Breaking the Stigma: Understanding Veteran Mental Health with Dr. Ron Acierno

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There are few things that make people successful.

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Taking a step forward to change their lives is one successful trait, but it takes some time to get there.

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How do you move forward to greet the success that awaits you?

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Welcome to Next Steps Forward with host Chris Meek.

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Each week, Chris brings on another guest who has successfully taken the next steps forward.

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Now here is Chris Meek.

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Hello.

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You've tuned to this week's episode of Next Steps Forward, and I'm your host, Chris Meek.

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As always, it's an honor to have you with us.

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Next Steps Forward is committed to helping others achieve more than ever while experiencing greater personal empowerment and wellbeing.

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Our guest today is Dr.

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Rana Cherno.

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Dr.

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Cherno is a professor and vice chair of Veterans Affairs in the Department of Psychiatry and Behavioral Sciences at UT Health Houston McGovern Medical School.

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He also serves as the executive director of the UT Health Trauma and Resilience Center.

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He has served as principal investigator on grants for a number of agencies and entities, including the National Institute of Mental Health, the Department of Defense, the Department of Veterans Affairs, and the South Carolina Department of Public Safety.

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He has more than 150 published articles and 30 book chapters to his name and has served on editorial boards of several journals.

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Dr.

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Rana Cherno, welcome to Next Steps Forward.

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Thank you so much for having me, Chris.

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Now I appreciate your time, and I know you're dealing with a bit of some folks under the weather, so I appreciate you jumping away from that.

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Happy for the break.

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Doctor, you spent decades researching trauma and working with veterans.

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What first drew you to this field and what's kept you in it all these years?

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Well, I started in the area of traumatized juvenile delinquents, basically, my people.

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And in 2005, I was asked to come over to the VA and do the evidence-based treatment that I was doing in the university clinic for our veterans.

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At the time, a lot of the care was in groups that were just supportive groups that never ended, so people might be in a group for 10 or 15 years.

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And I saw our veterans sometimes coming into my civilian clinic.

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And basically, what I saw was our veterans couldn't go to the movie theater, for example, or couldn't go to Walmart when it was crowded.

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And basically, what I saw was our veterans who fought for our freedom had their freedoms taken away from them, and I don't abide that.

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And it was sort of a duty-bound thing.

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I didn't serve.

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It's the one way I could serve was to work at the VA.

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I still work at the VA.

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I'm a university-VA hybrid.

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And September 11th was really a cementing factor, and I need to do this.

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And all of the last 20 years have sort of proven the point that we need to get the best care we can to our veterans for depression and PTSD and adjustment disorder.

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And because, just like first responders, when everyone's running one way, they have to run into the firefight as a part of their job.

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We might do that if we see a family member in a fire, but goodness gracious, they do it for every opportunity every day.

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So it's sort of a sense of moral obligation, I think.

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You know, it's interesting you say what you just did, because we're birds of a feather on a lot of those fronts.

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So I've never worn the nation's uniform, and like you, it's one of life's regrets.

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And I've done a lot of work supporting veterans and first responders over the last 20 years.

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I was at ground zero on 9-11 across the street.

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And so to your point, one of my most lasting memories of that day is while thousands of us were running away from the towers, hundreds of first responders were rushing in.

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And to your point, they have to do that.

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And I did my dissertation a few years ago on mental health for police officers.

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And one of the police officers I interviewed said that everybody has a bad day, but we see everybody's bad day every day.

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And so thank you for the work that you do.

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It's super important.

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It's very personal to me, and so I really appreciate the work that you've done all these decades.

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Yeah.

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And I see a lot of commonalities.

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You know, a lot of our first responders are veterans, particularly in Houston and in many other cities.

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So there's a lot of commonalities.

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But a major commonality is a value of service, a duty of service.

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You can make more money not risking your life in a lot of other jobs, and you choose the military because of this service allegiance you feel.

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And you choose to do first responding.

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You sure as hell don't do it for the hours or the money.

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You do it because you feel like you need to do this.

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And like you said, they're there running toward the buildings falling.

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Hell, there were two buildings.

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They didn't stop running after the first one fell.

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And the military is the same way.

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So to then see these men and women's freedoms restricted, they can't go to their grandson's football game because the crowd jumps up, and that's too shocking, or they can't go to a July 4 celebration, or they can't go to Walmart when it's crowded.

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It's not acceptable because there are tools to help with that.

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And so what we need to do is give people the action-oriented tools to help with that.

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And you know, might be leading a bit too soon into it, but talk is cheap.

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The treatments that work are very behaviorally focused.

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It's changing what you do to change how you feel.

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And if you want to feel the same way, then don't do anything different.

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And you know what?

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Veterans and first responders, they buy that.

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They understand it.

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They're action-oriented people.

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So that sort of fits with my personality, and that's sort of one of the reasons I'm in this field.

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When post-trauma stress is discussed, some people insist on using the term post-traumatic stress disorder, or we know the acronym PTSD.

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While others contend it's either inaccurate or inappropriate to call it disorder.

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What's correct, or which you prefer?

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Is it disorder, or should we call it something else?

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Well, it's a matter of timing, right?

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So post-traumatic stress, or post-traumatic stress disorder, let's just talk about the reaction.

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Increased heart rate, increased muscle tone, fight or flight response.

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In this situation, every PTSD symptom, more or less, is the appropriate response.

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It's not a disorder in the situation, right?

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In a firefight, to fear for your life, to be hyper-alert, to be tense as hell, that's going to keep you alive.

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Same thing if you're approaching a person who is radically high on drugs, has just stabbed his wife or his kid.

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Same thing if a bear is attacking you.

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Fight or flight.

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Normal response, not pathological.

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When reminders, though, of the original setting, so it's a marketplace with an IED and a lot of enemy combatants, now, it's two years later, you're in Walmart, and you have the same feelings because it's crowded and there's all crazy stuff going on, and there's a lot of neon clothes and spandex where there shouldn't be, and everything's insane.

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You might feel that response.

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Remember, it was a normal response in the situation that you just left two years ago, but now, it is a problem because it's functionally impairing.

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I tell my students, if a person has symptoms of this, that, or the other thing, and it doesn't interfere their roles in life, they can still be a good father, good parent, good They can still enjoy life, then they have some quirks, they have some things maybe they can work on.

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But when it gets in the way of functioning, and it's a constellation of symptoms that's pretty reliably evoked, then it is a disorder.

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Because of the functional impairment, not because of the symptoms.

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The symptoms were normal in the fight or flight situation.

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The symptoms are impairing.

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If you can't go to your grandson's football games because of the uncontrolled crowd responses, that is a disorder.

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I don't care what you call it.

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Let's call it a problem behavior that you need to get over, because your freedom is being restricted as a consequence of you fighting for our freedom.

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Again, I always go back to that, and I definitely go back to that with my minority veterans.

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You've seen your freedoms restricted 200 years ago.

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Are you going to abide by that now?

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I say it to the veterans too.

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You fought for our freedom, and you can't go to Walmart at three o'clock.

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You choose not to, but you feel like you can't.

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Let's get that feeling changed.

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The treatment involves doing what you really don't want to do.

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But here's an analogy I use.

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If you are a sniper firing in a 25-knot crosswind, how do you recalibrate that rifle when you're in a calm condition?

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You don't talk to it.

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You don't adjust the scope without firing it, without engaging.

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So when you're in a 25-knot crosswind, that's one situation, and you engage with it, you adjust the scope, you become out on target.

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When you come back into a calm situation, when you come back home here, if you don't interact with your environment, if you don't fire the weapon, you don't have the new scope setting.

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You can't recalibrate.

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And so you need to do those things.

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You need to engage in the community again.

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Now PTSD has a cardinal symptom of avoidance and withdrawal.

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It's like you never recalibrate the scope.

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You got to recalibrate the scope, and the only way to do it is not to talk to the scope.

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That would be ridiculous.

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Well, that, in PTSD, just talking about it is ridiculous.

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You got to get out there, but the trick, the art, is to figure out what a person's avoiding that they really want to do, maybe based on what they used to do, and then break it down into doable pieces.

