Veterans with PTSD

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whopper said:
This place gives out free signs to vets who have PTSD, saying to not light up fireworks around their home. If the moderators want to take it down, I get it cause it's a link to a store, but the sign is free so I figure that might be okay.

Store - Military with PTSD
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Thanks for sharing. With the summer holidays coming up soon I think a lot of my vets could benefit from these.
 
I went to boot camp at the end of the Vietnam War, and the navy has a pomp and ceremonious salute of firing of cannons at unexpected times. At one such event, all of the staff that recently returned from combat "hit the dirt."
 
I became aware of these signs only days before the last year's July 4th. I've been telling patients and colleagues about this now so patients can order them and get them in time.
 
Fireworks are not combat ordinance and there is no threat being posed by them. This is reinforcing irrational avoidance behaviors.
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Ever hear of stimuli triggering anxiety? Cause several vets I know with PTSD, when they hear a loud bang, get bad anxiety. You can call it "irrational" just as I can coldly someone raped who has PTSD to get over it.
 
whopper said:
Ever hear of stimuli triggering anxiety? Cause several vets I know with PTSD, when they hear a loud bang, get bad anxiety. You can call it "irrational" just as I can coldly someone raped who has PTSD to get over it.
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I believe the sentiment is more based on the VA's systematic approach to PTSD being that of engaging in activities that only reinforce and exacerbate the anxiety. This is merely an extension of that. It's just another benzo/ESA/etc. A notion that the environment needs to be continually re-shaped to accommodate a disorder, rather than actually treating the disorder.
 
whopper said:
Ever hear of stimuli triggering anxiety? Cause several vets I know with PTSD, when they hear a loud bang, get bad anxiety. You can call it "irrational" just as I can coldly someone raped who has PTSD to get over it.
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Yes, I have, and doing just that is at the heart of the most effective treatment(s) for this disorder, right?

When I do PE, I dont tell them to "get over it." I tell them avoidance keeps them symptomatic. So, lets start challenging that that behavior and its underlying beliefs. That's what PE is. And its why it works.

Anybody with an anxiety disorder, if we want them to get better anyway, should be encouraged to build skills that allow them to functioning in their environment. Not teach them that the environment should/will conform to them. Cause most of the times, it wont.
 
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My clinical time at the VA unfortunately came before I developed an understanding of anxiety disorders. In hindsight the whole ESA thing as well as the what we told people about fireworks, and the frequent use of chronic benzos seems like mass delusion. I offered PE to patients but I didn't sell it well enough due to my lack of understanding and thus I can only think of one patient who went for it. He was probably my most gratifying patient even though I never saw him again (tapered off meds over the phone).
 
erg923 said:
Fireworks are not combat ordinance and there is no threat being posed by them. This is reinforcing irrational avoidance behaviors.
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Lol when I saw this thread’s first post my initial thought was the psychiatrists would come in thinking “here is something nice that may help someone enjoy their holiday a little more” and the psychologists would come in with “you must suffer 24/7 until it sets you free”
 
Armadillos said:
Lol when I saw this thread’s first post my initial thought was the psychiatrists would come in thinking “here is something nice that may help someone enjoy their holiday a little more” and the psychologists would come in with “you must suffer 24/7 until it sets you free”
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OK, I chuckled at this. 🙂

But, real talk, do these signs actually deter use of fireworks? Because pets and little kids are also not fond of these noises either, and in my experience that argument seems to hold zero sway over the people who delight in setting off firecrackers in residential areas. If the yard sign just makes you feel more vigilant and aggrieved then I can't imagine it helps at all. People who flagrantly violate fireworks restrictions generally don't give a damn.

If someone can find a yard sign that also prevents people from firing gunshots into the air on July 4th and New Year's Eve, I would appreciate it because in my 'hood that is also needed. I'm a survivor of a robbery at gunpoint and wouldn't mind advertising that fact if it prevented this kind of stupidity. Unfortunately, I don't think it would.
 
