Wednesday, July 22, 2015

Into War with an Empty Gun: The Story of a Korean Veteran

I had the great pleasure to interview Robert “Bob” Brownbridge. I had first met Bob at a meeting held by the Boise City Police Department concerning the development of a resource manual that would be geared specifically towards helping veterans in any stage of life or circumstance. This resource manual would be a complete set of resources identifying various agencies and individuals throughout the local community that could be readily used by local agencies and law enforcement officers when they came into contact with them.
            Bob was immediately drawn to the fact that I had retired from the military and had started my graduate program in Social Work with the hope to help veterans after graduation. He had received his master’s degree in Social Work from UC Berkeley, where he was the founder and first editor of the Berkley Journal of Social Welfare. Bob lived in the bay area until 2009 and worked for over forty years as a psychotherapist and community organizer. Bob confided in me that since he had moved to Boise he began to see the need for a community outreach program specifically for veterans that would be sponsored by the local religious organizations. He had the idea but did not know how to bring this all together. We soon began to meet regularly speaking about our drive to help others and he has since been a friend and a mentor for me. When I started this assignment I could not think of a better person to write about than Bob Brownbridge.
Narrative
            Bob Brownbridge was born in Cedar Rapids, Iowa in 1930. A small rural town of 60,000 people spread out over various plots of land in which “neighbors would rely on each other for everything” (Brownbridge, 2013). Bob describes the culture as “farm town mid-western values in which hard work, integrity and faith was vital for the survival and social existence of the families” (Brownbridge, 2013). Because his family worked the land he was instilled with work ethic that revolved around hard back breaking work. The emphasis on education was down played because you did not need college to farm. When asked about how the rural world has changed Bob replied that the “small town farmer is gone, but there is still the core beliefs that I was brought up with” (Brownbridge, 2013). One of the biggest changes he has seen over the years is a decline in the value of hard work; instead people now rely on technology.
            Bob described his family as very close and church orientated, but there was an underlying cynicism that began to evolve in front of him. At age eight Bob began to see a hypocritical side of his family and this revelation would foster a desire to leave them and Iowa. He describes his family as secretly critical of outsiders and those who were of different cultures and ethnicities. They would not confront or say prejudicial things in front of others but when it was just the family they would talk about the “blacks and the Jews” as so different they could not be classified as a human. He began to withdraw from his family and started to cultivate his creative talents. He loved to write poetry, read books and paint, but this was frowned upon by his family because as he described it “it was looked at as individuality and in our small town and especially in my family if you were not part of the norm then you were different and different did not survive” (Brownbridge, 2013)
            There were two influential people in his life, the first being his aunt. She was a woman who had been all over the world, who had many boyfriends, and who would tell Bob about the fast paced life of a woman neither committed to anything or anyone. She was candid with him and would tell him of lovers and parties she would attend in places like Paris and Honolulu. He wished that he could just leave with her and get away from Iowa. He likened it to the 1958 movie Auntie Mame “Mame is an unconventional individualist socialite from the roaring 20's. When her brother dies, she is forced to raise her nephew Patrick. However, Patrick's father has designated an executor to his will to protect the boy from absorbing too much of Mame's rather unconventional perspective. Patrick and Mame become devoted to each other in spite of this restriction, and together journey through Patrick's childhood and the great depression, amidst some rather zany adventures.” (Thompson, 2013) He confided that he wished that she could have been his mother. The second person was his grandfather, who Bob was “ordered” by his mother and father to not like. He described his grandfather as good at everything, he was a huge man who had played minor league baseball, was a master craftsman and was known around town as a womanizer. Bob described a man that was not afraid of anything and would not back down from a fight and could drink with boys. Having been told to not like him made Bob like him even more and he began to set his sights as far outside Iowa as he could. At 12 years old he remembers his mother commenting “I just don’t know what happened to Bob, he changed” (Brownbridge, 2013).