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You want to be able to go to Walmart at three on a Saturday?

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Maybe you need to just go to Walmart parking lot at nine on a Tuesday, until that's boring, and then go to the front door, and then go inside, but not far.

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We do this over a period of weeks, all of a sudden you're in Walmart.

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Will you like it?

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No, it sucks.

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You have PTSD, you had PTSD, whatever, but we take people from being overwhelmed to being bothered, and we call that a win, because we can't make people forget the things that you don't want to forget, the important things in your life, good or bad.

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Would you call it immersive therapy, or is it a different type of treatment?

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You could do immersive therapy.

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They used to call it flooding.

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You could throw a person into the situation until they get over it.

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It's a good way to close your practice down, and maybe get punched in the face.

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What I like to do is break it down into doable parts, and do that two to four, maybe five hours a day.

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People are like, well, that's a lot of time.

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I say, okay, let's take your phone out.

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How long were you on the screen today?

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That's how long you need to take care of yourself.

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If you can do three hours of screen time, you can do three hours of behavioral therapy, getting back into the situation.

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We don't do it immersive, but we do immerse the day in it.

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We try and break it down into, I want you to be bothered by what you're doing therapeutically, not overwhelmed.

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It's a workout analogy.

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No pain, no gain.

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If you're working out and you're not sore, you're not pushing hard enough.

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If you're in these situations where I'm having, we call it prolonged exposure.

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We could also call it processing emotions.

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If you're going into these situations where you're uncomfortable, because it reminds you of a past trauma, and you turn around and leave, you'll feel better.

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Avoidance has just been reinforced.

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That's not good.

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You need to stay in the situation until you start to get used to it, and then you can leave.

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What you want to do is not make the situation so intense that the person feels like they have to leave.

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You want to be able to stay.

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It's like getting into a cold swimming pool.

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How do you get used to cold water?

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By jumping in and jumping out?

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No, you have to get in the water.

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You're a Northerner.

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You're in Connecticut.

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You know this.

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You get in the water, and you get used to it.

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Now, it won't be enjoyable.

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New York swimming pools and Connecticut swimming pools in the middle of August are still cold as hell, but you are less bothered by it.

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You can enjoy swimming and still be a little uncomfortable.

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That's what we're going for.

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You can call it a cure.

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I call it, let's get rid of functional impairment.

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There are still so many misconceptions about post-trauma stress.

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What do you wish more people understood about what it is and what it isn't?

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The way it's been sold has something to do with what I just talked about, the avoidance character, which is it's a permanent condition.

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If you are in a situation that makes you uncomfortable, triggers remind you of the past trauma, and you leave the situation, and you make that your regular coping response, you will have PTSD for 15 or 20 years.

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It won't go away.

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If you can engage in some of these, I call them opportunities for exposure, some of these workout opportunities, it's like taking the stairs instead of the elevator.

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If you can stay in the situation a few minutes longer, you will start to get better and overcome the PTSD.

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One of the things that I don't like is people sell PTSD as a permanent condition.

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It can be a permanent condition.

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It doesn't have to be.

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Now, I'm not saying you forget what happened.

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I'm not saying you can enjoy war movies like you used to before you went to war.

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If you see a movie about combat, you can't go to work the next day.

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No, we make it so that you have to turn off the TV, but you're fine in three hours.

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I'll take that.

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That's the big misconception that there aren't treatments as a permanent condition.

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You see that in the movies.

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You see it when people say my PTSD instead of PTSD.

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Don't tell me my.

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I don't want you to own it, right?

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That's your fight or flight response stuck in the on position.

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It doesn't need to be always in the on position.

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We can help you turn it down a little bit.

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We'll never turn it off, and it should have never turned off.

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If you've seen horrible things, you've seen horrible things.

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I wish I'd have met you 23 years ago.

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My listeners and viewers know that I self-diagnosed myself with PTSD from 9-11.

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Almost my entire career, I've worked within three or four blocks of there, and in 2018 was my first time actually going back to ground zero.

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But I didn't think about it that day, so I went the morning of 9-11, but I couldn't actually get there because of the ceremony they were having.

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I've never hyperventilated before, but I felt like that's what was happening to me.

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I'm like, well, that's fine because I've got New York's finest and bravest on either of my shoulders here, so that'll be okay.

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But actually, it was May of this year was the first time I've ever been back to physically touch the memorial.

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Yeah, I would have had to do that a lot sooner.

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Yes, you would have, and I would have listened to you.

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I went there three weeks after, and let me tell you why I went there three weeks after.

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I'll tell you the wrong way to treat PTSD, and the wrong way.

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You don't force people into treatment.

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You help them recognize what they're avoiding, and you say, look, man, you can get your life back.

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You give people hope.

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But there on the street corner in front of me was a woman from the Red Cross trying to be helpful, a good soul, a good Samaritan, and she heard the person in front of her who had been in one of the apartment buildings that was evacuated right outside the ring.

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And she says, would you like to talk about it?

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Do you need counseling?

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We have counseling.

212
00:17:30,880 --> 00:17:37,920
And the woman turned to her and said, I've been wearing the same clothes every day for three weeks.

213
00:17:38,720 --> 00:17:39,920
I don't need counseling.

214
00:17:40,080 --> 00:17:44,480
I need to get into my apartment and get my clothes back and get my life back.

215
00:17:46,000 --> 00:17:49,840
And I thought to myself, this is a natural resilience.

216
00:17:51,360 --> 00:17:57,520
This is a person who has a natural predilection toward resilience.

217
00:17:57,840 --> 00:18:02,480
I need to get back into my apartment, I need to get back into my life, and I need to do these things.

218
00:18:02,640 --> 00:18:04,960
Now, for her, it was manifest as clothing.

219
00:18:05,200 --> 00:18:11,120
But in reality, she was saying, I need to not be on my friend's couch.

220
00:18:11,280 --> 00:18:12,800
I need to get back on the horse.

221
00:18:14,480 --> 00:18:19,440
But you know what a real kick in the balls is to tell somebody, oh, just get back on the horse.

222
00:18:20,160 --> 00:18:24,400
Because the horse might have just kicked them in the face, and they have a crushed skull.

223
00:18:24,640 --> 00:18:26,880
So what we do is we do the rehabilitation.

224
00:18:28,000 --> 00:18:30,960
We say, what are you avoiding?

225
00:18:31,200 --> 00:18:32,160
What did you used to do?

226
00:18:32,320 --> 00:18:33,600
What's important to you?

227
00:18:34,320 --> 00:18:35,360
Let's get that back.

228
00:18:35,840 --> 00:18:37,200
You fought for our freedom.

229
00:18:37,840 --> 00:18:39,680
You deserve the freedom to do these things.

230
00:18:40,320 --> 00:18:42,240
Here's how you do it in small pieces.

231
00:18:43,120 --> 00:18:48,640
When you're doing rehab after shoulder surgery, you don't go right to bench 220.

232
00:18:50,560 --> 00:18:56,320
And so when you went back to the 9-11, to the memorial, that was an approach behavior.

233
00:18:56,640 --> 00:19:06,960
Now, if it were me talking to you 23 years ago, 22 years ago, I would have said, listen, you need to look at as much material as you can digest that you've been avoiding.

234
00:19:07,200 --> 00:19:10,240
You need to go to the places that are now realistically safe.

235
00:19:10,480 --> 00:19:13,840
You need to go into One World Trade Center, that new tower.

236
00:19:13,920 --> 00:19:14,880
You need to go around there.

237
00:19:15,200 --> 00:19:17,280
You need to talk to people about what happened.

238
00:19:17,920 --> 00:19:22,160
Not for talk's sake, but to put it in your mind and then recalibrate.

239
00:19:24,480 --> 00:19:26,240
So bad things happen.

240
00:19:27,280 --> 00:19:28,080
We survive.

241
00:19:28,320 --> 00:19:29,280
We have to function.

242
00:19:29,920 --> 00:19:34,320
Avoidance, avoidance is the poison pill.

243
00:19:36,000 --> 00:19:37,200
It's a good way to put it.

