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Working as a therapist near a Seattle-area military base, Sebastian Perumbilly saw many post-9/11 veterans struggling to readjust to civilian life. Traumatized by their combat experiences, they often complained of nightmares, insomnia and depression. Some self-medicated with alcohol or illegal drugs.

At the time, Perumbilly treated them for post-traumatic stress disorder, like most clinicians would have back in 2010. But today he believes some may have been suffering from a different post-combat condition: “moral injury.”

Recognized by clinicians only recently, “moral injury” occurs when soldiers do or witness something in combat that violates their own values or society’s moral code. While many symptoms overlap with PTSD, veterans suffering from “moral injury” also experience deep feelings of shame, guilt and remorse.

“A part of you dies. That’s what these veterans tell us,” said Perumbilly, now assistant professor of marriage and family therapy at Southern. “They don’t want to do certain things, but they are forced to,” causing a crisis of conscience. He said traditional mental health tools, such as psychotherapy and medication, do not heal these deeper wounds.

Perumbilly recalls one post-9/11 veteran he met in Seattle who complained of devastating nightmares. The veteran was haunted by memories of running over three Iraqi children who formed a human barricade in front of his military vehicle, blocking its path.

“He killed all three of them, but at the same time he had three kids back home almost the same age – 11, 9 and 7,” Perumbilly recalled. “He said each time he went to sleep, these kids were screaming in his head.”

He now cites the veteran as a textbook example of moral injury. Even though he was trained to act the way he did based on the military’s rules of engagement, Perumbilly said, he felt enormous guilt as a father and human being.

“While you are in combat, the rules of engagement are different (from the rules of society).When you are out in the field, you don’t know what’s waiting for you. You have to kill or be killed,” Perumbilly said. “But still it affects you when you come back.”

Perumbilly first learned about moral injury while looking into the high rate of suicide among post-9/11 veterans. An estimated 20 veterans per day die by suicide in the U.S., according to a 2014 study by the Department of Veterans Affairs.

Working under a grant with Valerie Dripchak, professor of social work at Southern, he set out to learn more about the phenomenon. His research led him to Edward Tick, Ph.D., one of the nation’s leading experts on moral injury and founder of Soldier’s Heart, a program that promotes “spiritual and holistic” healing.

Last November and December, Perumbilly spent two weeks in Vietnam with Tick and a group of Vietnam veterans on a “reconciliation journey.” The idea was to return to the place where the injury occurred so the soldiers, now in their 60s and 70s, could make peace with their past. Two post-9/11 veterans also made the trip.

One veteran wanted to go back to the Mekong Delta, where he recalled killing “anything that moved” in a firefight. Another, a Mennonite gardener, told how he was ordered to drive a truck through a rice paddy in an act of destruction, over the cries of Vietnamese women and children.

“We went back to the same exact spot. He removed his shoes and walked through the rice paddy,” said Perumbilly, who was there as an observer and researcher. “It was a very powerful, deeply spiritual, moving experience.”

The vets also met with former Viet Cong soldiers, and were surprised – and relieved– at the welcome they received and to learn the country has moved on.  Perumbilly has kept in touch with the veterans, who told him the trip did more for them than decades of treatment for PTSD. He hopes to share the lessons he learned with the future therapists he teaches at Southern.

“The conventional wisdom we have in psychology and mental health is not sufficient to treat this population,” he said. “They’re in a different world.”

 

 

While the heartwarming images of soldiers happily returning home into the loving arms of their families after years of service are ingrained in the American consciousness, the transition back to civilian life is often filled with unanticipated challenges.

The integration back into society – family life, the workplace, school – can be a bit of a bumpy road, especially for those who have been away for many years. It is even more difficult for those veterans who must contend with post-traumatic stress disorder (PTSD), as well as those suffering from depression, anxiety, and even thoughts of suicide.

As part of an effort to assist in this transition, the Family Clinic at Southern has created a program called, “A Soldier’s Home Project.” It involves free therapy services to active duty soldiers, veterans and their families. A range of services are available, including those focusing on healthy living after and during deployment, relationship building, PTSD, parenting during and after deployment, mindful living, emotional regulation, anxiety, suicide prevention, and grief and loss. Family members may participate in services even if their soldier is deployed or cannot attend. Group and individual sessions are available.

“Our soldiers and veterans have given so much to their country, and this is one way in which we can help them,” said Julie Liefeld, clinic director. “And we also want to assist families who are affected, as well.”

Liefeld, who also serves as director of the SCSU Marriage and Family Therapy program, said that PTSD is not unusual among those who have served in the military, especially in combat. Certain triggers – which vary from person to person – can spark a PTSD incident. She said that in some individuals, it can be the skidding sound of wheels while driving, or a truck that jackknifes and mimics a gunshot sound. In others, it might be a certain smell, or even the sight of garbage on the road.

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The limbic system, a part of the brain that regulates the fight-or-flight function, is responsible for an individual remembering certain sounds, sights or actions and translating them into danger signals, Liefeld explained.
She also said that while soldiers who are deployed are hypervigilant out of necessity, it takes time to adjust to the more laid back civilian lifestyle. “It’s not like flipping a switch in which people can just turn it off right away, especially for veterans who were deployed for a long period of time,” Liefeld said.

“We even see it in the classroom,” she said. “For example, some veterans want to make sure their backs are not to the door.”

She said that even if being hypervigilant does not create an immediate problem, it can lead to depression when sustained for too long.

Liefeld has worked on establishing this new program with Jack Mordente, SCSU’s coordinator of veterans’ and military affairs.

“Veterans are never going to forget their experience, but this program will help them come to terms with it,” said Mordente, a veteran who served during the Vietnam War era. “It will give them and/or their families another form of support.”

Mordente stressed that the lives of spouses and children of veterans also are affected by deployment and returning from combat. “The dynamics of family life change, so it’s an adjustment for them, too,” he said. “The Family Clinic here at Southern wants to reach out to the families, as well, and that’s very important.”
The Family Clinic is staffed by faculty in the SCSU Marriage and Family Therapy program, as well as many advanced graduate students.

SCSU also offers a variety of services for veterans, including a Drop-In Center, and the university Veterans’ Association.

(For further information about the “A Soldier’s Home Clinic” program, or to make an appointment, call the clinic at 203-392-6413.)