            The rift with his family dynamic grew and by age 15 he decided to leave the family church and thus began his self-described “rebellious” stage began. He began hanging out with the boys who were known simply in town as the “bad crowd”. He spent nights drinking, gambling and fighting.
            When Bob turned 17 years his mother tired of being poor and living a meager life off of the $225 per month his father made as a distributer of farm supplies decided to uproot the family and move to Spokane, Washington. His father would get a job with the same company as a salesman, a poor decision that did not last long due to his father being extremely introverted. This forced his mother to work as the primary bread winner of the family and Bob seeing that the family was in need of additional income began to work as well. Bob would continue to work all through his junior and senior year of high school and would even pay for his college tuition at Whitman College. While Bob’s younger years would shape him it was after he moved out of the home and struck his independence that he describes as the “real formative years”.
            Bob first began his secondary education at the University of Washington where he described as “not very successful”. Bob found the temptation of being out on his own for the first time drawn towards parties and drinking on campus. He spent only one semester there and then decided to move to Whitman College which was a smaller school located in Walla Walla Washington a small rural town that seemed a little like Iowa, a place he had looked forward to leaving but a place that now alone provided some comfort. While attending college Bob was active in sports playing basketball for the school and he describes himself as a “great athlete”. During the summers he would work for the Forest Service at Priest Lake, Idaho, located in the northernmost portion of the Idaho Panhandle, 80 miles north of Spokane, Washington. His modest earnings of $1,500 per summer would help pay his tuition at Whitman College. It was here that Bob would learn about the Korean War, the draft, and what life really had in store for him.
            Sitting on a mountain side overlooking Upper Priest Lake his Forest Service Supervisor sat with him at lunch and asked him “did you hear about the war that broke out yesterday in Korea?” (Brownbridge, Into War with an Empty Gun, 2012) Not knowing what or where Korea was Bob was to learn the next day that Congress had reinstated the World War II national draft and would begin to supply soldiers for the new war that was now labeled a “police action” by President Truman. He began to contemplate his future and the grim reality that being drafted was a distinct possibility. What would happen to his goals? What would happen if he was killed or even worse maimed in combat? Would he have to kill someone?
This lead to questioning the validity of the war and why Americans were in a place that did not put any Americans in harm’s way, the thought of running to Canada briefly entered his mind. Growing up in the family he had and the values that his community held that risking one’s life, even dying, was a better way to live with oneself than being forever disgraced as a coward and a draft dodger. So the draft was the only real patriotic option, but if there was a way to beat it, Bob knew he had to find it.
After a failed attempt to get into the U.S. Naval Officer’s Candidate School in New London, Connecticut he found himself in at reception in Fort Lewis, Washington and then off to the Army’s Signal Corps Training School at San Luis Obispo, California. On September 29, Bob began eight weeks of Basic Infantry Training followed by eight more weeks of specialty training in communications. “I found myself to be in excellent physical shape but failed to achieve the Army’s other three objectives; weapons proficiency, military teamwork and adherence and respect for military authority” (Brownbridge, 2013).
No matter how much training on weapons and marksmanship he went through he could not overcome his ineptness at using the weapons, “the M1 rifle, said to be a soldier’s best friend, never befriended me.” (Brownbridge, 2013). Learning to work with others proved to be a very task for Bob because of his resistance to cooperate with others. Killing another person weighed so heavily on his conscience he applied resistance to develop and foster any type of teamwork cohesion, he simply felt “whether working separately or as part of a team I could not bring myself to work with them so I simply practiced passive aggressive methods of personal rebellion” (Brownbridge, 2013).
Respect for military authority was simply drawn from his fear of how authority would be used against him, “I obeyed, but not out of respect” (Brownbridge, 2013).  In one instance Bob had a run in with one of the training sergeants who, during a weapons inspection informed him that his weapon was dirty, after arguing that it was not his weekend pass was revoked and he was given seven days of Kitchen Patrol (KP) with a stern follow on threat that additional punitive actions may be taken to “correct” his insubordinate behavior. After this encounter he learned that it was easier for him to just stay out the sergeant’s way, and found that by not being noticed he quietly excelled, even though he felt poorly prepared and ill equipped to serve in war.

