent of schools for 15 [years], and then I retired. During that period, we had five children. When you're a teacher and a coach, there's always something going on. So the mind is always spinning and looking way back in that hole is the war, see? It's way back there. Okay? And then I became superintendent of schools and then you've gotta speak to this committee and that committee and you gotta go out in the community and speak to the veterans and speak to the ladies quilting club--whoever wants you, okay? So there's always something that's making the mind spin. Okay?So I retired, and after 60 days I told my wife, "This is never gonna work," because the war came back. See, there was nothing to take up that space every day talking to the kids, making sure this was done, or that was done, talking to this teacher.
And so I came over to the VA and I was able to get into the VA because I got sick from Agent Orange [during the war]. So I have a pacemaker defibrillator that keeps me alive and I thank God every morning for modern technology and whoever invented it. They put it in out at North Central Heart, Dr. Huber and Dr. Olson, who have studied Agent Orange so they see a number of our veterans who have pacemaker defibrillators because their hearts have been attacked by Agent Orange.
I've had cancer, and I've beaten that. I have diabetes, I have PTSD, but we have five children, we have eight grandchildren, and I'm alive. And I have the best wife in the world. She stuck with me all the way through, through all this stuff and finally, let's see, be about four years ago when everybody was at our house for Christmas. I'd been working with Dr. Lithgow at the VA--he brought me back, he's a great doctor. You know, what do you smell? He'd have me close my eyes and we'd just sit there. What do you smell? What do you hear? What are you doing on this date? And so I recorded and I still have it, everything he said, "This is what we do. We record every time you're here and then you play that back to yourself and write down if you missed something." And man, there was always something that was supposed to go in there.So then when I was all done he said, "Now, you need to tell your wife, and then you need to tell your children, and any grandchildren who the parents think are old enough." And I've done that. It felt good, it felt good."
Dr. Leiting, the war came back. You hear that often I bet.
Yeah. The way he kind of described keeping himself busy until retirement and then everything kind of got different. That's not at all uncommon. One of the things we see quite frequently with PTSD is avoidance, and that's avoiding thinking about or talking about anything related to trauma. That's avoiding people, places, things, sights, sounds, smells. One of the other ways that it can sort of manifest, if you will, is that we keep ourselves so busy that we don't have time, energy, or emotional space to even think about anything related to trauma. That works really well in this case of overworking or keeping yourself busy all the time. And then as soon as people retire they have all this time and all the stuff that they kind of shoved back into that closet and kind of kept closing the door that starts creeping out a whole lot more, because there's not as much holding against it.
Prolonged exposure therapy then sort of is what it sounds, but walk us through how you do that safely and without sort of re-injuring someone psychologically.
Part of the way prolonged exposure is set up is in two pieces. What he was talking about is the imaginal exposure component of it. The idea with that our brain records our memories, our brain keeps them. But when it comes to PTSD, what can happen is our brain starts to react to the memory itself as if it's really happening every time we have the memory. The memory itself is dangerous and sends us into this fight or flight sort of reaction. So the imaginal exposure component is essentially retraining your brain and yourself that you can remember it and talk about it, and the memory itself is safe. The experience, terrible. Agreed. But remembering the memory isn't dangerous in and of itself.
So by going through that with the therapist in session it is a safe environment, and they can practice some relaxation things afterwards and then go home and listen to it. So that again, it's kind of that if you're trying to learn something new you have to practice it.Same sort of thing, which is why he recorded it and then would listen to it outside of session. The idea being is that we can take that terrible experience and not make it less terrible, but make it just the memory of something that's terrible as opposed to it literally being the monster in the closet.
Right. Memory is a slippery thing. What if you don't remember it all? You know something happened but you really don't have the memory but yet it's still causing problems for you. How do you deal with that?
If there are pieces about it that you don't remember, do you have to remember? I mean it's still causing problems. If there are giant chunks of it that you don't remember, prolonged exposure might not be the best fit. Cognitive processing therapy might be a better fit, which is going to get more at the impact that it's had on your life and how it's affected your belief system about yourself or other people of the world. So kind of getting at it that way. Knowing that both of those treatments are equally effective, it allows us to present both options. We don't want to go into as far with imaginal exposure, we don't want people making up what they think might have happened because that is a slippery slope and we don't want to go down that.But there are pieces of it that you do remember and those are the pieces that bother you, well then we talk about those.
How does a person get through the challenges of just going through that, knowing that on the other side this might be worth it, but in the meantime, I have to talk about this? I have to take it home with me, and I have to tell other people about this in some circumstances, maybe not all. Do you have advice for them? How do they prepare themselves to go through the experience of getting healthy?