How, exactly, is one "courteous" with fireworks? They have a volume button I am unaware of? Or Is this just a veiled way of asking me not to shoot off my fireworks at all? Or maybe just silent sparklers? Where does the line get drawn? Is it the veteran status thing that makes the difference? What about non-veteran PTSD? What about for babies? Geriatrics? People with diagnosed Pyrophobia?
 
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In my state, personal fireworks are illegal and people use them anyway at all sorts of crazy hours, even days before the fourth of July. They're a nuisance, especially to people with pets. Everyone should be more courteous to everyone with regard to that.

I can't speak to the avoidance thing generally, but it seems like if it were one set time for the city you could at least prepare however you wanted (wearing earplugs etc.).

I think it's the randomness of it that is probably terrifying to some combat veterans. Not to mention that they go on and on. It's not just the city show (which we also have) but the random firecracker at 2 AM two days later or two days before.

With all of the excess sentimentality and deference that we as Americans tend to have for veterans and the military, I find it annoying that we have to analyze why we can't give one incredibly small tangible thing to veterans who have been in combat. We have to take away one thing some of them ask for because they aren't coping the way we'd like them to. Yet we give them so many false platitudes they don't ask for. Maybe you're technically right that it's enabling. Who cares. As if we ever measured the value of their mental health and life seriously enough against the necessity of sending them into combat to begin with. Why start now with nitpicking how they choose to cope in their own neighborhoods.
 
WisNeuro said:
Ah, the dichotomy of keeping someone coming back for your services for a lifetime vs wanting them to have a manageable level of symptoms and not having to see you. It's a cruel, cruel world.
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Joking aside, my biggest issue with the psychologists we most frequently refer to for trauma in our systems is that 50%+ of the patients get bounced back for “not being invested enough” in exposure therapy, having a couple no shows, drinking too much, etc. So ends up the psychologists are mostly treating the patients who are already sober and well enough to show up 2hrs every single week and we are stuck taking care the folks who are most significantly impaired.
 
Armadillos said:
Joking aside, my biggest issue with the psychologists we most frequently refer to for trauma in our systems is that 50%+ of the patients get bounced back for “not being invested enough” in exposure therapy, having a couple no shows, drinking too much, etc. So ends up the psychologists are mostly treating the patients who are already sober and well enough to show up 2hrs every single week and we are stuck taking care the folks who are most significantly impaired.
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Amotivation and active substance abuse (escape conditioning) behaviors are (generally) contraindicated for PTSD treatment that involves any kind of exposure or narrative restructuring/rewriting. I didn't make the rules. Behavioral science does.

There is nothing worse than sending someone for an empirically supported treatment (such as PE, CPT) who then concludes is BS cause "it didn't work" when in actuality....they weren't ready to actually address it, actively abusing substances, etc. It makes them adverse and skeptical about future treatment. You don't send people for treatment they aren't ready for. Use MI or whatever else...but please don't enable their beliefs and behaviors or work against their recovery and self-efficacy.

Your patients may need MI, SUDs treatment (both?), some insight oriented therapy first....more time to think about it? Who knows??? You should not feel "stuck" (even though I understand it is indeed frustrating to work with these types of patients) but rather invested and motivated to work with them (and us) in the spirit of moving them forward toward actual treatment (rather than just symptom maintenance).

Watered down treatment (whoever is at fault) is bad news and doesn't help anyone.

Although it may feel like its just a "anything worth doing is worth doing right" attitude.... their is actually significant behavioral science to back it up in this case.
 
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birchswing said:
In my state, personal fireworks are illegal and people use them anyway at all sorts of crazy hours, even days before the fourth of July. They're a nuisance, especially to people with pets. Everyone should be more courteous to everyone with regard to that.

I can't speak to the avoidance thing generally, but it seems like if it were one set time for the city you could at least prepare however you wanted (wearing earplugs etc.).

I think it's the randomness of it that is probably terrifying to some combat veterans. Not to mention that they go on and on. It's not just the city show (which we also have) but the random firecracker at 2 AM two days later or two days before.