Figure 1 Private Robert Brownbridge, Basic Training Honor Guard January 1953.
            Upon completion of Basic and Specialty training Bob headed home to spend a few weeks with his family before heading to Korea. While at home he spent the obligatory time with his parents but found himself looking for his old girlfriends and the promiscuity that a soldier going to war can hope to engage in. Time would speed by and Bob would give a heartfelt farewell to his parents and silently contemplate whether he would ever see them again as he watched them disappear as the train pulled away from the station.
He embarked on a 21-day trip from Fort Mason on San Francisco Bay and arrived in Yokohama, Japan. The inevitability of war loomed over him and he felt the first pains of loneliness and fear. Bob had turned away from the church as a 15 year old boy in Iowa soon found himself trying to remember those bible passages and he repeats a popular proverb many of us who have seen combat remember “there are no atheists in foxholes”.

Figure 2 Corporal Robert Brownbridge

On July 27, 1953 Bob came out of his tents to the shouts of “The truce is signed, The War is over, we’re going home” (Brownbridge, 2013). Although this news brought joy and celebration to him and the troops around him, Bob was dealing with another problem. A problem that moved slowly and like the enemy he had fought over the years slowly tore at his well being and resolve. He was getting sick.
Not a sickness like a cold but a he knew something was wrong. He would pass out and find himself waking up on the floor of his tent nauseous and tired and he was having almost regular seizures. He went to the medic repeatedly only to be told that it was exhaustion and he just needed to get some rest.  As he was doing his discharge physical the doctor found what he called a “corpus callosum, a body of nerve tissues that lies between your two hemispheres,” he continued “is off center; it’s to the left of where of where it should be” (Brownbridge, Into War with an Empty Gun, 2012) The doctor told Bob that he was going to send him to Tokyo immediately.
Bob went on to describe numerous tests done by the doctors that left him writhing in pain and many times simply passing out because his body and mind would shut down to “save me from simply giving up” (Brownbridge, 2013). Finally there came some results it was found that he had a brain tumor. The doctors were amazed and commended him several times for his work on the front lines of Korea even though he was suffering from physical pain and regular seizures. After surgery Bob told me a story that happened almost ten years after the surgery that would save his life.
While attending college he was sitting in his apartment speaking with a friend and his fiancĂ© abut there upcoming wedding when her ten year old son sat on Bob’s lap. He looked right into his eyes and he could see his gaze travel to the burr on his forehead. “What’s that” he asked. Bob was caught by surprise because nobody had ever been that bold before.
“Well Danny, I was very sick once and the doctors looked inside my head” he said. Danny sat back looked intently and said “Does it hurt?” I responded, “No, it doesn’t Danny. Not anymore” With a satisfied look on his face , the boy declared, “God took good care of you, didn’t he?”
Bob told me his eyes moistened before he could manage to respond, “Yes….Yes, he did, Danny”.
While I could continue to write about Bob’s fascinating story while serving in Korea and his fight and eventual successful win in his fight with cancer for the sake of this post and brevity I will move onto the next section.
Critical Analysis
Religion played various roles in Bob’s life. It was a defining factor in his family dynamic as well as a forceful and visual way for him to show his individuality and rebel. “Humanistic theories provide two foundational concepts for transpersonal theory: self-actualization and self-transcendence” (Robbins, 2012). As a child around 12 years old, Bob began to develop and express his creative side. These actions are seen in the definition of self-actualization which is “a natural inherent tendency of people to express their innate potentials for love, creativity, and spirituality” (Robbins, 2012). The strictness and the harsh environment that he grew up in left him with little means to express his love for the world and those around him. Bob related that the only time he ever hugged his father was when he was leaving for war, that image is still ingrained in his memories. Although he did not receive the conventional nurturing that Maslow describes, Bob was able to find the necessary nurturing from other people around him such as his Aunt who prompted him to have a world view as well as encouraged him to write and paint. At his current stage in life Bob has achieved a transegoic state of understanding that there is a larger purpose for him in the world. This purpose is to help those who have seen war and suffer from the environmental factors that block access to care, stigma associated with care and community acceptance of a systemic problem.
