Strong on the field right now, and i hope it regains the healthy once had the health it once had off the field as well. To our panelists, thank you for joining us. To those of you who followed us online and on television, thank you. We bid you good night from washington, d. C. Any of the bigd 12 discussion on College Sports and athletes, will have an encore presentation tonight at 8 00 eastern here on cspan, or watch any time online. Search big 12 at www. Cspan. Org. Next, exploring early attempts to treat posttraumatic stress disorder or ptsd in soldiers. Former ap reporter talks about her own experience with ptsd after a 2006 car bombing in iraq. Speakers include the Huffington Post senior military correspondent and a kernel with the armys health service. Dickinson college in pennsylvania hosted this event. This is about an hour and 23 minutes. Good evening. A student project manager at the clark forum for contemporary issues at Dickinson College. On behalf of the clark forum and Dickinson College, i would like to welcome you to tonights event, ptsd a Panel Discussion. Decade,ast posttraumatic stress disorder has come to the forefront of national discussion, in part because of its prevalence of veterans in the wars in iraq and afghanistan. Ptsd, however, is not a new medical condition. It was observed in soldiers from the world wars, although it was called shell shock at the time. Only affects not soldiers. Anyone who has entered a traumatic event can experience the nightmares, anxiety, flashbacks, and difficulty sleeping that characterize this disorder. Tonight, we have experts in several fields who all have different perspectives on ptsd. Theerly dozier, currently, chair for strategic leadership, has firsthand experience with ptsd. In 2000 six, while reporting for cbs news and iraq, she was severely injured in a car bombing that killed members of her crew and their military escorts. She wrote a book about the experience and her recovery. Rocess wendy moffat is a professor of. Nglish at Dickinson College currently, she is researching and writing a biography on a psychiatrist and war correspondent, both of whom were engaged in the events of the First World War. Colonel Rebecca Porter is currently the commander of the dunham u. S. Army Health Clinic at the carlisle barracks. Previously she served as director of Psychological Health for the army and chief of the Behavioral Health division as office of the army surgeon general. She is also a fellow of the American Psychological association and a member of the order of military medical merit. David wood is a senior military correspondent for the Huffington Post. He has worked extensively with American Military units, including a company that went into combat during the iraq and afghanistan wars. He one of Pulitzer Prize for the wounded veterans. At this time, i would like to ask that you silence cell phones and electronic devices. Tonights event will be live tweeted. You can follow along. A question and answer session will follow the Panel Discussion so please hold all questions until then. Because tonights event is televised and available for live streaming, it is imperative that you wait for the microphone before speaking. And now, please join me in welcoming our moderator and Panel Discussion, wendy moffat. [applause] good evening, thank you for coming. On this veterans day. Im going to be talking about one of two of my subjects, dr. Thomas to be a salmon who was the first psychiatrist in any American Army and then early discover and treater of war trauma, particularly Mental Illness amongst the allied American Expeditionary forces in the First World War between 1914 in 1918. He was born in 1876 and died quite young in 1927. His work is very important and the history in the history of understanding this disorder. Even though he was a prescient figure, ptsd would have been an elocution that would have been bewildering. He came at psychiatry from a Public Health perspective, and he began as somebody who was an advocate for Mental Health and the prevention of Mental Illness. Also for training doctors to understand that this is a legitimate form of medicine. This is at a time when people who were incarcerated in institutions where therefore reasons that were not medical illness. Many people who had tertiary syphilis had Mental Illness kinds of symptoms. Many people that chronic alcoholism, people who we would think of is to build mentally developmentally disabled, people with cerebral palsy. A great range of disabilities that made people be marked as sub normal and warehoused way. Initially his work was in the National Community for Mental Hygiene trying to differentiate between the kind of Mental Illness he was confident that could be cured and the kinds that were caused by organic brain injury. This is not easy in the premri time. Allies. That offered him a chance to see not only what was called shell shock, this terrible set of mental disabilities but also the ways in which the allies screwed up the treatment of people who have those problems. He became almost incandescent with anxiety about what was going to happen to the American Expeditionary force. He studied canada, he studied france, he went to great britain. We see him here at the headquarters at his office in 1918. Salmon was a person with a really intense, beautiful, clinical mind. He was quite sympathetic as a doctor of individual people, but he also had a systematic mind and he understood that treating the soldiers was going to be an important and complex matter. This is one of the hospitals in the battle line. You can see that if you sneezed, you could probably knock them down. It says ambulance here on the righthand side. This is some of his doctors. They built these on the fly. Here is the doctor on the side, he sort of towers over people. He was dubbed the nut picker by the rest of the very skeptical u. S. Army medical corps and he was shoehorned into this because he came from a Public Health and private sector place. He literally forced his way and became the only psychiatrist in the army to run this whole enormous setup. What he discovered about traumatic injury, mental injury in particular, was that it was mitigated by treating it immediately. It was mitigated by the process of believing that people could get well. That sounds sort of silly, but it is very true. And it was mitigated by intense activity to help patients right away. What you see is that core of trauma psychiatry now. We call p. I. E. Proximity he devised treatment on his own with other people thinking it through. This is a map from the american front here. This is where the headquarters was. And what he discovered is if you put advance hospitals in the field and train doctors to see people who have these mental symptoms, that you could filter out in a triage system very quickly and get to people when they needed help. If you look here, you can see, here is headquarters. This line, roughly speaking, this is an active front. You see here, 1, 2, 3 advanced neurological hospitals. These are within five or six miles off the front. A very dangerous place to be. Sometimes no more than a tent where the soldiers were taken