With all of the excess sentimentality and deference that we as Americans tend to have for veterans and the military, I find it annoying that we have to analyze why we can't give one incredibly small tangible thing to veterans who have been in combat. We have to take away one thing some of them ask for because they aren't coping the way we'd like them to. Yet we give them so many false platitudes they don't ask for. Maybe you're technically right that it's enabling. Who cares. As if we ever measured the value of their mental health and life seriously enough against the necessity of sending them into combat to begin with. Why start now with nitpicking how they choose to cope in their own neighborhoods.
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Teaching them to just "not like it (I don't)" versus being terrified of it as if they are in a combat zone is just as much your job as it is mine.

I care about the well-intentioned, but ultimately counter-productive encouragements we say and give to our patients. You should too. This is part of the nuance of working with mental health patients.
 
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erg923 said:
Amotivation and active substance abuse (escape conditioning) behaviors are (generally) contraindicated for PTSD treatment that involves any kind of exposure or narrative restructuring/rewriting. I didn't make the rules. Behavioral science does.

There is nothing worse than sending someone for an empirically supported treatment (such as PE, CPT) who then concludes is BS cause "it didn't work" when in actuality....they weren't ready to actually address it, actively abusing substances, etc. It makes them adverse and skeptical about future treatment. You don't send people for treatment they aren't ready for. Use MI or whatever else...but please don't enable their beliefs and behaviors or work against their recovery and self-efficacy.

Your patients may need MI, SUDs treatment (both?), some insight oriented therapy first....more time to think about it? Who knows??? You should not feel "stuck" (even though I understand it is indeed frustrating to work with these types of patients) but rather invested and motivated to work with them (and us) in the spirit of moving them forward toward actual treatment (rather than symptom maintenance).
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I’m not claiming the evidence based treatments don’t work, I’m saying the trauma therapists we are referring to seem to think it’s beneath them to do even a few session course of the supportive therapy/MI/insight oriented therapy/etc that the traumatized patient may require to build rapport and stability before being able to tolerate PE. I’m not referring a patient to get prolonged exposure, I’m referring them to get psychotherapy to improve their symptoms and it should be on the therapist to meet the patient where they are and use whatever techniques are needed at the moment.

Instead they kick them back to the Med management clinics and I do whatever I can squeeze into my 30 minute monthly appointment.
 
Armadillos said:
I’m not claiming the evidence based treatments don’t work, I’m saying the trauma therapists we are referring to seem to think it’s beneath them to do even a few session course of the supportive therapy/MI/insight oriented therapy/etc that the traumatized patient may require to build rapport and stability before being able to tolerate PE. I’m not referring a patient to get prolonged exposure, I’m referring them to get psychotherapy to improve their symptoms and it should be on the therapist to meet the patient where they are and use whatever techniques are needed at the moment.

Instead they kick them back to the Med management clinics and I do whatever I can squeeze into my 30 minute monthly appointment.
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You, with your expertise in human behavior and mental pathology (just like mine), are/should be referring them for appropriate treatment and should not work against the spirit of this by agreeing that the sound of fireworks needs a trip to the psych ER. This should be addressed in your sessions/meetings. Its not just my job, right? Basic explanations of this disorder's exploratory model should not beneath you. Its the job of any and all mental health professionals working with them.
 
erg923 said:
You, with your expertise in human behavior and mental pathology (just like mine), are/should be referring them for appropriate treatment and should not work against the spirit of this by agreeing that the sound of fireworks needs a trip to the psych ER. This should be addressed in your sessions/meetings. Its not just my job, right? Basic explanations of this disorder's exploratory model should not beneath you. Its the job of any and all mental health professionals working with them.
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You may be mixing up posters here,
I haven’t mentioned the ER at all, that’s just silly.