In Erickson’s stages of adult development, Bob has reached the generativity vs. stagnation stage. In the generativity stage the person works on being productive within society and essentially leaving behind a personal legacy. In this stage typically people work within three domains: procreative domain, productive domain and creative domain. In the procreative domain Bob is being a mentor helping students such as myself who are working to get into the field of work that he has been successful at for 40 years. His continued contributions to the community of veterans here in Boise has been relentless are an example of the creative domain. Another example of this domain is his current endeavor to bring together various religious groups in a community outreach program that will provide peer support for veterans suffering from substance abuse and homelessness.
In stage eight of Erickson’s adult development Ego Integrity vs. Despair “despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends” (Davis, 2013). I am confident that from all that Bob has experienced with the war and secondary illness that almost took his life his fear of death is very negligible. During our interview he expressed “content that I have been blessed with a life of accomplishments and experiences that I have been able to walk away from” (Brownbridge, 2013). That does not mean that he does not fear for the death of his wife or family members. I have seen in many combat veterans after they return from war the feeling of contentment that life was not swept away from them and that since they got to come home and some of their buddies did not than living life to fullest carries a new meaning, it is the feeling that to waste your time would be a dishonor to those who did not have the choice whether they got to live theirs.
Levinson’s stages of adult life early adulthood “ranges from about 17 to 45 this is the era of "greatest energy and abundance and greatest contradiction and stress." It is the most productive time of a person's life, during which one carves one's niche in the adult world. The satisfactions can be rich, but the stresses can be "crushing." "We incur heavy financial obligations when our earning power is still relatively low," notes Levinson. Important choices about marriage, family, and work are made before the person necessarily has enough maturity to choose wisely” (Dewey, 2007). During this phase of Bob’s life he had made the decision to move out of the family home and attend college. Although he did not do very well his first year due to “extracurricular” activities he was none the less able to begin to carve his place into society. After seeing that he was not mature enough to handle a big school Bob moved to a smaller school where he was more comfortable. After being drafted into the Army he found himself back into a transitional institution, he was away from his family but he was still under the control of his training sergeant’s and those appointed over him in the platoon. He did not have a dream per se but he did have immediate goals such as graduating from college and entering the work force. This was cut short after he was drafted into the Army and the imminent reality of death removed all hope to achieve any goal he may have set for himself earlier.
In Piaget’s Cognitive Theory age seven to eleven is referred to as the concrete operational phase. This is a phase when “children can use logic, but tend to be literalistic and abstract concepts are not easily understood” (Robbins, 2012). As mentioned before at the age of eight Bob began to see the hypocritical side of his family when behind closed doors. How they would smile at someone then talk behind their backs. Bob was able to use this logic to know that just because someone was black did not make them “not human”. This is because he became less egocentric and better at conservation tasks meaning that he was able to understand that although the appearance of something changes, the thing itself does not.
Fowler’s Theory of Faith Development in stage five states that “critical thinking allows for developing one’s own personal beliefs and practices and the determination of whether one remains in a traditional religious context or not takes place. Another way to view this is “The adolescent also develop interpersonal multi-perspective cognition's and begin to desire a personal relationship with God in which they feel loved in a deep and comprehensive way” (Fowler, 2005). During this time Bob decided to turn away from formal religion and turn away from the rules that had been established by his family and those that were practiced by the members of his community. Not because Bob did not believe in God but because he did not understand the concept behind being a good Christian at church but a gossiper and hypocrite behind doors. Bob stated during our interview his feeling on his decision to leave the church “if you believe in god and have faith you should have it all the time not just when someone is watching you” (Brownbridge, 2013). This belief would eventually evolve to the present where he is an active member of his church community as well as a strong proponent to faith based community services.