Yeah, it is an experience. I tell patients all the time, "I'm not sure you will ever tell me that you are looking forward to or that you loved your homework, because you won't."
Avoidance is a really great short-term strategy because it works in the short term. You don't have to think about it, it goes away. But, it doesn't actually go anywhere for long, and so while avoidance works really great in the short term, it really doesn't work in the long term, which is why you're here in my office to begin with.It's because it doesn't work. So when you have times when you don't want to do your homework or you don't want to come to session, which I can almost promise there will be, let's call it what it is, and that's part of the problem. That's why you're here to begin with. So kind of taking essentially the drive that they have anyway and applying it, saying “okay I'm going to do this, I'm going to do it right, I'm going to do this, I'm going to do it and be done.”
Who are you seeing coming in? Are you seeing men, women, Vietnam vets, Iraq, Operation Iraqi Freedom? Is it running the whole gamut?
Yeah, all of the above. I see anywhere from vets who are kind of fresh from post 9-11 conflicts, some of them are like 22, so they're really young and I've got vets who were in Vietnam or even older in their late 70's that are coming in. "I didn't deal with this for 50 years, can I do something?" Yeah, let's do something. Let's go.
How about the difference between veterans who saw combat on the ground versus someone who had a distance from it. A sailor who spent a lot of time at sea, a drone operator, someone like that. Are you seeing people still suffer from PTSD even if they weren't in the physical space of their combatant?
Less so, but it's not impossible. It kind of depends on the meaning that they've made from their experiences. Going back to what Secretary Zimmerman was talking about, the experiences themselves you can have, the disorder is how many problems it is causing. I mean, there are people who will experience all kinds of things on the combat field but it doesn't cause long term problems. Excellent, they're resilient. That's what we would like for more people to be, but at the same time it doesn't mean that anyone is more so or less so. It kind of just depends on the meaning that they've taken from their experiences and how that's created problems or not.
Isn't that one of the great mysteries of this though? That there could be people side by side in the same unit. A Harrier pilot dropping bombs, and then another Harrier pilot, one has issues the other does not. Do we have any sense from the research why some people are impacted by the same situation differently?
I mean we've got lots of ideas. We know that there are things that we can call risk factors, right? But at the same time they're so individually based that it's a little bit difficult to predict; mostly because we are different. A lot of times the beliefs that we have before, leading up to any sort of traumatic experience are different or so varied. Then the meaning that we make from that then impacting our lives can be different. So it's a little bit difficult. It's not like A plus B equals C.
Right. We talked a little bit about prolonged exposure therapy as a gold standard. The other kind, the cognitive processing therapy. What does that look like?
So essentially cognitive processing therapy came of cognitive therapy. The idea being that we all have beliefs about ourselves, the world, other people. They've developed over time, and a lot of times when we experience trauma they conflict in some way. And a lot of times that will end up with us having beliefs either that, most of the time, are in the extreme and negative end of the spectrum. Whether that's negative beliefs about ourselves or blaming ourselves for traumatic experiences, which is pretty common. Or even, and/or experiences where we start to take kind of really general and negative beliefs about the world in total, people can't be trusted, the world's completely dangerous, I'm never safe, I have no control. The goal for cognitive processing therapy is to identify where those spots are, where are those beliefs that have gotten you stuck in kind of the recovery trajectory, and what can we do to modify, tweak, and get us to a place that's maybe not quite so negative but a little bit more balanced and a little bit more realistic.
Again, neither of the treatments can erase what happened. We can't go back, we can't remove memories, we can't remove experiences, but if we can take away kind of that sucker-punch quality that a lot of times those experiences have when we think about them, then we're in a much better spot.
Let's talk a little bit about military sexual trauma because this isn't just a combat trauma or a traumatic experience. Do you see a lot of women, men coming in with sort of rape and sexual trauma in their background?
Absolutely. Military sexual trauma is a big piece. It can, but not always, lead to PTSD. Sometimes it does. As far as military sexual trauma in general, the statistics are about one in four for women and about one in one hundred for men, which leads to obviously higher rates for women, but pretty significant numbers given for both genders given the demographics of the military.
So as far as treatment, if someone experiences military sexual trauma and develops PTSD, we offer them the same treatments. Again, it's kind of nice to know that for both of our treatments we started with rape victims, and that's where these treatments started. And then they started doing research and expanding to see if we can treat all kinds of trauma with similar treatments. Mostly because while we have these gold standards for treatments, they're tailored for the individual-- whether it's their beliefs or their experiences, those pieces are going to determine which way we go and what they do on session to session.
Is there a difference between military sexual trauma and sexual trauma as a civilian? What's the difference?