when they exhibited the signs we associate with ptsd. What is interesting as he going back and forth not only from this headquarters here were we saw him but also to the only dedicated Psychiatric Hospital in the entire army. That is what you were looking at earlier. He is spending a huge amount of time going back and forth and he is bringing the soldiers back who are up at these advanced hospitals if they do not get well within 72 hours. It was a very simple protocol that sounds rather primitive, but it is quite remarkable. The men who come in who were unable to hold a gun, unable to stand up, shaking so hard they cannot stop, catatonic, various other kinds of symptoms, gives them a hot drink and a bed they can lie on by themselves. He is an empiricist, so he watches. They sleep in average of 32 hours after they drink the hot drink. So we may not be talking about ptsd. We may be talking about simple exhaustion, combat fatigue. This is the view from the top of the chateau. The 12th century chateau in france where this was set. They commandeered a ruined chateau and built a hospital which started in the summer of 1918 with three patients and by january 1919, had more than 600. He treated more than 2500 people at that hospital. These are people who got brought back. This is a monastery in the middle of Argonne Forest where some of the tents was set up. Is the one that was the furthest up on that map. You can see that the chateau, the old chateau is sort of norman in its era, and the officers were billeted down at the mayors house down the road. Were looking through the portcullis. Very primitive conditions they lived in. Salmon was a remarkable sketch artist. He was ambidextrous and he did a lot of beautiful sketching of things. This is not very clear. You can see that he is sketching the line. In the left hand side, it says the loon in flames as it goes up and down. We have stood exactly where this is, towards the end of the war. As the allies and americans are pushing up. This is a photograph from the 18th of november, 1918. He was touring around a great deal and he moved around a great deal. At the end of his life, he became very worried and concerned about the treatment of veterans and he advocated for a Veterans Bureau, which is the forerunner in the early 1920s of the v. A. He viewed it as a signal failure of his life that he was unable to get some things that we now think of as absolutely central for Mental Health. Mental Health Parity for veterans, that is that their Mental Health should be treated on a par with their physical health. Destigmatizing people with Mental Illness, the belief that people with Mental Illness, particularly from more trauma could get better, and probably most importantly, that we have to pay for what our veterans need. He was very upset, and he was caught in a huge rats nest of political problems including fighting privatization of military health care. So he feels like a very prescient person to me. I will leave it there. Im sure we will have questions. Thank you. The panelists should come up and sit now. Im the last of the av. This is where we ask you a couple of questions. You do. Im automatically taking the moderator role. [laughter] as i was watching the pictures and thinking, ok, this has always been a problem that is with us. With the work that he was able to do you went to france and had to dig this out of archives. How widespread were the Lessons Learned across the military . There was a lot of resistance within the army at the time, but there is a huge reckoning in the immediate aftermath. In 1920, 1921, and there is a an interest in all the lessons that one could get. There was a huge set of volumes in which they put all their insight and a lot of what he has written is in those. There is a lot of anxiety as the army goes down after the war and there is a lot of this interest disterest disinterest in continuing to fund veterans and military health. It gets dismantled. One of the final ironies was a great deal of his patient records were poked during the vietnam war. They were in san antonio. At the Army Medical Corps archives. He said we knew we had better weapons so we would never have ptsd again and i said youre joking, right . He said not about the pulping. That underscores this is a perennial problem. He would want us to build on the knowledge that we have and not dismantle it in peace time in the hopes we did not have to pay for it. Can you tell us can you hear me . We all need to talk loud. We will all project. I want to know more about the mechanism of moving. There was a lot of befuddlement among military doctors about what caused shellshock. They believed that somehow it was the reverberation of exploding shells that caused this jitteriness. They noticed that a lot of patients who were jittery had never been around shells. What was his understanding . His locution was a war neurosis. In that he is picking up the most advanced of the british doctors. I never heard that word used in that context. What do you mean by his locution . They are trying to frame what is this new iteration of behavior that they are saying and soldiers. Youre right. Many of them have never been subjected to artillery. They are aware that there are mood changes that have been with traumatic brain injuries that might not be the same thing as what we would call ptsd. And so he viewed war neurosis, as a perfectly rational, curable response to the conditions of combat. He remarks that it is a surprise that more soldiers do not have it. He understands it as an unconscious phenomenon. He is aware of for it but uninterested in freudian apparatus of individual ways of developing and psychosexual behavior. He is a pragmatist. He has this idea that the mechanical qualities of the First World War were somehow the instigator of this. It is probable we have had Something Like this in the civil war as well. He saw it as something that was emerging out of modern conditions. We can go way back in history even to see evidence of what we now call ptsd. Even before the First World War. You look at jonathan shays work and the idea that if you read homer you can see some of this. Salmon was interested in making sure that the people are injured get treated and get better. He is not a philosopher of the longterm, but he does notice that they have a huge incidents of this. It is hard to know whether statistics actually bear out but there was a quite low incidence of suicide amongst the people he treated. There was a quite low incidence relative to the brits and the french. He thought that he was empirically Getting Better. Its a debate whether p. I. E. Still works. We still use it. , intensity, expectation of Getting Better psychiatry as they call it. Treating people right at the , front and working them back as they need more treatment. Any military person, the idea of curing soldiers is to get them back in fighting shape. Were not talking about trying to get them out of the army or out of fighting. Were trying to get them so they are whole enough so they can continue combat. I wanted to ask a question that might lead naturally into davids presentation did he have a hierarchy of what caused the worst