References


Brownbridge, R. (2012). Into War with an Empty Gun. Boise: CreateSpace Publications.
Brownbridge, R. (2013, March 20). (E. Hicks, Interviewer)
Davis, D. (2013, Jan 01). Psychosocial Theory: Erikson. Retrieved from Haverford: http://www.haverford.edu/psych/ddavis/p109g/erikson.stages.html
Dewey, R. (2007, Jan 01). Stages of Life. Retrieved from Intropsych: http://www.intropsych.com/ch10_development/stages_of_life.html
Fowler, J. &. (2005). Stages of faith from infancy through adolescence: Reflections on three decades of faith development theory. Thousand Oaks: SAGE.
Robbins, S. P. (2012). Contemporary Human Behavior. Upper Saddle River: Pearson Education Inc.
Thompson, R. (2013, 04 01). IMDb. Retrieved from IMDb: http://www.imdb.com/title/tt0051383/
Zastrow, C. H. (2010). Understanding Human Behavior and the Social Enviroment. Belmont: Cengage Learning.

Monday, June 9, 2014

Healing our Hero's and Family

As I move close to graduation from USC I began to think about what it was I truly wanted and how could I use my experience and education to help my fellow service members and Vet's. That is when I began to toy with opening a nonprofit that would focus on helping not only those Vet's that qualify for VA services and family members but, also those Vet's who do not. So as of May 2014 I have begun to see this dream become a reality. and I have now started Healing our Hero's & Family Our Mission: Healing Our Hero’s and Families mission is to “Provide military veterans, current service members and their families with therapeutic care and to help enrich their personal and family lives.” The road to recovery following a traumatic experience can be difficult to navigate alone. Healing our Hero’s and Families is an organization that was created to provide service members, veterans and family members with tools and resources to fully engage in life. Yadira and Gene have combined forces to help families develop practical solutions to problems associated with Post Traumatic Stress Disorder, Anxiety, and Depression. Special emphasis is also placed on the family members and children of veterans who may be experiencing secondary trauma or even caregiver burnout. Healing our Hero’s and Families also provide services for veterans who do not qualify for Veterans Affairs services. We serve: All current service members Veterans of all eras of combat Victims of Military Sexual Trauma Those veterans and family members that do not qualify for VA or Vet Center services. Children, Spouses and Family members of veterans and current service members. Programs Offered: Individual, group, couples and family counseling Military Culture Training Caregiver support and groups Sand Tray Therapy Art Therapy Crisis Management Please visit my website www.HEALINGHEROS.ORG We are also able to accept donations through this site, please help me by passing this on to organizations that could help us on a successful launch.

Tuesday, February 4, 2014

“Is a leader made or Born?”


 

“Is a leader made or Born?”


This is a question that has been included into the syllabi of every leadership school I have attended from Primary Leadership Development Course to the Senior Leader Course. There is no definitive answer to whether a person is born a leader or made a leader. Instead it seems that leadership is a combination of intelligence and aptitude.  For this post I will discuss the history of the study of leadership and also how the Biological approach and the humanistic approach would explain the personality traits that are associated with the subject of leadership.

            To understand leadership and the development or nurturing of it I thought it was important to look at the way leadership has been studied over the years. Two early foundations of the leadership concept are; philosophy and moral law.

            Leadership has numerous theoretical roots. Socrates in Plato’s Republic, said that the “leadership of civil institutions were to be reserved for the “specially” trained philosopher-kings, not to the ill-trained or uniformed masses who were meant to be followers.” (Hays, 1967)  Many military classes at West Point or The Naval Academy still quote Sun Tzu when discussing senior and subordinate relationships. Aristotle described moral conduct and behaviors that all leaders should poses, these “codes” influenced many great leaders notably Alexander the Great. Machiavelli describes the cruelty, dishonesty, and sometimes brutality that were shown by leaders in his book The Prince.

            Moral Codes affect many concepts of leadership. Marcus Aurelius spoke often of the moral and ethical responsibilities leaders were held too under the Roman Empire. Judeo-Christian teachings emphasize the divine source from which all leadership is derived from.      These teaching have emphasized the necessity for the up most ethical standards by all leaders.  Moral Codes were the foundations for the formation of the Japanese code of conduct known commonly as Bushido or the “The Warriors Way” which emphasized tenets such as honor, loyalty, and frugality. The west had a much similar concept known as chivalry which also emphasized the duty to your king, to your God, and to your women. In today’s Army Officers and Non-Commissioned officers are consistently judged on their moral and ethical standards.
 

             The psychological and trait approach to leadership can raise numerous questions about the development and the emergence of the leadership trait or quality. Using the biological approach or more specifically Hans Eysenck’s theory on personality a leader exhibits some of his personality dimensions on certain levels. The first being extroversion, a leader can usually be described as an A-Type personality. The leader is usually outspoken and can excel within the group dynamic, the leader is usually an outgoing person that has many contacts. Most leaders are usually not introverted, but in my experience I have seen some of the more effective leaders that were border line introverted. Much of their leadership was derived from charisma and their knowledge of their profession, this in turn prompted respect from their subordinates. Neuroticism is a trait that a leader does not want exhibit because having very strong emotional reactions to minor frustrations may not solve the problem but may in fact exacerbate the problem, especially with subordinates, because a leader needs to be a level headed person that weight facts objectively without investing to much emotional bias into the problem. But then again a leader does not want to display the psychoticism supertrait because he does not want to appear cold or impersonal to the subordinate. A good leader needs to be empathetic and show concern for them.