244
00:19:38,400 --> 00:19:45,040
You talk about coming back from shoulder surgery and you can't bench press 220 and it's the old adage of how do you eat an elephant?

245
00:19:45,520 --> 00:19:46,480
One bite at a time.

246
00:19:47,840 --> 00:19:48,640
Same concept.

247
00:19:49,840 --> 00:19:52,320
Veteran suicide remains a national crisis.

248
00:19:52,800 --> 00:19:55,920
We're down from 22 suicides a day to roughly 17 a day.

249
00:19:56,320 --> 00:19:57,520
It should be zero a day.

250
00:19:58,160 --> 00:20:02,800
From your perspective, what's driving this and what are we still not addressing effectively?

251
00:20:04,480 --> 00:20:10,080
Well, that's a hard one, but let me put it this way.

252
00:20:10,640 --> 00:20:12,080
I think there are different reasons.

253
00:20:12,640 --> 00:20:31,280
But one thing that I hear from a lot of veterans, and I do both clinical work but I'm also doing clinical research, so I'm the on-call guy for about seven or eight studies, and a thing I hear repeatedly is things just don't matter anymore.

254
00:20:32,480 --> 00:20:34,000
Everything here is bullshit.

255
00:20:34,960 --> 00:20:36,160
There was life and death.

256
00:20:36,560 --> 00:20:37,520
There I had my team.

257
00:20:37,920 --> 00:20:39,600
There I was protecting my team.

258
00:20:41,120 --> 00:20:43,760
And now it's just a bunch of bullshit.

259
00:20:45,280 --> 00:20:46,960
So that's a search for meaning.

260
00:20:47,120 --> 00:20:56,800
And that's why a lot of them go into firefighting, police work, EMT, intense jobs where there's meaning.

261
00:20:57,200 --> 00:20:58,640
The meaning is what you do every day.

262
00:20:58,800 --> 00:21:00,000
You don't have to look for it.

263
00:21:02,000 --> 00:21:12,160
So I think that, and this is sort of shifting gears because I told you talking about PTSD is a waste of time.

264
00:21:12,480 --> 00:21:14,000
You have to do things differently.

265
00:21:14,560 --> 00:21:28,720
Now I'm shifting to a more existential thing because suicide is not just avoidance, it's complete avoidance, and it's deciding that there's not a meaning, right?

266
00:21:29,760 --> 00:21:39,120
So people need to do things that they value, family level, spiritual level, vocational level, hobby level.

267
00:21:39,440 --> 00:21:54,080
And so one thing is, can the veteran who's come back find a position in life, either as a parent, a spouse, or a worker, volunteer, that gives some meaning?

268
00:21:56,480 --> 00:22:05,120
The other thing is, is there enough support to put some time in between the impulse and the act?

269
00:22:05,520 --> 00:22:20,880
So what we know about suicide and suicide prevention from Tom Joyner and Craig Bryan and Matthew Nock and these super famous researchers in this area is you need to put some minutes in between the urge, the intent, and the act.

270
00:22:21,440 --> 00:22:24,000
And if you can do that, think about what I'm saying.

271
00:22:24,160 --> 00:22:34,080
If you can put some minutes in between the decision to kill yourself and the action to kill yourself, you can prevent suicides.

272
00:22:35,600 --> 00:22:38,480
Because things can happen, the mind can change.

273
00:22:40,560 --> 00:22:42,800
What's the major way veterans are killing themselves?

274
00:22:44,720 --> 00:22:47,280
Well firearms are a big issue.

275
00:22:48,560 --> 00:22:53,120
If there's a firearm present, it's very hard to slow the bullet down.

276
00:22:54,960 --> 00:22:59,040
So you no longer have the opportunity to put minutes.

277
00:22:59,200 --> 00:23:00,480
And guess who's armed?

278
00:23:00,800 --> 00:23:02,880
All of our veterans are first responders.

279
00:23:03,120 --> 00:23:04,720
Well the entire country more or less.

280
00:23:04,800 --> 00:23:07,840
I mean if you live in the southeast, the chances are 100%.

281
00:23:08,160 --> 00:23:10,960
I mean I have weapons, I live in the southeast, that's what happens.

282
00:23:11,440 --> 00:23:22,080
But if you've been suicidal, if you feel like you are going to kill yourself, think about the family, think about the kids.

283
00:23:22,400 --> 00:23:28,000
If you have sons, you've just increased their potential tremendously and daughters, but particularly if you're a guy.

284
00:23:28,400 --> 00:23:32,800
You need to lock the weapons up or give them to a buddy for a few months.

285
00:23:34,080 --> 00:23:34,640
That's it.

286
00:23:35,520 --> 00:23:37,680
They're still your weapons, you can still get them.

287
00:23:39,040 --> 00:23:40,320
Make it inconvenient.

288
00:23:40,640 --> 00:23:41,840
Put some minutes in between.

289
00:23:42,160 --> 00:23:47,040
Well how is putting them in a safe in my neighbor's house going to do anything if I can go over there and he gave me the key to the house?

290
00:23:47,200 --> 00:23:48,960
Well it's some minutes.

291
00:23:50,000 --> 00:23:52,240
Put minutes in between the acts.

292
00:23:52,320 --> 00:23:55,120
So to answer your question, why is veteran suicide so active?

293
00:23:55,200 --> 00:23:57,200
Well because they have the means to do it too fast.

294
00:23:58,320 --> 00:24:00,800
And same thing with first responders.

295
00:24:01,120 --> 00:24:03,280
And so we want to put some minutes.

296
00:24:03,440 --> 00:24:08,160
Now you can put some minutes by also, you have people you can call, you have battle buddies.

297
00:24:08,320 --> 00:24:13,440
A lot of times, I mean the last three veterans I called said, well I have my wife or I have my husband.

298
00:24:14,560 --> 00:24:18,240
That's great, but sometimes you want to protect them so you don't talk to them.

299
00:24:18,720 --> 00:24:20,960
So I want you to have somebody you don't need to protect.

300
00:24:22,240 --> 00:24:26,960
And your wife, and your husband, you know, whoever.

301
00:24:27,200 --> 00:24:32,640
So I try and build up, again, the number of people a person can call early, why?

302
00:24:33,280 --> 00:24:35,840
I want minutes in between the thought and the act.

303
00:24:36,800 --> 00:24:38,640
So that's the main reason.

304
00:24:38,960 --> 00:24:43,360
I think it's because the way of killing yourself is very accessible and very fast.

305
00:24:43,920 --> 00:24:45,280
And we need to put some time.

306
00:24:45,760 --> 00:24:51,200
And so we can put some time through inconvenience, gun locks, neighbor's safe, whatever.

307
00:24:51,280 --> 00:24:57,120
We can put some time through people that you can call that you know you can call and you don't have to worry about it because they've been through it as well.

308
00:24:58,880 --> 00:25:01,360
What role does moral injury play in suicides?

309
00:25:01,520 --> 00:25:05,120
And for people who may not be aware of the term, would you please define moral injury?

310
00:25:05,520 --> 00:25:07,280
Yeah, well, that's the one that scares me the most.

311
00:25:07,440 --> 00:25:14,480
I'll give you a scenario that I've heard so many times, and these are the people I have my most to worry about in terms of suicide.

312
00:25:16,000 --> 00:25:25,280
You are engaging an enemy combatant who has a weapon on your team, and you have to kill that person.

313
00:25:25,520 --> 00:25:28,560
And you see it's a 14-year-old or a 13-year-old kid.

314
00:25:29,600 --> 00:25:31,360
And now you have horrible guilt.

315
00:25:31,440 --> 00:25:37,520
Now, you know, if you didn't pull that trigger, you and the rest of your team could have been killed.

316
00:25:38,560 --> 00:25:40,880
And then the next day, another team could have been killed.

317
00:25:41,040 --> 00:25:43,760
So you had to pull the trigger, but you got a 14-year-old kid at home.

318
00:25:44,560 --> 00:25:49,920
Or what happens is your kid turns that age, and all of a sudden, everything comes back.