shellshock . Was it everything from being too close to the explosion to moral injury . He does not differentiate it that way. And maybe that the American Experience was so interested time that is not get to play these things out. What he does do that is interesting is he insists on longitudinal studies of the people who were affected. So there is a survey and a study in 1920 and another in 1924 and if he had not died in a loading a boating accident in 1927, that would have gone straight through. He wanted to followup. He followed them back in the states. He fought hard for nonprivatization of medical facilities and he was furious that the first thing that the Veterans Bureau did to save money was ask all of them, which you like to be in a Mental Hospital or would you like to go home . Theyll said we would like to go home. They said problem evaporated, no need for this. His speeches in the early 1920s are unbelievable, but you will have to read my book to know more. [laughter] what i want to know is what did he find out in those longitudinal studies . The last one was in 1924. Six years after the war. He found that people get better with treatment. That is what he found out. Which means that is what we find in army medicine. We estimate that 80 of soldiers who are treated for ptsd do recover, if they complete the treatment. So many of them do not complete treatment. What ive seen the reason are not looking you is because the mic is over here. Ok. [laughter] what we have seen is 5 to 10 of soldiers will meet the diagnostic criteria for posttraumatic stress disorder. That is a sizable number. As many as 10 to 15 will have other Behavioral Health conditions that require some kind of treatment. What the army has done since 2007 is with some appropriated money from congress, has developed the Behavioral Health service line that coordinates and synchronizes Behavioral Health care delivery into a system that really builds on p. I. E. Proximity, immediacy, and expectation that people will get better. Soldiers, specifically will get better. We have embedded Behavioral Health teams that are right in the brigade combat teams and those are primarily in the garrison. Before they deploy. There are other Behavioral Health aspects that are part of the organization when they deploy. Even in garrison we have these behavioral Health Clinics, specialty clinics that are in the brigade footprint. What we found is that makes it more likely that a soldier will come in and get help. He does not have to get as much time off work. He does not have to get a ride to the hospital. He or she can come right in and see a Behavioral Health professional. But we have done is we aligned those professionals with a specific battalion and brigade, so that if there is a unit that has an exercise coming up or more pointedly, if they had certain experiences while they were deployed, the Behavioral Health professional knows what that experience was and can take that into account and treatment. We find that in those cases, we have fewer risky behaviors and soldiers who have those Behavioral Health teams embedded. We have fewer Psychiatric Hospitalizations. Fewer suicide attempts in those organizations. The Behavioral Health providers grow to have a sense of trust if command team in those organizations so that if they have to share information about the safety of a soldier, that command team will use the information responsibly. Similarly, the commanders and First Sergeants trust that the Behavioral Health providers will let them know if there is a soldier who is in danger. And so it has been, that is the hallmark of this Behavioral Health service line is the embedded Behavioral Health teams that are right there with the units, even in garrison. I dont know if you wanted to [laughter] it is a little bit awkward with the mic over here. Salmon was very worried about the stigma thats associated with seeking treatment. There is still stigma. But embedded Behavioral Health teams, we find, have gone a long way toward addressing that. We had several leaders in the army who have come out and said i have posttraumatic stress disorder or i am in treatment. I have been at different Treatment Facilities where even general officers would come in and say i do not want special treatment. I want to sit in the waiting room so that everybody can see that having some kind of an impact from being in combat is not dependent on your rank. I think that is helping a lot. We still have a ways to go on that as well. There are still the whispers. The moment someone, especially a senior officer admits to having ptsd, there are problems with the next promotion. And then it becomes the issue with the promotion, if we do not promote him or her now that they have admitted to having this issue, if we do not promote them for some other reason, everyone will think it is because of that old stigma. I do not have firsthand experience. With what is said on promotion boards. When carter ham, an amazing general, admitted that he was suffering from posttraumatic stress disorder, people thought he will not get another star. But if he doesnt get another star, we all know we cannot talk about it. When he got the next star, people were like oh, yeah, his detractors. Like every major organization, there is a hierarchy and pecking order and catty mean girls. They were saying, he just got this because now the army has to give it to him. That was one of those issues. David, i do not know how much you were hearing. The hams had me over to europe to speak to their team over there, after i was injured, so i really tracked his career. I think it is the case that if you go seek any kind of Behavioral Health can everyone hear me . Were two down. This doesnt work, so let me know if you cant hear me. I have spent almost my entire career with what i call a workingclass military. Mostly enlisted junior officers, the people that make things happen, get their hands dirty. Among those folks, if you go seek Behavioral Health help, Everybody Knows it and then its like the next time you deploy, you want to take this guy, you know he has been getting treatment. I am not sure if i can depend on him. Better leave him at home. There is that problem, i think. Do you think that is more and i am asking this generally. Is that really the case or is that more and urban myth that that happens . I do not have any data to back this up and i think it is probably half and half. People believe it. Its like the alligators crawling out of new york city subways. Everyone know someone who has seen it. Certainly, there is among the grunts, the workingclass military the fear that if they go seek help, it will somehow impact their career and the impact will not be good. It is a continuing fight. General odierno has been really adamant about this, saying if you have a problem, go to get help. I will guarantee it will not impact your career. I did a thing for the Huffington Post on suicide prevention. We had the first lady, michelle obama, videotape a short for us where she basically said the same thing. I tried to get obama say i am commander in chief i , guarantee you will not suffer. He would not do that. It is a continuing