My concern is I refer severely traumatized patients to the trauma therapists and not infrequently they essentially refuse to treat the patient because the patient’s trauma related symptoms (substance use, avoidance, irritability,etc) are too severe to neatly fit into the inclusion criteria for whatever is the therapist’s favorite therapy modalities. If your claiming to be a trauma therapist you should not only have one hammer in your toolbox.
 
Armadillos said:
You may be mixing up posters here,
I haven’t mentioned the ER at all, that’s just silly.

My concern is I refer severely traumatized patients to the trauma therapists and not infrequently they essentially refuse to treat the patient because the patient’s trauma related symptoms (substance use, avoidance, irritability,etc) are too severe to neatly fit into the inclusion criteria for whatever is the therapist’s favorite therapy modalities. If your claiming to be a trauma therapist you should not only have one hammer in your toolbox.
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Sorry, I may have. And, I agree that some of the trauma therapists you refer to may be overly rigid in their approach to treatment.

I also agree that some degree of flexibility is order. On both sides though.

There are, however, some prerequisites for effective trauma treatment. It is what it is. We all have a role to play in this. And the first step toward making it so...is to eliminate well meaning, but ill-advised/counter-productive advise about psychological wellness.
 
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This reminds me of the recent discussion here about off work notes. Getting to the reason for the aversion or avoidance is so important in all these situations. So many times, we take it at face value that "the patient doesn't want this, therefore it must be harmful to them."

I had an argumentative patient many years ago who was always shaking his fist at the heavens at those meddling teenagers who did x, y, z. He was always trying to get out of jury duty for mental illness, citing some sort of anger problem. I was like, "No way, are you kidding me? You're probably the type of guy who needs to get on a jury and do something proximal about your complaints." I wouldn't sign the form. He's probably been responsible for a million convictions...
 
I appreciate the sentiment but not the sign because it furthers stereotypes.

The sign says “combat veteran” but uses it synonymously with “PTSD.” Most combat vets do not have PTSD.

These things further stereotypes that are unhealthy and obstacles to care for many veterans. In my military role, the hardest thing to getting vets to seek care at the VA is the stereotypes and the coddling. This kind of thing furthers it.

Any given Fourth of July, you’ll have more vets at the parade than avoiding it because it’s triggering.
 
Armadillos said:
Joking aside, my biggest issue with the psychologists we most frequently refer to for trauma in our systems is that 50%+ of the patients get bounced back for “not being invested enough” in exposure therapy, having a couple no shows, drinking too much, etc. So ends up the psychologists are mostly treating the patients who are already sober and well enough to show up 2hrs every single week and we are stuck taking care the folks who are most significantly impaired.
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Sounds like they should have followed protocol and treated the substance use first.
 
WisNeuro said:
Sounds like they should have followed protocol and treated the substance use first.
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Lest some our less experienced members get the wrong idea, there is an incorrect assumption that SUD and PTSD need to be treated sequentially and that you can’t treat them concurrently. This idea is out-of-date and leads to prolonged suffering.

Even at the VA. See the following:
www.ptsd.va.gov

VA.gov | Veterans Affairs

Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more.
www.ptsd.va.gov www.ptsd.va.gov

Not agreeing with some of the characterizations of my psychologist colleagues bouncing back therapy referrals because of some substance use. Not my experience, neither when I’m the referring prescriber nor the psychotherapist.

You need a degree of stability (both in terms of PTSD and SUD) before you should be referring someone to PE or CPT, but you can manage both issues concurrently.
 
It can definitely be treated concurrently.....if you have the right resources........and they're willing to enter into SUD treatment. But, in an individual who is currently abusing a substance, with no plans to stop, will likely not do well in PTSD treatments. The VA itself acknowledges much poorer treatment outcomes, even in those who will engage in both treatments.
 
Totally agree. I just bristled at the idea of “treat the substance abuse first” without clarifying. It’s a stereotype that students and residents internalize.

We have a lot of vets get PTSD treatment later than they should because folks do t understand that both can be treated concurrently. The VA even has standalone clinics with good results doing just that (e.g., SUPT).
 
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