319
00:25:53,040 --> 00:25:58,320
Or another one is you rotate a tour, you want to call your wife.

320
00:25:58,480 --> 00:26:01,200
So somebody says, no, I'll grab this convoy.

321
00:26:01,280 --> 00:26:02,160
You take the next one.

322
00:26:02,400 --> 00:26:03,120
And they get killed.

323
00:26:04,480 --> 00:26:06,000
It should have been you, you think.

324
00:26:08,240 --> 00:26:14,000
So this idea of guilt, can we treat it?

325
00:26:14,080 --> 00:26:14,560
Yes, we can.

326
00:26:16,880 --> 00:26:23,280
People understand on the surface, but they don't believe it.

327
00:26:23,600 --> 00:26:32,400
And so we actually have people go through treatment, go into the memories, go into the events over and over again, replay the movie.

328
00:26:32,480 --> 00:26:34,880
You don't want to replay the movie randomly.

329
00:26:35,040 --> 00:26:37,680
And when it triggers it, we have you replay it yourself.

330
00:26:37,760 --> 00:26:39,520
It's not you're being thrown into the pool.

331
00:26:39,680 --> 00:26:41,440
You're getting into the pool yourself.

332
00:26:41,760 --> 00:26:56,080
And we have them go through the memory and the experience in graphic detail, in present tense over and over and over again, not to torture themselves, but to help them get used to the memory so that the memory comes on their terms.

333
00:26:56,880 --> 00:26:58,640
So it doesn't punch them in the face.

334
00:26:59,280 --> 00:27:01,200
It's a bad memory and you feel bad.

335
00:27:01,920 --> 00:27:05,200
But you start to see, I had no other choice.

336
00:27:07,360 --> 00:27:10,480
And you start to realize this is what had to happen.

337
00:27:11,360 --> 00:27:22,720
But if you push those memories out of your mind, as they come in, because you see somebody, your son is now that age or whatever, you don't go through that process of realizing.

338
00:27:22,880 --> 00:27:24,800
You know it, but you don't realize it.

339
00:27:24,960 --> 00:27:25,840
You know the difference?

340
00:27:26,480 --> 00:27:33,200
And so the problem with moral injury is you feel like you deserve the pain.

341
00:27:35,200 --> 00:27:40,480
And in some situations, you might, but those are rare.

342
00:27:40,720 --> 00:27:48,000
Like if you're a serial killer, or you get high and you go out and shoot up a family, but that's not what our veterans did.

343
00:27:49,040 --> 00:27:56,160
They defended their team and there were other casualties and they had to make that choice.

344
00:27:57,120 --> 00:28:02,080
But you don't, you know that, but you don't know it until you re-experience it over and over again.

345
00:28:02,320 --> 00:28:02,960
You have to go.

346
00:28:03,280 --> 00:28:05,120
It's a no pain, no gain treatment.

347
00:28:05,200 --> 00:28:11,360
It sucks, but we don't have surgery to take out memories, nor should we, because that's what defines the person.

348
00:28:12,080 --> 00:28:17,200
Your experiences, the sum total of your experiences, good and bad, make you the person you are.

349
00:28:18,480 --> 00:28:34,720
So this is sort of a long diatribe, but moral injury is, if you're suffering from what we call also traumatic guilt, you need to talk to somebody, because it's going to impact all of your life and it's going to impact your kids' lives.

350
00:28:34,960 --> 00:28:41,920
And you want your kids to see you liking yourself, so they like themselves, because they observe and they model and they learn.

351
00:28:43,040 --> 00:28:54,320
So if you have self-hate, if you have traumatic guilt, that's a form of post-trauma response that can be treated and should be treated, if not for you, for your kids.

352
00:28:55,360 --> 00:29:15,440
Yeah, I'm doing some work for the 25th commemoration of 9-11 next year, and I've been interviewing some folks, veterans who were at the Pentagon that day, and there were two in particular who remember they were at a table in the wing that got hit, and spouses of those have come to them saying, one in particular, the veteran said, well, I was here.

353
00:29:15,920 --> 00:29:16,560
He was killed.

354
00:29:16,720 --> 00:29:17,280
He was killed.

355
00:29:17,440 --> 00:29:18,160
She survived.

356
00:29:18,320 --> 00:29:18,800
He was killed.

357
00:29:18,960 --> 00:29:19,600
She was killed.

358
00:29:19,760 --> 00:29:26,000
And the spouse was like, how come you survived and not my husband or not my wife?

359
00:29:26,560 --> 00:29:29,120
And I couldn't imagine going through that.

360
00:29:29,440 --> 00:29:33,120
I really couldn't, to your point, year after year, decade after decade.

361
00:29:33,360 --> 00:29:38,800
And so that just has to be a monumental rock on your back, on your shoulders.

362
00:29:39,440 --> 00:29:39,760
It is.

363
00:29:40,080 --> 00:29:44,080
But if you go through, and in that situation, it was luck of the draw.

364
00:29:44,800 --> 00:29:49,280
So you go through these memories over and over again, and some people say, you know what?

365
00:29:49,840 --> 00:29:50,480
It was luck.

366
00:29:50,560 --> 00:29:51,600
I was given another chance.

367
00:29:51,920 --> 00:29:55,520
What am I going to do that I value that is good?

368
00:29:56,720 --> 00:29:57,120
You know?

369
00:29:57,520 --> 00:30:01,120
And I tell people, listen, this might not solve it.

370
00:30:02,560 --> 00:30:05,760
But if you feel this guilt, what can you do?

371
00:30:06,720 --> 00:30:08,160
Don't talk to me about what can you do?

372
00:30:08,320 --> 00:30:09,200
And they say, what are you talking about?

373
00:30:09,200 --> 00:30:17,440
I go, what can you do to make the situation that is currently level X a little bit better?

374
00:30:18,640 --> 00:30:19,840
Can you volunteer?

375
00:30:20,560 --> 00:30:22,400
Can you go talk to school?

376
00:30:22,640 --> 00:30:23,440
What do you want to do?

377
00:30:23,760 --> 00:30:24,800
What's your skill set?

378
00:30:25,600 --> 00:30:27,840
You know, can you work in a soup kitchen?

379
00:30:27,920 --> 00:30:29,040
I mean, what do you want to do?

380
00:30:29,120 --> 00:30:31,600
Do an hour a week or something and tell me if that helps.

381
00:30:32,000 --> 00:30:33,680
I guarantee it won't hurt.

382
00:30:35,360 --> 00:30:47,760
And it always comes back to the idea that by and large, veterans, first responders, they're doing these jobs because they're action-oriented people.

383
00:30:48,960 --> 00:30:54,880
And I need to remind them of that and then suggest that they do something.

384
00:30:55,840 --> 00:30:56,640
You feel bad.

385
00:30:56,880 --> 00:30:57,760
What can you do?

386
00:30:58,320 --> 00:31:04,400
You can't give this lady her husband back who is sitting next to you, but maybe you can mentor a kid.

387
00:31:05,040 --> 00:31:07,760
Maybe you can give lectures in school a couple hours a week.

388
00:31:07,920 --> 00:31:08,560
What can you do?

389
00:31:08,800 --> 00:31:12,080
What do you want to do to make the world situation a little bit better?

390
00:31:14,240 --> 00:31:23,200
And I find that that's extremely effective for a lot of people, particularly veterans and first responders who are doing types of people.

391
00:31:23,520 --> 00:31:26,480
That's why they're veterans and first responders, right?

392
00:31:29,040 --> 00:31:33,360
Are we doing enough to involve peers, families, and others in suicide prevention efforts?

393
00:31:33,840 --> 00:31:36,960
Well, let's just talk about it writ large in mental health efforts.

394
00:31:37,200 --> 00:31:40,080
So we just did a study, Dr.

395
00:31:40,240 --> 00:31:48,000
Melvin Hernandez Tejada and others, a DOD study where we added peers to this exposure treatment.

396
00:31:48,240 --> 00:31:51,360
Remember I told you, you go to Walmart in the parking lot and then you go inside.

397
00:31:52,080 --> 00:31:55,600
That's the in vivo exposure we call it, in the world exposure.