struggle. Im working on a book on resiliency in special operations forces. We will make you talk into this one. First of all, for someone in the seal community, they found the best way to get care to the operators was to send out roving counselors who write nothing down. And they meet them in coffee shops, they do not meet them at the office. Out in the field, what the chaplains do is they buy these amazing coffee makers. There are 2000 espresso machines. Everybody in the camp gets the espresso, and the chaplains door is right there. And the doc is a couple of doors down. That is the way to make it ok. One of the things that mccraven was struggling with was he had managed to fix for the special operators the system where the clearance would not be affected if they admitted to having had posttraumatic stress disorder counseling. All the support when people say zero dark 30, you think of the s. E. A. L. S. If it is 10 people on the mission it is Something Like 200 people supporting them. The intel officers who are working with socom are under fire just as much, having the same issues with combat stress. They could not go get the ptsd counseling because it still would affect their clearance. Their clearance could get pulled. That hasnt been my experience at all. The admiral talked about it quite openly, and he just left command the summer. My research for the past three months and the cia, dia, some of the other have you talked to people who have had their clearance revoked . I talked to special operations officers who worked on rescuing someones career who had gone into the field with them. Went to get counseling, and then had the clearance a large reinvestigation because they had trouble with combat stress. Once you have a reinvestigation, that can derail your whole career. I think its important to differentiate between any issues that would come up from maybe not being able to successfully make it through treatment. Just because someone goes to treatment does not mean their clearance will be revoked, but if they are not successful in getting through treatment and they are not Getting Better, then that might be the reason their clearance gets revoked. Or they have to leave the service. It is not because they sought care. Can i change the subject . We have to move on. Would you explain what is the mechanism of injury of ptsd . How do people get ptsd, what causes it and what are the ramifications . I dont know the neurological reasons. Can i explain . No. [laughter] i want the doc to explain. What is ptsd . Ptsd is typically, it is a normal reaction to a horrific incident. So it could be rape, it could be combat, if you have some fear of losing your life, it is a normal reaction to something terrible like that. As i understand it i was trying to think about ptsd. Have you ever just stumbled and started to fall . The first thing that happens is your face flushes. I thought it was embarrassment, but it is the beginning of that involuntary physical reaction that i think causes ptsd where your body goes, falling, push the panic button. There is this huge physical reaction and adrenaline spurts your muscles, bloodstream, your heart rate goes up, your eyesight improves, you can fight your way through a battle or out of the wreckage of a car wreck. Thats all good. I think the problem comes when you go through this cycle over and over again, as you do in a combat zone. When you come home, that reptilian part of your brain that kicks off the panic button doesnt know you arent home. You are having dinner with your wife in a restaurant, and panic, and all that stuff starts happening. In a war zone its good, in a restaurant or a library or when you are sleeping not so good. The way i understand it is guys have described it to me as either that happens, and when it happens, you have to burn off energy. People get angry, punch walls, they have to burn off that adrenaline that is happening, or they are worried that its going to happen. I know lots of guys who, for example, a guy comes home. The family plans an outing to walmart, its going to be a big deal. The kids are been looking forward to it for weeks. They walk in, and the veteran says i cant do this. Hes afraid hes going to have one of those things happen, and he cant control it, because its involuntary. He says honey, i cant do this. She goes whats wrong, we have been planning this for weeks . They get into an argument, and bad things happen. I dont know if you are familiar with charles hoags book, he talks about the very phenomenon. Whats very adaptive and a combat environment is actually the problem when they come back. They talk about it as that kind of physiological responses being hardwired when it is repeated again and again and again. That is the phenomenon, and one theory about how it comes to be. Can you talk a little bit about the relationship between ptsd and the work you are doing right now . I want to talk about moral injury, which i think in my experience on the is something that is experienced or suffered by almost everybody who goes to war. When i say moral injury, is not in a finger wagging sense that you did something wrong. We are not talking about atrocities. We are also not talking about people who are disabled or broken, or scary, or mass murderers, or anything like that. Heres the thing. This is something i have learned from 35 years of spending 35 years reporting on wars. We all think we are good people. Im a good person. Ok, i dont always live up to it. In fact, most of the time i dont. But its my ideal. I know what good is. When i do good, i feel good. I sort of expect other people to be that way. When we walk out of here tonight, we are not going to expect we will expect it now because im saying it. But we are not going to expect a suicide bomber out there because we are all good people. We expect other people to be good. We expect the world to be good as well. Thats how we grow up. Whatever moral codes we have, do unto others, all this stuff, we learn in church or synagogue or mosque adds into that moral code. Now we go to war, and guess what . Bad stuff happens. It just does. And when that happens, what happens to our picture of ourselves as good people . What happens to our moral foundation . This is kind of a hard concept to grasp. It took me a long time to figure this out. A guy named nick rudolph, its a long story. You can look it up. The taliban are in an adobe farm compound firing at marines that are out there, trying to take cover. At some point, nick sees a guy running around the corner of a building spraying machine gun or ak47 fire at them. He raises is a four carbine, and gets this person in his sights, and realizes its a kid. Blam, killed him dead. And i said what happened . He said i corrected the weapon and went on chasing the taliban. He didnt have time to think about it. Heres the thing about that story, in that moment, in afghanistan killing that person , was the tactically right thing thing to do the legally right , thing to do, and the morally right thing to do. Because tactically, he is the enemy. He is firing at you. You are a marine, you take him out. Thats war. Legally, because you know, i dont know. Legally, im