Difference is essentially what we're calling it. I mean, the difference is just that it’s happening while you're in the military. That's what's going to make it be military sexual trauma as opposed to just sexual trauma otherwise.
Is that adding layers for people who are victims in a space where they thought they were going to be protected? Is it just very similar to being raped in a college setting?
It can, and again, it depends. I hate that answer, but to some extent, yes. Military adds another layer in the sense that depending on who the perpetrator is, whether or not it's someone who is a peer or someone who's above them, that can create their own set of layers. To some extent that can also happen with civilians.Sexual trauma as well. I would say that I think with military sexual trauma you have military training and military culture on top of that which can sometimes be hard for the individual to be like, "I can't believe that it still happened to me."So then you have to go after that a bit more in treatment if that's kind of where they end up landing on it.
From a PTSD standpoint when do you know you need help? We talked to Secretary Zimmerman about just the stress of being in the military in general, the stress of deploying. For people who are listening without military experience and saying this sounds like me because I had a car accident, because I was raped, because I was abused. When do you know that it's time to reach out and pick up the phone and when do you know it's just regular stress that we all kind of go through?
I think it's going to depend on what is it ... How is it impacting your life? Is it impacting your life in a lot of different areas? Is it making work hard? Is it making your relationships hard? Is it making kind of your day to day life really difficult? If it is, it's worth going in and at least talking to someone. Maybe it's PTSD, maybe it's something else. But either way, let's figure it out so life doesn't have to keep being so difficult all the time.
Are you seeing success on the other side? Are you seeing people come through and find a life that's bigger than what they had before treatment?
Absolutely. That's why I love what I do. I love seeing old and young. I love seeing young guys be like, they feel more prepared to be able to take on everything else because they've been able to some extent put certain things to bed. You see people being able to kind of take back the reigns of their life where they don't feel like the PTSD's controlling them, but that they have some control over their experiences and their reactions, and how they're going to do it. I love seeing that. I've had quite a few Vietnam guys go through and be like “after 50 years I can't believe I can actually like... the way I look at the world is so different than the way I used to.
There has to be some pain to that as well. What do you say, how do you deal with that?
Well, you do it when you were ready. If you weren't ready before, your being here wouldn't have done a lot of good. You would've fought me every step of the way, and as much fun as that is, you did it because now is the right time for you. And there's lots of reasons why people aren't ready for treatment. It doesn't mean we can't encourage them or get them to talk to someone. But I think it's recognizing that at least you did something now. You could've never done it. Again, we talk a lot about avoidance and it's a great short-term strategy because it works really well and ultimately what we're asking people to do is face the things that are in the closet. They're in the closet for a reason--because you don't like them, and they're not pleasant, and they're not fun to talk about or think about. So the fact that you're able to do it regardless of when you were able to do is a big step, and it's worth being proud of regardless of how long it took you to get there.
You might not know the answer to this, but is it expensive? Is cost causing some people not to sort of seek the mental health treatment they know, or is that not something that you deal with?
Sadly, no, it's not something I deal with. I think there are a lot of good services at the VA and there's a lot of things that people can do with respect to working with billing and working with those sorts of things. I unfortunately can't offer probably more information than that.
Family members, how do they sort of walk this walk with their loved ones? When we heard Hawk talking earlier he had not told this story to his wife, and now she has to go through something as well.
Yeah, and I think it's worth kind of thinking about with respect to whether or not the veteran chooses to share their story with his or her family. I think that's very much an individual piece, both for the veteran and for the family, taking stock as to whether or not you really do want to know. I think we have this compulsion to push people to share with the idea that that's going to be what's best for them. Sometimes it is, sometimes it's not if you're not sure how you're going to take it. Then, don't push it right away because that can have an impact too.
I think that recognizing that the same thing we work with our patients is, in the sense that we can't go back and change what happened, we can't remove memories or remove experiences, but the goal is to keep moving forward and get life back to a place that feels manageable, feels okay, and it’s what we want to be.
So it's possible to go through gold standard treatments and not share with someone else necessarily. It could be between you and your therapist and that could be the choice that you make together.
Any last thoughts on post-traumatic stress that you want to leave us with? This has been such an enriching conversation I think for all of us. I'm getting emails coming in now saying how great it is as we speak. So any final words?
There’s a lot of information out there. I think looking for the resources and talking to the people. I know that the National Center for PTSD is a great resource website. It's got a lot of information both about treatment and how to determine FAQ's about what treatment will look like. Frequently asked questions from veterans like, "What, do I have to do this, what do I have to do here?" I think get your questions answered. It doesn't have to be as scary as it sometimes feels.