398
00:31:56,720 --> 00:32:00,800
And normally you don't involve peers in those active parts of the treatment.

399
00:32:00,880 --> 00:32:01,840
You just involve peers.

400
00:32:01,920 --> 00:32:04,800
Hey, you get, you know, confocal, hey, you're getting your treatments.

401
00:32:05,120 --> 00:32:06,080
Is everything okay?

402
00:32:06,400 --> 00:32:06,480
No.

403
00:32:06,720 --> 00:32:07,840
We rewrote the book on that.

404
00:32:07,920 --> 00:32:09,760
We said, let's do it the way we're not allowed.

405
00:32:09,920 --> 00:32:17,680
Let's actually have them meet at the exposure sites like workout buddies, like you might meet at the gym.

406
00:32:17,920 --> 00:32:23,040
And what happened is when you join the gym and someone's, come on, join the gym with me, join the gym.

407
00:32:23,200 --> 00:32:23,920
We'll go to the gym.

408
00:32:24,080 --> 00:32:27,680
And then it's like Tuesday and you're getting ready to go to the gym and they call you like, yeah, I'm not going.

409
00:32:27,760 --> 00:32:28,880
Like, no, you son of a bitch.

410
00:32:28,960 --> 00:32:30,160
You made me join the gym.

411
00:32:30,320 --> 00:32:31,520
We're going to the gym.

412
00:32:31,920 --> 00:32:33,760
Let's go get off your ass.

413
00:32:33,920 --> 00:32:34,000
Right.

414
00:32:34,400 --> 00:32:35,040
They push it.

415
00:32:35,440 --> 00:32:36,880
Same thing happened in this situation.

416
00:32:37,520 --> 00:32:43,440
And but veterans, if you say, hey, you just finished this PTSD treatment, you did well.

417
00:32:44,560 --> 00:32:48,320
We need some peers to help other veterans who are having problems with the in vivo.

418
00:32:49,040 --> 00:32:49,680
Oh, shit.

419
00:32:50,080 --> 00:32:51,040
We were hoping for 10.

420
00:32:51,200 --> 00:32:52,000
We got 70.

421
00:32:52,880 --> 00:32:54,480
The veterans will help each other.

422
00:32:54,880 --> 00:32:57,040
And we don't want to make people dependent.

423
00:32:57,200 --> 00:32:59,840
So we just said, look, they're going to be doing this for about 10 weeks.

424
00:33:00,080 --> 00:33:04,160
We just want you to meet them two or three times a week for two or three weeks.

425
00:33:04,400 --> 00:33:07,840
So like six total out of the 10 weeks where they do it every day.

426
00:33:08,560 --> 00:33:15,600
The people who had a peer and met the peer even one time finished treatment at 95 percent.

427
00:33:15,760 --> 00:33:18,480
If you met the peers at least three times, it was 98 percent.

428
00:33:18,640 --> 00:33:22,240
If you didn't meet the peers at all, it was 50 percent.

429
00:33:23,040 --> 00:33:25,840
So what's the role of peers in treatment?

430
00:33:26,000 --> 00:33:27,840
The role is potentially very big.

431
00:33:28,560 --> 00:33:36,400
And so what I tell all my students, I just gave the lecture last week, the role of social connection in any treatment.

432
00:33:37,520 --> 00:33:38,080
It's big.

433
00:33:39,120 --> 00:33:43,040
Get somebody involved in what you're doing.

434
00:33:44,480 --> 00:33:45,760
You don't have to do it every time.

435
00:33:45,920 --> 00:33:47,360
You don't need to be dependent on them.

436
00:33:47,440 --> 00:33:50,240
It can be a spouse, can be a battle buddy, can be something.

437
00:33:50,640 --> 00:34:03,840
But if you treat it like a workout, where you have a partner, or if you treat it like a battle where you have a battle buddy, then you're going to give each other motivation when it's lacking in one or the other.

438
00:34:04,880 --> 00:34:08,240
And so the same thing can apply to suicidality.

439
00:34:08,400 --> 00:34:14,240
Remember I told you we need to put a few minutes in between the intent and the act.

440
00:34:15,600 --> 00:34:21,600
But they need to be able to call somebody who won't be, that they don't need to protect from the truth of what happened.

441
00:34:22,640 --> 00:34:23,760
Well, that's a peer.

442
00:34:24,800 --> 00:34:27,920
And so I don't do it with general peer support group.

443
00:34:28,240 --> 00:34:29,280
I do it with a peer.

444
00:34:29,360 --> 00:34:35,040
They know one of their peers, not somebody who just happened to be a veteran, but somebody they already know.

445
00:34:35,680 --> 00:34:44,000
Now, if I can't find that, then a general peer support might be good, but I'd like it to be somebody that they connect to, that they already know.

446
00:34:44,640 --> 00:34:47,360
But yes, absolutely, that's the type of person it is.

447
00:34:47,440 --> 00:34:48,640
So yeah, peers are everything.

448
00:34:49,280 --> 00:34:50,080
Social is everything.

449
00:34:50,400 --> 00:34:56,080
I tell people, if you can get busy doing something, and you can socialify it, socialify it.

450
00:34:56,160 --> 00:34:56,960
So you like to read?

451
00:34:57,360 --> 00:34:59,600
Read a Barnes and Noble instead of reading at home.

452
00:35:00,000 --> 00:35:00,320
Why?

453
00:35:00,480 --> 00:35:01,840
Well, you're out amongst people.

454
00:35:01,920 --> 00:35:03,120
Maybe you'll see somebody.

455
00:35:05,120 --> 00:35:07,600
One in a hundred chance is better than zero out of a hundred.

456
00:35:08,640 --> 00:35:09,840
And so it's the same thing.

457
00:35:10,080 --> 00:35:14,560
If you can involve a peer, you want to join a gym, see if you can join it with somebody else.

458
00:35:15,200 --> 00:35:18,720
You know, you're going to volunteer, see if you can get somebody else to volunteer with you.

459
00:35:19,360 --> 00:35:20,800
It'll make it more meaningful.

460
00:35:22,160 --> 00:35:23,120
Strength in numbers.

461
00:35:23,440 --> 00:35:23,920
That's it.

462
00:35:24,240 --> 00:35:25,440
That's what they're trained for.

463
00:35:26,000 --> 00:35:27,280
That's how they're trained.

464
00:35:28,960 --> 00:35:29,840
These aren't my ideas.

465
00:35:29,920 --> 00:35:31,040
These are veterans' ideas.

466
00:35:31,120 --> 00:35:36,000
They said to us, shit, if I had a battle buddy who would do this with me, it'd be a hell of a lot easier.

467
00:35:36,160 --> 00:35:38,640
And I'm like, yeah, but we don't want somebody to have your six the whole time.

468
00:35:38,800 --> 00:35:40,240
We want you to feel a little bit worried.

469
00:35:40,400 --> 00:35:42,560
And she said, yeah, that's why I won't do it with them every time.

470
00:35:43,760 --> 00:35:44,160
Okay.

471
00:35:44,400 --> 00:35:48,000
And that's why we came up with the three to four times a week for three to four weeks.

472
00:35:48,160 --> 00:35:50,080
The veterans sort of directed us to this.

473
00:35:50,320 --> 00:35:51,920
We just put the pieces together.

474
00:35:52,560 --> 00:35:53,040
Amazing.

475
00:35:53,120 --> 00:35:54,000
That's awesome.

476
00:35:54,640 --> 00:35:59,120
Have you ever worked with a patient who defied the odds or surprised you in how they responded to treatment?

477
00:36:00,160 --> 00:36:11,360
Well, it's hard to say because I think that these treatments are very effective and that if the person engages in the treatment, I think they're going to get better.

478
00:36:11,680 --> 00:36:15,360
I mean, I already think that, but I will give you one person.

479
00:36:16,720 --> 00:36:22,880
I don't know if you know the story in the Bible of Job, but Job kept on having a lot of bad things happen to him.

480
00:36:23,520 --> 00:36:25,120
This guy was one of the most faithful.