not sure. Lets skip over that part. But morally president obama and , president bush before him had declared that these are these are just wars. Killing the enemy is fine. You can do that and its fine. Nick did the right thing. He comes home, and he killed a child. He killed a child. There is no way around that. So how does he think of himself now, that good person who went off to war and did a bad thing . Do good people kill children . Not really. So thats a moral injury. I picked a dramatic example, because its fairly easy to understand. We can all put ourselves in that situation. And so i think the people who experience moral injury like that range from pretty serious stuff to i just kind of feel bad. I know a lot of people, for example, who signed up, got into the military, went to iraq or afghanistan, not to kill the enemy, but to do good. Those werent wars of battlefield victories, although there was a lot of fighting, needless to say. But the point of being there was that we were helping people. So i know a chaplain who went to iraq, for that very purpose. We are going to go help people. He realized halfway through his yearlong tour, not only are we not helping people, but we are destroying stuff. People are getting killed, and they hate us. His belief in god went to zero. This is a chaplain. He got them back after a couple of years, but that was a moral injury. The reason why i came here tonight was because i was invited, thank you very much. But heres the important thing. What is our part in moral injury of our troops . Its kind of a difficult question. We send kids like that off to war. We dont tell them bad stuff is going to happen. We dont tell them that. We dont even tell ourselves. Were like hurrah, lets go to war. Invaded iraq, lets do it. If we dont tell ourselves and the people we send the bad stuff is going to happen, and its inevitable, and you will suffer. On this veterans day, i hope that we can take a minute to say to ourselves war is bad. Sometimes we have to do it. I get that. But war does bad things to people. We need to be honest about that. We need to listen to our veterans. Find a way to listen to their stories in a validating way. And by validating, i mean this is something i learned from therapists. Very few therapists who are working with people with moral injury. Dont say to nick rudolph well, you killed a child, but you did not mean to, it was not your fault. Dont worry about it. It is ok dont worry about it. ,no. He does worry about it. You cant undo that. Listening in a validating way means yet, that was fucked up. Lets just put it out there. But it doesnt have to define you for the rest of your life. That sounds like a segway to ue to kims story. For those who arent familiar with my story, i was a cbs news correspondent for a number of years based in jerusalem. From 2001 to 2003, and i moved over to iraq from 2003 to 2006. I get hit by a car bomb. I was told by the doctors and the psychologist who was treating me at the time that, much to my surprise, though i had many of the symptoms you all associate with ptsd, i never had ptsd. I had posttraumatic stress. The practitioners who were treating me at the time defined as everything from hypervigilance, flashbacks, anxiety a grab bag of nightmares, that only lasted four to six weeks, and it didnt interfere with my daily life after that time. Therefore, it was not the disorder. Is that still the way it is defined . I had pts. And pts became the phrase they use to describe what you have processed your pain and moved beyond it posttraumatic growth. I try to use that phrase. It defined the 80 of people you were saying move on from there posttraumatic stress or combat stress experience. Just to give you an idea of what its like to be in the middle of it, the first time it happened was a Common Campaign against the israelis, and i lived in israel. This was after the israelis had encircled the town. You can get into who started what, but what it amounted to for me was i was either driving into the west bank to report on demonstrations, or it was i was driving around jerusalem at highways at top speed to get to a suicide bomb that had just gone off. I got very good at identifying which one the bomber was amongst all the dead bodies. It was usually the one with the bare rib cage and the head was popped off, because thats what a suicide bombing vest does to a body. After a couple of years of this and we counted once, out of 60 suicide bombings, we had gotten to more than 30 of them. My cameraman and i had. I developed a survival skill of hypervigilance. You didnt go anywhere in israel without thinking if you are going to a cafe, there is always a chokepoint of the door, where they checked your bags. That is often where the suicide bombers would try to move in and blow themselves up amongst the line people waiting for their backs to get checked. Once you got past that chokepoint and into the safety of the restaurant, then i start replaying all of the bomb scenes in my head. Ok, if the bomb goes off outside of the building, the plate glass windows will come flying this way. Ok, im going to choose that table there, because its behind a large supporting column. Or if there is no column to hide behind, im at least going to sit with my back facing the door so the glass wont hit my face, it will just hit the back of my neck. That was my reality way before i got into iraq. Then in iraq the first six , months was a rebuilding mission. It was pretty safe. The Insurgency Campaign began. It started with an attack on a u. N. Compound, and then they hit the Jordanian Embassy and the red cross. Then they started hitting small hotels with foreigners in them that were not very well protected. After you have covered a few of those and you know what a car bomb can do to a small, poorly built hotel, it basically sheers off half of the hotel. You are looking 50 feet into the back half of the place. I would go back to my own small hotel, poorly defended, we watched the guards outside regularly let in their brother without looking in the back of a car, and park right beneath our window. And then i would try to go to sleep. As you can imagine, sleep wasnt easy after a bit worried. Some nights i ended up sleeping in a bathtub. I later found out Richard Engle and a few other people were doing the same thing. You have all these crazy bargains with yourself. I just need a few hours sleep. I learned i could handle it for about three to four weeks until all of my symptoms of hypervigilance so intensely interfered with my ability to work that i wasnt functional anymore. I could barely do a live shot. I couldnt string my thoughts together. I hadnt have enough sleep. I was freaked out all the time. Thats how i developed over the threeyear period that i was there before i left rather unwillingly. I would be in four to six weeks for the symptoms would get so bad that i was not functioning. I would start snapping at everyone. And our staff would do the same thing. I would go out, it would take me about two weeks to down regulate is the phrase i have heard used in clinical settings. It means to me that i got my adrenaline back in order. 