Mix Soldiers and Analysts: What Can Come of This?
Nathan Szajnberg, MD Managing Editor
Service Members and Veterans Initiative (SVI), a committee founded by past American Psychoanalytic Association (APsaA) President, Prudy Gourguechon, MD and chaired by Harold Kudler, M.D., has two foci: war’s impact on families and children and long term treatment for war injuries.
This year Dr. Kudler invited Jonathan Shay, MD, PhD, author of Odysseus in America and Achilles in Vietmam, to present to the committee. Later that day, Dr. Shay was awarded honorary membership in APsaA for his contributions to understanding Posttraumatic Stress Disorder (PTSD) in veterans.
Click Here to Purchase: Odysseus in America
Click Here to Purchase: Achilles in Vietnam
Here’s a brief overview of Shay’s comments at the SVI meeting. Service members prefer the term “injury” to “disorder”: one may be honorably injured in war and recover; a “disorder” suggests that the service member is, at best, “unlucky”, may imply personal fault or weakness and may interfere with promotion. Therefore Shay and others have suggested renaming PTSD to PTS Injury so that affected service members are more likely to seek help. One major general explained to Shay that he was interested in effective treatment for PTSI because he didn’t want to compromise his fighting force.
Shay reframes three basic DSM criteria in adaptive rather than pathologic terms that service members and veterans “get”:
Intrusive symptoms are a form of “hyper-remembering” so that the service member has a kind of radar to forewarn if something that happened before might happen again;
1. Numbing/withdrawal is a form of resource-sparing. In order to respond quickly, one needs to shut down or down-regulate other systems. For instance, when a gazelle is chased by a lion, both animals shut down organ systems not needed for the chase. This translates to more blood flow to the limbs;
2. Hyperarousal is a form of keeping oneself mobilized to meet danger; a form of sharpened senses.
Chronic mobilization results in sleep loss, which in turn can degrade frontal lobe function leading to loss of social awareness and impaired judgment. Shay’s prescription for many service members and veterans is to increase sleep time. Many vets may use alcohol and drugs in the false hope of achieving satisfying sleep which leads to a spiraling downwards (alcohol, for instance, disrupts EEG sleep architecture, resulting in poor quality sleep).
Shay introduced the concept of “moral injury” which has three components:
Betrayal of what is morally right;
1. Betrayal by a legitimate authority (superior officers);
2. Betrayal in a high stakes situation. (Others have varied the second criterion to “I did this….”)
Service members and veterans respond better in treatment that is situated within a community of peers (at least three according to Shay) who help diminish expectations of 1. harm, 2. exploitation and 3. humiliation. The service member/veteran responds to these inner expectations by either 1. striking first; 2. withdrawal/isolation; or 3. Creating a false self, such as a front of bravado (such as Ulysses).
Harold Kudler described several free, accredited on-line courses he and colleagues have developed to help community clinicians (mental health, primary care and employee health) work with Veterans and their families. See www.aheconnect.com/citizensoldier for these.