481
00:36:25,360 --> 00:36:30,560
The devil said to God, I bet you can shake his faith if you kill his family, take his home, take his fortune, do all this stuff.

482
00:36:30,640 --> 00:36:32,160
I bet then he would have his faith shaken.

483
00:36:32,160 --> 00:36:34,160
You know, Job wouldn't have his faith shaken.

484
00:36:35,200 --> 00:36:46,480
And I had a woman who was a very strong woman and she was a grandmother, a lot of losses.

485
00:36:46,560 --> 00:36:50,160
I mean, I won't go through it, but she lost her husband through a heart attack.

486
00:36:51,280 --> 00:36:52,480
She lost her son.

487
00:36:53,600 --> 00:36:55,040
He was a mail deliverer.

488
00:36:55,360 --> 00:37:03,200
Over 4,000 people came to his funeral because he was one of these guys that you would talk to as he delivered the mail.

489
00:37:03,680 --> 00:37:12,560
He had a car accident, bringing her other son's medicine in an ice storm in Long Island.

490
00:37:15,520 --> 00:37:21,360
Her other son that he was bringing the medicine to was currently, when she was seeing me, dying of sickle cell.

491
00:37:22,240 --> 00:37:27,520
She was defrauded by one of the scammers of all of her money.

492
00:37:31,520 --> 00:37:33,680
And then she got diagnosed with breast cancer.

493
00:37:36,000 --> 00:37:40,800
So what did she do?

494
00:37:43,440 --> 00:37:45,680
I don't know about you, but I probably would have given up.

495
00:37:47,120 --> 00:37:49,440
Well, she said, maybe I need to go talk to somebody.

496
00:37:49,600 --> 00:37:51,440
I said, yeah, you need to talk to somebody.

497
00:37:51,440 --> 00:37:52,000
She came in to me.

498
00:37:52,160 --> 00:37:54,960
Unfortunately for her, she didn't get a soft shoulder to cry on.

499
00:37:55,280 --> 00:38:00,240
She got somebody who said, well, what are you doing about it now?

500
00:38:01,200 --> 00:38:02,160
She goes, what do you mean?

501
00:38:02,240 --> 00:38:03,360
I go, what's your day like?

502
00:38:04,720 --> 00:38:08,400
She goes, well, the surgery went okay.

503
00:38:08,480 --> 00:38:09,600
They say I'm cancer free.

504
00:38:11,760 --> 00:38:13,520
So I'm trying to be here for my son.

505
00:38:14,160 --> 00:38:18,000
And I said, he's dying of sickle cell, right?

506
00:38:18,160 --> 00:38:18,640
She goes, yeah.

507
00:38:20,160 --> 00:38:24,640
I said, is it better to be a depressed mom or a less depressed mom?

508
00:38:24,800 --> 00:38:26,880
She goes, well, probably be better to be less depressed.

509
00:38:26,960 --> 00:38:39,120
I go, okay, well, you need to do some things that you value, that you enjoy, that give you some motivation to be a better mom for him, even if it means you have to leave him with a caretaker for a few hours and stuff.

510
00:38:40,080 --> 00:38:41,600
And she goes, yeah, you're right.

511
00:38:42,080 --> 00:38:43,520
And I said, she goes, how do I do that?

512
00:38:43,520 --> 00:38:46,320
I go, you just get a schedule and start volunteering a little bit.

513
00:38:47,440 --> 00:38:48,800
You do this, that, or the other thing.

514
00:38:49,520 --> 00:38:51,120
She liked to work in a clothing store.

515
00:38:51,200 --> 00:38:52,080
She loved to talk to people.

516
00:38:53,600 --> 00:38:59,040
So despite all of the things that happened, she was justifiably depressed.

517
00:38:59,200 --> 00:39:04,160
If events can cause depression, this was a justifiably depressed person.

518
00:39:05,520 --> 00:39:07,040
And I gave her a bit of a lifeline.

519
00:39:07,280 --> 00:39:14,160
I said, you'd be less depressed if you did two hours a week out of the house to help other people, because you live to help people.

520
00:39:16,240 --> 00:39:18,000
On the surface, you're helping people enough.

521
00:39:18,160 --> 00:39:19,920
You devote your whole life to yourself.

522
00:39:21,040 --> 00:39:24,560
But maybe you want to help other people too, just out of the house.

523
00:39:25,120 --> 00:39:26,560
My whole point is get her out of the house.

524
00:39:26,720 --> 00:39:29,040
I mean, her son would call me and say, you got to get her out of the house.

525
00:39:29,120 --> 00:39:30,160
She's driving me crazy.

526
00:39:30,320 --> 00:39:32,080
She's, you know, I'm okay.

527
00:39:32,800 --> 00:39:38,960
I mean, I'm not well, but she's just self-destructing here, you know, because he could tell.

528
00:39:40,320 --> 00:39:41,760
So yeah, she surprised me.

529
00:39:42,080 --> 00:39:49,520
But she is sort of like these veterans, the first responders, the veterans who have seen, you might see a couple of horrors in your life.

530
00:39:49,840 --> 00:39:50,480
Hopefully not.

531
00:39:51,360 --> 00:39:52,400
They see them every day.

532
00:39:54,000 --> 00:39:59,200
You know, it's hard to get past that.

533
00:39:59,520 --> 00:40:15,440
But the data show, if you do these things, if you interact with your environment, if you recalibrate, if you get out there and do the things that you know you value, can't just be going through the motions if you don't, but you got to value it.

534
00:40:17,040 --> 00:40:18,800
You can be as good a person as you can be.

535
00:40:19,040 --> 00:40:25,920
You might not be who you were, but you can be as good as you could be for your spouse, for your kid, for your job.

536
00:40:28,000 --> 00:40:34,320
As a follow-up to that mother in Long Island, you work with and have done research on elderly patients as well as military veterans.

537
00:40:34,720 --> 00:40:39,360
Does post-trauma stress manifest itself differently across generations or life stages?

538
00:40:39,600 --> 00:40:42,960
Are its symptoms and effects the same or different regardless of age?

539
00:40:45,360 --> 00:40:50,720
Well, I did a big study and I was all excited about these results.

540
00:40:50,880 --> 00:40:56,320
It was on the Florida hurricanes in 2004 when Florida got four hurricanes in a row.

541
00:40:56,800 --> 00:40:57,920
Bam, bam, bam, bam.

542
00:40:58,160 --> 00:41:01,200
We thought, geez, these old people in Florida, because that's God's waiting room, right?

543
00:41:01,280 --> 00:41:02,560
That's a retirement zone, right?

544
00:41:02,640 --> 00:41:03,280
I can say that.

545
00:41:03,360 --> 00:41:04,000
I'm from New York.

546
00:41:04,080 --> 00:41:05,920
You're required by law to retire there.

547
00:41:06,400 --> 00:41:10,160
I'll go there when I'm older, as the law states.

548
00:41:11,520 --> 00:41:16,800
I found that the older adults had way less PTSD.

549
00:41:18,400 --> 00:41:22,160
I present these results and I'm like, it's because of the wisdom that you get with age.

550
00:41:22,240 --> 00:41:26,240
Somebody raised their hand in the audience and goes, well, what about all the ones ...

551
00:41:26,800 --> 00:41:28,240
Maybe it's not wisdom with age.

552
00:41:28,400 --> 00:41:34,880
Maybe that's part of it, but maybe it's all the people who get really freaked out and upset or dead by the time they're older adults.

553
00:41:36,960 --> 00:41:41,360
That made me think, shoot, it's not good to be anxious and depressed all the time.

554
00:41:41,520 --> 00:41:42,480
It's not good for your health.

555
00:41:42,640 --> 00:41:53,520
Now we know there's an inflammation event that constant anxiety and depression can cause inflammation, and that can cause heart problems and lung problems and all sorts of issues.

556
00:41:59,440 --> 00:42:12,080
As you get older, if you survive, you do gather a certain wisdom that allows you to cope if you can find meaning.

557
00:42:13,840 --> 00:42:21,200
A lot of our families used to find meaning, and I can see how it works now because I have a granddaughter.