2006, my team was out with a Fourth Infantry Division patrol and we got hit by a car bomb. Got ambushed. It killed the captain and the translator, killed my camera crew. I woke up in a Regional Medical center in pretty horrible pain, with shattered femurs, earr drums blown out, they had done a craniotomy and taken shrapnel out of my brain. I had burns from my hips to my ankles. They kept taking me in and out of surgery to debris the rest of the dead flesh. They do that with a firehose, im glad i was under for that. It was a painful experience, and i really wanted to get back to the states. I thought once i got from germany to the states, things would get better. That is when i started getting hit i the posttraumatic stress. When i took the ambulance ride with all the other wounded to from the hospital to the base, irammstein air was convinced that every car riding around us on this unit beautiful road was a suicide bomber bent on blowing us up. I was shrieking away from the shrinking away from the window, terrified, until we got to the plane. Once i got to bethesda, i had nightmares, flashbacks where i would feel the force of the bomb throwing me forward in the bed, and i would come to in the hospital bed, unable to move. And i wanted to talk about the bombing. Because i had a brain injury, my doctors had an internal fight. The majority opinion was i should not talk about the bombing. I did not careful stop everybody who walks through the door, i would start telling them what i could remember. I had a desperate need to remember everything from the scene. Finally about two weeks in, a psychotherapist on his reserve duty came in and said, i hear you are the patient who will not shut up. I will work with you if you really want, but i normally work with marines, so i swear a lot. You good with that . And i am like yeah. And one more thing, i can tell already tell you are a talker, so occasionally i will tell you to shut up. That is how i ended up talking with him every day about he would come and stay for an hour and just what you were talking about in that very first experiment or series of patients that the doctor treated back in world war i, treating them immediately and the prospect of getting well, those were the things that i instinctively went for and needed. I had a doctor who came in and said, a psychologist who said, trust your instinct. You want to talk about it, talk about it, and if we trust our instincts, you will be fine. Keep talking until you do not need to talk anymore. What i found was and it is apparently common for a lot of folks i needed to have this illusion of control over the bombing by figuring out exactly what happened. I spent the next year and a half actually trying to track down everyone who had been there, and one of the most reassuring things in the process was when i found a powerpoint of the bomb scene with where everyone was laying, and that confirmed to me that my memories of where i was laying and who was treating me and who was talking to me, that i had it all right, and it was very reassuring. So after about five weeks in, my nightmare stopped, my hypervigilance stopped, i stopped being afraid. That the mill cart was going to blow up still did not like the food. And that faded. What did not fade was survivors guilt and grief. I had lost my guys. I had never expected to lose someone in the field. When i found out that the families were all furious with me, the families of the dead soldiers, the families of the cameraman and the soundman, i blamed myself, too. The other thing i found was one of the things in the stages of grief, that grief afterwards is you find someone to blame, and in my case it was me. Finally, what released me from that was bob woodruff had been hit four months to the day before i had, the abc news correspondent. He came in to see me. No, no, we talked on the phone, because he was still in his recovery because. It had hit him in the head. Head. Mb had hit him on a he said, look, paul, james i understand you feel bad that you have lost them. Paul douglas and james brolin. Those guys on the team. Those guys chose where they went, when they went, why they went. If you try to take responsibility for them being there that day, you are dishonoring their memory. You did not order them to be there. I found that became one of these lifelines that i realized he was right, and so but i still, every memorial day, i basically go into a fog because it that is when we were hit, memorial day. Now i know, ok, i am just going to have to check out for the next three days. I am going to be miserable, depressed, i am going to be asking myself why am i still here and two amazing professionals who had survived so many wars and had families and children, why are they gone, and then i will try to keep it paying it forward when this holiday is past. I got past all that. The hardest part was coming out of it to find that no matter how far along i thought i was, that the American Public that i met on the street when i got out of the hospital would not let me out of the injured box. Everyone thought i was a walking ptsd time bomb, because of what they had seen in hollywood, because of the stories the media have putn the media out. We did this yeomans effort of trying to teach the public that there were people within the military who needed help from their war injuries, and yet we somehow tarred the whole force with that brush. I have shared this a few times with the other folks who would come back from overseas, and there was only like knowing nods around the room, including in a special operations committee. One Sergeant Major who had been everywhere from mogadishu to all the worst places across afghanistan and iraq no matter how many times i tell my mom i do not have ptsd, she does not believe me. So the hard part is that becomes a selffulfilling prophecy. If you are experiencing bad symptoms of posttraumatic stress and youre not that over talkative news correspondent in her 40s from the oprah generation, are you going to seek help like i did . Are you going to fight through that wall . That is what im worrying about that we are putting this message out there that with that very traumatic and evocative poster for tonights event, that is not an image of someone you want to be. It is a guy like this i want people to see the posttraumatic growth part so they know there is an endpoint to shoot for. We have to shift from wow , everybody is broken, to there is some people, 10 , 8 , who have something that may always be with them. And there is a larger part of the bell curve of people who will take this experience, make it part of their wisdom, their resilience, their life story, and they will be able to share these lessons to help people through every other hard thing in life. I think we want some time for your questions, and that seems like an opening to your questions. We will begin the q a. If you have a question, please raise your hand. Wait for jason to bring you the microphone. The microphone is traveling across the room. What are any thoughts on the higher rates of posttraumatic stress, or posttraumatic stress disorder from urban combat and jungle combat versus, say, the open plain or open field . The Jonathan Chase book, he talked about the constant adrenaline, not just the cycle, the constant adrenaline that has to come from having to be vigilant in a jungle environment where you cant ever see, and i expect that would be similar in a city environment, that that creates a greater reaction. What are your thoughts on that . I think i think david was going to talk about yeah, i just wanted to validate what you were saying. In both iraq and afghanistan, i think the majority of firefights , which i witnessed were one way, which was a sniper would open up, there would be an ambush, or there would be an ied that would go off for a car bomb, and then there would be nobody should back at. It just makes guys and when i say guys, i so mean men and women it makes guys go berserk. I was with a Marine Battalion once, and we were hunkered down in this farm compound, and somebody shot an rpg, and it exploded in amongst us. Nobody was hurt. Man, you shouldve seen those marines boil up out of there, finally, we get to fight back, but we looked out there, and it was absolutely quiet, nobody out there. There was such a huge amount of frustration, and that happens day after day after day after day after day, and, you know, which explains some of the incredible violence of the firefights when they do find an enemy and they just go after them tooth and nail. I think that adds up to a pretty significant psychological burden after a while. I know jonathan has talked about that in relation to vietnam, and you can find that goes way, way back. This is not new stuff. These wars in particular, because the enemy has been so elusive, have been particularly hard psychologically. Hi. Based on what you were saying about pts versus ptsd, do you think the difference comes from the treatment, the immediate treatment, like what you received, or was it more derived from the actual incidents that cause it . As it was explained to me, it is all posttraumatic stress, but only gets diagnosed as a disorder if it interferes with your daily life, and that is generally after four to six weeks. If it still keeps going. And typically, the post part of it, when you are talking about the disorder, has to do with the arrival of symptoms. It may not be immediate. It may be months or years down the road before you actually start to have symptoms. What you had was probably more accurately called acute stress, but because it was immediate. Do you feel better . [laughter] and that is actually what i was thinking, so much of the semantics of this are almost irrelevant to the person who is going through it, and really for a lot of the treatment as well. We have Clinical Practice Guidelines to tell us one of the best treatments. The evidence tells us what of the best treatments for the ptsd we do not have that for acute stress or combat and operational stress reaction. We do not have that necessarily. It does not mean you cannot pool from those other aspects. Wait a minute. You do not have a way to treat stress . I did not say that. I misunderstood. We have Clinical Practice Guidelines that the v. A. And the dod published that tell us based on the evidence what are the three best ways to treat ptsd. And what are the three . Prolonged exposure and i guess that is what i naturally did. Prolonged exposure. I mustve naturally going over and over and over the incident. There is cognitive processing therapy, and there is another therapy called emdr are you familiar with it . Eye movement, desensitization i always forget the r. What is strange about this is that two of those three are didgs that salmon instinctively. Yes. People ask about what his methods were, even in the absence of these particular notes. He worked individually with people. He was patient with them and stayed up all night talking to them, if that is how long it needed to be. He listened to people talking about their fears, their experience, and he did not think it was magic, but it was very humane, and one of the things that is frustrating to us now is that medical systems are delivered in 50minute increments or we do not have enough time to follow through with somebody, and this is true in military life that it is going to take as much as it takes to do that. Just in terms of the social compact, we have to be willing to pay for what it costs to do the wars, and that is really what salmon was about, anticipating this huge Mental Health crisis that he saw in the wake of the First World War and insisting that it be something that was painful. Could you give us a quick dick and jane of what the quick Rapid Eye Movement thing is . I will not explain the mechanism of it, but it is a process that uses you may be able to explain better than i can but it is a way and people have to be trained how to do it on top of having a ph. D. In clinical psychology, it is an additional training. You get a person to focus on my hand, how it is going back and forth like this, there is something that happens while they are doing that and talking about the event that seems remember, i mentioned the hardwiring earlier theres something about that that seems to break that so they are able to process the event better. So by having the eye follow something going back and forth, it must be activating the left and the right side of the brain. I do not know, and im not sure that anybody who knows exactly what the mechanism is. But what the Research Tells Us is that there is evidence that it works. We have a question from an alum who is watching by way of live streaming. Are there differences in ptsd between male and female soldiers, and do they cope with it differently, and are their symptoms similar . The diagnostic criteria are the same for men and women. An individual might have a different constellation of the symptoms, that diagnostic criteria are the same for men and women. I think women are more likely to have a concomitant depression within it than men are, but that is only speaking very generally. Between individuals, i do not think you can specifically say there are differences between the genders. Care of individuals who are suspected of having ptsd cannot do they have an eagerness to immerse themselves in war, because you talked about hypervigilance of anxiety and fear. You cannot act that way in a walmart. Do they want to go back to work so bad, or any sort of violence, so they are acting normally so they are feeling more comfortable . It is more accurate to say they are feeling more couple back in a combat environment. It is not that they want to be engaged in combat, but they feel more at home in that environment oftentimes, is what i have heard. My experience i know guys who only feel comfortable in combat. I have to say that some of the reasons we like to go back to a combat zone is not particularly the combat, the people you are with and the shared mission, which is very hard to find stateside. There is the sense when you are overseas whether you are in a news crew or diplomats were soldiers that there is this shared mission that you need each other for your survival, and theres almost nothing like that back in the states that i know of. And so a lot of people really miss that, and then they get here