            The humanistic approach to leadership would say that the leader is in a position that he chooses to be in and that nobody is forcing him to take the responsibility that he has chosen to take. The humanistic approach would say that a leader takes personal responsibility for the actions he or she chooses to take or not take and in effect suffer the consequences of their action or bask in the glory that may come from the decision to act. From the humanistic perspective a psychologist may say that a leader is ineffective because they spend too much time planning on the future or reflecting on the past. The humanistic psychologist may also say that a leader should remember their past experiences but should not allow them to dictate what they are. We all know that much of leadership is derived from the experiences that they gain throughout their career.

            Leaders can be classified into different categories. The first category is the manner in which the leader achieves his or her position. In informal groups a leader may emerge from the group by asserting himself or herself.  This can be an example of the “born” theory, in which the individual is able to shut down his competition and take over. In the Army we often call this “initiative” and it is part of the Army’s definition of leadership which is; “the ability to influence others to accomplish the mission by providing purpose, direction, and motivation.” The charismatic leader is much like the emergent leader. The charismatic leader is that person that can walk into a room and all eyes turn to look and people seem to just gravitate towards.  The charismatic leader may not have the technical or the tactical experience that some other leaders may have but they still have the ability to influence people to follow them an example of this type of leader is Adolph Hitler.

            The second category is the more formal raise in the hierarchy of leadership.  The rise to a leadership position may either through a democratic process, such as our elected officials.  These leaders were “made” in the sense that they went through the education process and climbed through the ranks to get to that position. In the Army I came in as a private and served first as a rifleman, then progressed to the position of team leader, squad leader, platoon sergeant, and first sergeant.  In my experience it is important for a leader to progress through the ranks and serve in those positions where “the rubber meets the road”.  Each position capitalizes on the experience of the previous position. 

            An example of great leadership can be found in the movie We were Soldiers. In this movie Mel Gibson plays Lieutenant Colonel (LTC) Hal Moore the Commander of the 1st Battalion, 7th Cavalry. General Moore graduated from West Point in 1945 and attended graduate school at George Washington and Harvard University. Later in his career he taught at West Point where General Norman Schwarzkopf was one of his students.  General Schwarzkopf would later comment that General Moore was the biggest influence in his decision to become an Infantry officer. The 7th Cavalry was the unit General George Armstrong Custer led in the Battle of the little big horn.  Prior to their deployment to Vietnam LTC Moore gives a speech to his Soldiers saying;  "Look around you, in the 7th Cavalry, we got a Captain from the Ukraine, another from Puerto Rico, we got Japanese, Chinese, Blacks, Hispanics, Cherokee Indian, Jews and Gentiles, all American. Now here in the States some men in this unit may experience discrimination because of race or creed, but for you and me now, all that is gone. We're moving into the valley of the shadow of death, where you will watch the back of the man next to you, as he will watch yours, and you won't care what color he is or by what name he calls God. Let us understand the situation; we're going into battle against a tough and determined enemy. I can't promise you that I will bring you all home alive, but this I swear: when we go into battle, I will be the first one to set foot on the field, and I will be the last to step off. And I will leave no one behind. Dead or alive, we will all come home together. So help me God."

LTC Moore was able to draw from his experiences leading Soldiers and from his education which taught him the principles of leadership. These experiences would later be passed on to his students at West Point. All leaders draw upon their experiences as a foundation for developing their own style of leadership. So is a leader made or born? With the proper education I believe that anybody has the potential to be a leader but at different levels of responsibility. Leadership is a lifelong process and when you think you have seen it all you get blindsided by some new situation or a subordinate that you just can’t seem to figure out.

Work Cited

Adams, N. M. (1992). The Prince. New York: W.W. Norton & Company.

Hays, C. S. (1967). Taking Command. Harrisburg: STACKPOLE BOOKS.

Wednesday, November 20, 2013

Veterans diagnosed with PTSD are more likely to die from suicide than those without PTSD


Hello everyone I apologize for not being as pro-active in keeping up my blog. Well a lot has happened since my last post. I am now in my final two semesters of graduate school (graduate Aug 2014) I also have run into a few bumps in the road that have helped re-evaluate some actions and think about how poor choices can adversely effect the goals you place for yourself. But more about that later! As for now I want to post a few things I have written concerning suicide and the impact that Post Traumatic Stress Disorders plays in increasing the propensity for completed suicide as well as increased attempts. Although this is a dark subject it is something that needs to be addressed.