558
00:42:21,360 --> 00:42:25,200
A lot of our families find meaning through the intergenerational support, right?

559
00:42:25,360 --> 00:42:26,880
Grandparents helping grandkids.

560
00:42:27,200 --> 00:42:28,240
Parents are working.

561
00:42:29,600 --> 00:42:34,400
As you get older, if you can do that, but what do we have in our society a lot of times?

562
00:42:34,640 --> 00:42:35,680
We have relocations.

563
00:42:35,920 --> 00:42:37,760
We have parents living in other states.

564
00:42:39,200 --> 00:42:40,400
They have no purpose.

565
00:42:41,040 --> 00:42:42,320
They have no grandkids.

566
00:42:42,480 --> 00:42:43,200
They're retired.

567
00:42:43,360 --> 00:42:45,040
They go to doctor's appointments.

568
00:42:45,360 --> 00:42:49,200
I immediately, when I ran the older adult clinic, and you saw I have two hats.

569
00:42:49,280 --> 00:42:51,840
One is geriatric psychologist, one is veteran.

570
00:42:52,720 --> 00:42:53,760
People would come to me.

571
00:42:53,840 --> 00:42:56,560
I ran a clinic in Delray, Florida, South Florida.

572
00:42:56,720 --> 00:42:57,520
They were all retired.

573
00:42:57,680 --> 00:42:59,280
They did nothing but doctor's appointments.

574
00:42:59,520 --> 00:43:00,720
I would say, go volunteer.

575
00:43:01,040 --> 00:43:02,080
Why would I volunteer?

576
00:43:02,160 --> 00:43:02,800
I worked my whole life.

577
00:43:02,960 --> 00:43:03,760
I want to retire.

578
00:43:03,760 --> 00:43:05,200
I've been waiting to retire for 30 years.

579
00:43:05,280 --> 00:43:06,800
I go, yeah, but you got used to working.

580
00:43:08,800 --> 00:43:10,480
What are you doing that's meaningful?

581
00:43:12,000 --> 00:43:12,960
You got to give back.

582
00:43:13,200 --> 00:43:13,920
Go volunteer.

583
00:43:14,000 --> 00:43:14,400
Go do anything.

584
00:43:14,640 --> 00:43:15,200
It doesn't matter.

585
00:43:15,360 --> 00:43:16,320
Go help the animals.

586
00:43:16,480 --> 00:43:17,280
Go help other kids.

587
00:43:17,680 --> 00:43:18,400
Go help your daughter.

588
00:43:18,560 --> 00:43:19,680
Your daughter lives around town.

589
00:43:19,760 --> 00:43:22,400
You told me your daughter is constantly bothering you to watch the kids.

590
00:43:24,000 --> 00:43:25,040
Get a schedule.

591
00:43:25,360 --> 00:43:28,880
Tell her you'll do it every day from this time to this time when it's convenient for you.

592
00:43:29,680 --> 00:43:31,360
They're like, they come back to me.

593
00:43:31,520 --> 00:43:33,280
This is the thing I've heard so many times.

594
00:43:35,760 --> 00:43:42,080
I did what you said, and I'm not going to say I'm not depressed, but I'm too busy to be depressed.

595
00:43:42,160 --> 00:43:42,800
I'll take it.

596
00:43:43,040 --> 00:43:43,680
I'll take it.

597
00:43:43,760 --> 00:43:44,320
That's a win.

598
00:43:44,880 --> 00:43:50,880
So older adults, I think if they survive to be older adults, they evolve more coping responses.

599
00:43:51,120 --> 00:43:52,720
They can handle stress better.

600
00:43:53,600 --> 00:44:03,600
They can handle trauma better if they have purpose, if they have connection, if they have somebody to help them.

601
00:44:03,920 --> 00:44:07,520
The middle age tend to be the worst, and we call it the burden of middle age.

602
00:44:07,600 --> 00:44:08,400
That's when you're working.

603
00:44:08,480 --> 00:44:09,440
You're taking care of your kids.

604
00:44:09,680 --> 00:44:10,720
You're taking care of your parents.

605
00:44:11,120 --> 00:44:12,400
You're taking care of your marriage.

606
00:44:12,560 --> 00:44:14,080
Everything's on you at the same time.

607
00:44:15,440 --> 00:44:21,840
So it's really difficult from 30 to 60.

608
00:44:24,880 --> 00:44:31,280
But older adults, if they're not isolated, but if they're isolated and withdrawn, all bets are off.

609
00:44:31,440 --> 00:44:34,080
It's just as bad for them as it is for the most vulnerable people.

610
00:44:34,480 --> 00:44:38,720
So you've got to connect, and I tell people, look, call on the video call.

611
00:44:39,680 --> 00:44:40,640
Get a schedule.

612
00:44:40,720 --> 00:44:44,320
Every time you're in a car on your long commute, call one of your older relatives.

613
00:44:44,720 --> 00:44:45,360
Just do it.

614
00:44:45,440 --> 00:44:46,880
Monday is Aunt Therese.

615
00:44:47,040 --> 00:44:48,400
Tuesday is Aunt Carrie.

616
00:44:48,400 --> 00:44:49,760
Wednesday is Uncle Frank.

617
00:44:50,720 --> 00:44:51,360
And you call them.

618
00:44:51,680 --> 00:44:55,040
Then one, you're the favorite grandson, and that's important.

619
00:44:55,760 --> 00:45:00,720
And two, you're not wasting your time in the car being angry at traffic.

620
00:45:01,200 --> 00:45:03,200
And three, you're connecting to somebody.

621
00:45:03,600 --> 00:45:07,920
And so that's sort of how we try and keep people connected, if at all possible.

622
00:45:08,320 --> 00:45:09,360
But keep them busy.

623
00:45:09,360 --> 00:45:10,320
Keep connected.

624
00:45:10,880 --> 00:45:16,320
Older adults will deal with trauma better than younger adults, by and large, if they have those social connections.

625
00:45:17,200 --> 00:45:19,200
I love your comment about going to Florida.

626
00:45:19,360 --> 00:45:23,040
My wife has said to me, so I'm in my mid-50s, and she's like, when are you going to retire?

627
00:45:23,280 --> 00:45:24,880
And I'm like, I'm not going to retire.

628
00:45:25,040 --> 00:45:27,440
Because to your point, I am involved in too many things.

629
00:45:27,600 --> 00:45:30,320
And she goes, well, can we at least not retire somewhere warmer?

630
00:45:30,640 --> 00:45:31,760
Yeah, exactly.

631
00:45:31,760 --> 00:45:32,080
Exactly.

632
00:45:32,400 --> 00:45:33,120
I understand that.

633
00:45:33,360 --> 00:45:43,440
You have no, I mean, you can put in a waiver to go to South Carolina or Hilton Head or one of those places.

634
00:45:43,680 --> 00:45:46,720
And sometimes they'll grant that to the New Yorkers and the Connecticut people.

635
00:45:46,880 --> 00:45:47,360
Exactly.

636
00:45:47,520 --> 00:45:48,640
Some people from New Jersey.

637
00:45:48,720 --> 00:45:50,000
But that's a hard group to let.

638
00:45:50,400 --> 00:45:52,480
They're sort of funneled right down to them.

639
00:45:53,360 --> 00:45:54,320
Easy pass, right?

640
00:45:54,400 --> 00:45:55,360
Just direct flight.

641
00:45:55,600 --> 00:45:55,680
Yeah.

642
00:45:56,320 --> 00:45:58,560
So let's put your VA hat back on for a moment.

643
00:45:59,040 --> 00:46:04,880
What innovations or reforms do you think have been most impactful in recent years in improving mental health care for veterans?

644
00:46:05,680 --> 00:46:06,720
Home telehealth.

645
00:46:07,040 --> 00:46:08,560
So here's the deal.

646
00:46:09,120 --> 00:46:15,840
A lot of our veterans, when they come back, they come from rural areas or they seek out rural areas or nobody's going to bother them.

647
00:46:16,240 --> 00:46:18,320
And getting care is hard.