where most people go from their jobs to the grocery store, home to the dvr, and they do not have much interaction, and they miss when you are living with 11 other people and they knew your business and you knew theirs. It is more than that. People in combat units develop love for each other. I think that is not too strong a word, all do not use it, the idea that they are for your body, the first day at boot camp our basic training, and that becomes a shared moral value, and they are bound to each other and closer to each other in many ways than they are to their wives or parents or children. And when they come home and get out of the military, bang, they lose everyone they love, and so veterans are Walking Around with a lot of grief and sense of loss, and that adds to their difficulty, whether ptsd or other injuries. I know folks who have gone back knowing they have pts or ptsd and should not go back, but hey got to go back with the team. Hi. I want to thank you for putting this all together. So exciting, especially your research. I am learning a lot, but i want to thank all. My soninlaw was in tikrit in the Fourth Infantry Division. He came home well. He has no problems. But his wife, my daughter, had problems, especially with postpartum depression. In the army war college, i had to take her there from missouri. That was at the beginning of the war. I have a strong passion for mental wellness. There is an International Program that is called metal Health First Aid. Have you heard of it . I left you some papers here because i am so excited about it. I was one of the first hundred trained in the country, and that was in 2008. I could not get my daughter help. She had a brandnew baby, a war hero, and nobody gave her help. She was probably one of the first that used telemedicine with the war college psychiatrist. My question is, you do not know about Mental Health first aid, but i hear you saying listening is very important. Support when you get home is very important. Mental Health First Aid is international, and there is now mental military members, and their families, modules, and the whole aspect of Mental Health first aid do you feel if people here at home could help someone who know someone like you because you came out and who helped you i think you misunderstand me. I received great help within the hospital when i asked for it, and i continue to ask for it. And now what you have is a resource of some of these veterans who have come back, and have 80 have incorporated the posttraumatic stress or combat experience, and what they have was for them to offer all of us. Right. And that is the message that needs to get out. I know you are about them having the wisdom because of going through. To get well, you need to have people who have support systems for you. If we do not have them for people and their families, if the husband does not know how to help the wife to us come back with ptsd, im asking you if you think if we and our country can do a better job of helping our military veterans, for active military service people, get well from their issues that they have because they went on and suffered for us, for our freedom. Is there more that we can do to help them to get well, or do we have to let the professionals do their job . Yes, we can do more. Well, it is such a huge subject. Hello. It is such a huge subject, and i do not think me a time to go into it tonight. We have to talk afterwards. I really feel strongly that it is everybodys responsibility to be part of the solution, and i understand what you were saying of about you getting great professional help. The Mental Health care that the government provides is absolutely superb, the best that there is, but it cannot possibly be enough. At some point, veterans come home and get back into our communities, we need to be in touch with them, and im reluctant to say we can help them, because i do not know if we are smart enough to do that, but we can certainly welcome them back. I am so worried i do not want people leaving this forum, thinking, oh, those poor veterans, they have things to share with us, they have wisdom and experience and this sense of building a team. That is not really so for resonant in our population back here. It is great to be willing to help them, but i would like people to look at them with a preset notion that they are one of the 80 who is more resilient than the rest of us, and they can be leaders as opposed to people we need to pick up off the ground. Because also, those who are out there who are still struggling, if they know that is the vision of what they can be and what their country thinks they are, they are going to reach out to do the hard work to become that. We have time for two more questions. Two more hands. Thank you. I think ptsd by its nature is a very physical Mental Illness. I was just curious what you think might be an effective treatment approach for the more physical symptoms. There was discussion about the adrenaline rush that kicks in automatically. Well, i am not a psychiatrist, so i do not have an m. D. I know the army tries not to use as a way to decrease that hyperarousal. We try not to use that because there is the possibility of potential to become addicted to it. What we typically do in addition to the therapies that i mentioned earlier would be to teach someone how to do relaxation, deep breathing, to regulate their physiological arousal. Anyone can download the app on their smartphone, and you can listen to it as you are Walking Around but not driving. Not driving. Im a vietnam veteran. I was a medic in vietnam. I met my wife there, who was a combat nurse, and we both have been diagnosed with ptsd. [indiscernible] nurses were not exposed to combat. My wife, one of the most highly decorated nurses who served in vietnam the question i have is, i have interacted with a lot of people in the medical area, who did not develop the symptoms for 10, 15 years. We had each other. She wanted to go back to vietnam. I did not want to go back. She volunteered to go back. I did not. [indiscernible] the v. A. Has sent her to all different in the united states, being tested for ptsd, and no one has been successful in treating her for ptsd. A lot of people i work with, doctors, nurses, saying they said the reason it is different now in iraq and afghanistan, they went over there as units and came back as units, so they supported each other. In vietnam, you fly there one day, you fly back, and you were saying that 80 of the people with ptsd get better. Is that correct . 80 of the people who go through a complete course of treatment. Were not talking about world war ii, korea. [indiscernible] v. A. Hospital, and if we did not have each other i think we are in a unique situation. The most important thing that i am looking at recently is ptsd and developing dementia. Last two years or three years, there was one study, of 200,000 veterans, with ptsd showed that there is a twofold chance of developing dementia later in life. I would like you to address that. Is there anything being done about that now . You want to know if there is anything being done for veterans who may develop mentioned [indiscernible] studies out