 
Suicide is unquestionably the most challenging mental health issue after Post Traumatic Stress Disorder (PTSD) that is being faced by the military today. Suicide has been the second leading cause of death in the United States military, exceeding the number of combat-related losses in both Iraq and Afghanistan (Rudd, 2012).
Veterans diagnosed with PTSD are more likely to die from suicide than those without PTSD, and this risk is substantially greater among veterans with PTSD and comorbid mental disorders such as substance abuse (Jakupcak, 2011).

Can addressing PTSD decrease the number of suicides by service members diagnosed with PTSD? Yes, and steps are currently being taken to further research and present empirical and best treatment practices that will lessen the symptoms of PTSD and thus reduce the number of suicide attempts and completions. While there are a number of treatment options available to practitioners the three that have been successful are: Cognitive Behavioral Therapy more specific Cognitive Therapy, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) Therapy (see figure 1). For the purpose of this paper I will discuss Cognitive Behavioral Therapy in which the treatment focus relies on relearning thoughts and beliefs generated from the traumatic event, which may impede current coping skills.
Studies have linked the relationship between suicidal ideation and self-reported psychiatric symptoms among 407 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans in a post deployment study at a specialty Veterans Affairs clinic. Accounting for symptoms of major depressive disorder, alcohol abuse, and illegal drug abuse, veterans who screened positive for PTSD were found to be more than four times more likely to report suicidal ideation relative to non-PTSD veterans (Jakupcak, 2011).

 Cognitive Behavioral Therapy is an individualized type of psychotherapy used to treat PTSD that is based on the principles of learning theory and cognitive psychology. From a cognitive psychological perspective, trauma exposure is thought to evoke erroneous automatic thoughts about the environment (as dangerous and threatening) and about oneself (as hopeless and incompetent). CBT directly confronts such PTSD-related distortion thinking.

 Cognitive therapy addresses the thoughts and beliefs that are often associated and generated by the traumatic event rather than the conditioned emotional responses addressed by exposure therapy. This approach focuses on how individuals with PTSD have interpreted the traumatic event with respect to their appraisals about the world and themselves (Friedman, 2003).

 Cognitive therapy has a number of elements that are distinctive in its treatment plan compared to others types of therapy. Some of the elements that make it appealing to service members and their families include being relatively short-term (for the most part), active, directive, structured, and collaborative, with a core theme being the development of individual understanding, coping, and mastery of skills essential for day-to-day living (Rudd, 2012).
There have been several studies that have shown that the effectiveness of CBT in reducing suicidal behaviors. There are several effective treatments used to reduce suicidal behaviors and they all share several of the same common elements, including theory-driven, structured strategies that are designed to target suicidal risk factors, increase motivation and treatment compliance, and introduce skills training to promote self-reliance, responsibility, and the ability to manage distress and crisis. A 2005 study by Brown, G.K titled Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial found that, compared to participants receiving usual care from community providers, participants in CBT therapy for suicidality reported significantly less depression and hopelessness six months after initiating therapy and were significantly less likely to reattempt suicide in the 18 months following their initial suicide attempt (Jakupcak, 2011).

One proposed approach to treating PTSD with OEF/OIF veterans at high risk for suicide is based on a treatment plan with core features of psychosocial interventions designed for the treatment of suicidal behaviors and the treatment guidelines proposed by the International Society for Traumatic Stress. This successful (validated and reliable) approach consists of three phases: (a) comprehensive assessment, treatment engagement, and initial safety planning; (b) suicide risk reduction and CBT skills specific to suicidality; and (c) CBT for PTSD and comorbid mental disorders. The implementations of the three phases are only the beginning of a whole treatment concept which involves maintaining regular supportive contact, fostering motivation for treatment, and continually assessing changes in risk factors and symptoms must remain a priority through the treatment process.

Phase I: Assessment, Treatment Engagement, and Initial Safety Planning

  This phase allows the clinician and initial assessment opportunity to fully assess warning signs and risk factors involved in suicidal behaviors. This time can be critical in establishing rapport necessary to engage the veteran in care. Not only is this a time to discuss things such as unanticipated assignments outside of the veterans primary Military Occupational Specialty (MOS) but also the possibility of being personally re-deployed or the possibility of friends or family members being redeployed it is also a time to assess other factors of risk behaviors such as recent aggression, smoking status, family history of suicide, childhood or adult sexual or physical victimization, and current access to firearms. This will assist the provider in estimating the level of current risk and will help to guide safety and treatment planning (Jakupcak, 2011).
Phase II: Suicide Risk Reduction and CBT Strategies Targeting Suicidality
 After the initial assessment takes place suicide risk reduction and safety plan refinement is an ongoing process. The clinician is encouraged to take the lead in facilitating a coordinated treatment plan, with each provider identifying their role in a collaborative process to reduce suicide risk. There are many ways other treatment providers can provide critical support in the reduction of suicidal risk. During this phase the veteran is encouraged to identify specific emotional states that frequently cue suicidal thoughts (Jakupcak, 2011). Those veterans that devalue or fear discussing vulnerable emotions may benefit from an emotional examination of personal and cultural schemas regarding traditional norms as part of the emotional skills training. Reviewing both general and idiosyncratic functions of specific emotional states can normalize the experience of vulnerable emotions and help to address skills deficits (Jakupcak, 2011).

Phase III: Treating PTSD and Comorbid Psychiatric Symptoms
After the introduction of the safety plan and basic CBT skills to help reduce suicidal thoughts , impulses, or self-harm behaviors, it is important to address more specific psychiatric disorders. During this phase it is important that the provider remain flexible approach in treating specific disorders and other psychiatric symptoms, carefully monitoring safety, continued ambivalence, and resistance to treatment. It is not uncommon that for the veteran to become resistant to the treatment process. These resistance actions can be seen through active resistance (e.g. cancelling appointments or no-showing multiple appointments, using alcohol, or other substances immediately prior to or following a session) or may be expressed less directly through such behaviors as forgetting to do “homework for sessions, or bringing up topics that distract from trauma-related session (Jakupcak, 2011). See figure 2 for some common barriers to mental health care in general population and among former deployed military personnel.

 The most common resistant that most veteran’s exhibit is substance abuse, substance use can increase impulsivity and suicidality, but OEF/OIF veterans abusing alcohol may not be aware of the problematic nature that their drinking may be playing in their recovery process. Many veterans will reference their behaviors to peer-based norms and may even perceive benefits from alcohol consumption in terms of sleep and anxiety reduction (Jakupcak, 2011).

  In conclusion the necessity to understand local and national resources that are available to practitioners who work with OEF/OIF veterans are important to help with complex psychiatric profiles and physical disorders. IT is also important to acknowledge that treating patients who are at risk for suicide is often both challenging and stressful to providers. A substantial portion of mental health providers report having experiencing a patient suicide (rates that vary 11% to 50% across types of professions and clinical settings) and providers may experience significant emotional distress in response to a patient’s suicide attempt or completed suicide. It is just as important for providers to seek out appropriate supervision, consultation, and peer support.
  
Figure 1:

Cognitive Behavioral Techniques Used in PTSD Treatment
CBT Technique
Treatment Focus
Prolonged Exposure Therapy (PE)
Disconnecting the overwhelming sense of fear from trauma
Cognitive Therapy
Relearning thoughts and beliefs generated from the traumatic event, which impede current coping skills.
Cognitive Processing Therapy (CPT)
Understanding both emotional and cognitive consequences of trauma exposure
Stress Inoculation Training (SIT)
Anxiety Management to increase coping skills for current situations.
Interapy
Exposure and cognitive restructuring through a protocol-driven CBT treatment accessed via the internet.
Imagery Rehearsal Therapy
Changing disturbing traumatic nightmares by rehearsing "new dreams"
Biofeedback and Relaxation Training
Anxiety management to help patients master overwhelming anxiety feelings and physiological reactions elicited by a trauma reminder.
Dialectical Behavior Therapy (DBT)
Treating borderline personality disorder, a syndrome of associated with PTSD and complex PTSD.

 Figure 2:

Barriers To Mental Health Care in General Population and Among Former Deployed Military Personnel
In General Population  (Kessler, Berglund, et al., 2001)
Among Formerly Deployed Military Personnel (Schell and Marshall, 2008)
Lack of perceived need
Negative career repercussions
Unsure about where to go for help
Inability to receive a security clearance
Cost (too expensive)
Concerns about confidentiality
Perceived lack of effectiveness
Concerns about side effects of medications
Reliance on self (desire to solve problems on one's own or thoughts that the problem will get better)
Preferred reliance on family and friends
 
Perceived lack of effectiveness

 Written by Gene Hicks 2013
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