648
00:46:19,120 --> 00:46:25,680
And we have a lot of sites where it's very hard to recruit providers because they don't live there.

649
00:46:26,080 --> 00:46:28,320
But the veterans live there, but the providers don't.

650
00:46:28,640 --> 00:46:37,840
And so when I was doing this telehealth research, doing home-based telehealth, so treating PTSD in the home versus in person.

651
00:46:38,240 --> 00:46:41,280
I'll tell you right now, if you can get the person in person, that's better.

652
00:46:41,440 --> 00:46:41,680
Of course.

653
00:46:42,160 --> 00:46:42,240
Right?

654
00:46:44,400 --> 00:46:45,520
No one's arguing that.

655
00:46:45,600 --> 00:46:46,960
But is it good enough to do it?

656
00:46:47,200 --> 00:46:49,360
Is it almost as good to do it remotely?

657
00:46:49,680 --> 00:46:52,960
Well, the screen fades away and you start talking to the person.

658
00:46:53,280 --> 00:46:54,560
It's different than on the phone.

659
00:46:54,640 --> 00:47:04,560
If you can see the person's facial expression when they're agreeing, when they're disgusted, and with the treatment we do, we need to make sure they're getting bothered by what they're remembering.

660
00:47:05,040 --> 00:47:11,280
They have an emotional reaction, not a panic attack, but a bad reaction that they then overcome.

661
00:47:12,080 --> 00:47:13,840
You need to see the facial expression.

662
00:47:13,920 --> 00:47:20,400
So the biggest thing that the VA has done is home telehealth because it's meeting the veteran where they're at.

663
00:47:20,560 --> 00:47:23,600
That's Peter Shore, who's on the West Coast, who came up with that.

664
00:47:24,320 --> 00:47:28,720
Meeting the veteran where they're at is a way to give care.

665
00:47:29,760 --> 00:47:31,120
Is it better to bring them in?

666
00:47:31,200 --> 00:47:31,280
Yeah.

667
00:47:33,120 --> 00:47:37,120
They were taking a small plane to different islands that the providers were from.

668
00:47:37,920 --> 00:47:39,360
That's new telehealth, right?

669
00:47:40,240 --> 00:47:41,600
So that's the major change.

670
00:47:41,840 --> 00:47:48,000
So now Charleston, South Carolina is serving up and down the Eastern Seaboard to places in Georgia where they couldn't get providers.

671
00:47:48,080 --> 00:47:51,040
Now people are getting care very quickly.

672
00:47:51,200 --> 00:47:55,280
Then COVID came and everybody started doing that, right?

673
00:47:55,600 --> 00:48:12,400
That became another, because for once we actually had, we'd already done four studies with older adults, with PTSD, with depression, where we had the research that showed people get pretty much just as better on telehealth as in person.

674
00:48:12,560 --> 00:48:16,320
It's a little bit better in person, but compared to not getting treatment at all.

675
00:48:16,560 --> 00:48:19,040
So that's a major, major, major innovation.

676
00:48:19,200 --> 00:48:25,280
And VA is nice because VA moves super slow until they move super fast.

677
00:48:25,760 --> 00:48:29,120
And so when they saw this was working, I was like, yeah, bam, we're doing this.

678
00:48:29,760 --> 00:48:30,400
Make it happen.

679
00:48:31,360 --> 00:48:32,240
I was like, we can't do it.

680
00:48:32,240 --> 00:48:32,800
We can't do it.

681
00:48:32,800 --> 00:48:33,200
Can't do it.

682
00:48:33,200 --> 00:48:33,920
Oh, it's working.

683
00:48:33,920 --> 00:48:34,880
Okay, make it happen.

684
00:48:35,280 --> 00:48:36,720
And they made it happen.

685
00:48:36,880 --> 00:48:43,520
It's nice when you have a giant national healthcare system that you can shift gears and do the best practices overnight, basically.

686
00:48:44,080 --> 00:48:45,120
So that's one thing.

687
00:48:45,360 --> 00:48:48,400
You know, VA has tons of innovations that they do.

688
00:48:48,640 --> 00:48:54,000
The VA research came up, you know, first transplants, the first this, that, the telemedicine.

689
00:48:54,000 --> 00:48:57,200
I mean, VA has led the way in innovations that people don't know about.

690
00:48:57,280 --> 00:48:59,040
They're like, wait, that was VA research?

691
00:48:59,120 --> 00:49:00,560
I didn't even know VA did research.

692
00:49:00,560 --> 00:49:01,680
It's one of the missions.

693
00:49:02,160 --> 00:49:10,400
And so you might want to do a show with one of the VA historians one day or senior research people about all the VA innovations.

694
00:49:10,960 --> 00:49:11,920
It will blow your mind.

695
00:49:12,240 --> 00:49:17,440
You would not have believed how many innovations came from VA research.

696
00:49:17,680 --> 00:49:21,520
We actually, in my veteran nonprofit, we work with the VA's innovation ecosystem.

697
00:49:21,680 --> 00:49:22,320
Well, you know that.

698
00:49:22,800 --> 00:49:27,840
And I've worked with the gentleman who actually created the Million Veterans Program.

699
00:49:27,840 --> 00:49:28,960
Million Veterans Program, yeah.

700
00:49:28,960 --> 00:49:29,040
Yeah.

701
00:49:29,120 --> 00:49:36,560
And it's, to your point, similar to DARPA, they create things that people aren't aware of that become mainstream and part of everyday life.

702
00:49:36,800 --> 00:49:42,240
And so, you know, they get a lot of bad rep every now and then they need some positive reinforcement.

703
00:49:42,240 --> 00:49:43,280
Yeah, they need some positive PR.

704
00:49:43,600 --> 00:49:44,000
Exactly.

705
00:49:44,000 --> 00:49:44,720
They're doing good stuff.

706
00:49:45,040 --> 00:49:52,400
I mean, if you look at VA outcomes, blood pressure, diabetes, the outcomes in their primary care are better than the general public.

707
00:49:52,720 --> 00:49:56,560
People don't know that because the clinicians are held to account there.

708
00:49:57,920 --> 00:50:00,880
And all they're hearing about is the veteran that committed suicide in the parking lot.

709
00:50:01,040 --> 00:50:01,680
Right, right, right.

710
00:50:01,840 --> 00:50:03,600
Couldn't get in and committed suicide.

711
00:50:03,680 --> 00:50:03,760
Yeah.

712
00:50:04,720 --> 00:50:09,600
What do you personally find most rewarding and most difficult about working with trauma survivors?

713
00:50:11,680 --> 00:50:14,720
Well, giving people their lives back is pretty damn rewarding.

714
00:50:14,960 --> 00:50:20,800
Like I said, veterans who fought for our freedom had their freedom taken away until they get this treatment.

715
00:50:20,880 --> 00:50:27,120
Then all of a sudden they're able to go to, I use the example of the grandson's football game because that's a real patient.

716
00:50:27,280 --> 00:50:27,840
He came to me.

717
00:50:27,840 --> 00:50:28,880
He goes, I just want one thing.

718
00:50:29,040 --> 00:50:31,520
He goes, my grandson is getting a college scholarship.

719
00:50:32,240 --> 00:50:33,440
I need to see him play.

720
00:50:34,160 --> 00:50:35,920
I've never been to one of his games.

721
00:50:36,400 --> 00:50:40,000
And so, you know, that's a win right there.

722
00:50:40,080 --> 00:50:41,360
I'm like, oh yeah, we can do that.

723
00:50:41,520 --> 00:50:41,840
Wow.

724
00:50:42,000 --> 00:50:42,720
I would break it down.

725
00:50:42,800 --> 00:50:43,680
Here's how you do it.

726
00:50:44,080 --> 00:50:50,480
And I said, you don't have to like the crowds jumping up, but you won't have to leave anymore.

727
00:50:50,880 --> 00:50:52,960
You know, so that was a big win.

728
00:50:53,280 --> 00:50:56,400
I had another guy who, this was a horrible thing.

729
00:50:56,800 --> 00:50:58,320
His team forgot him.

730
00:50:58,720 --> 00:51:05,200
Like he was in Afghanistan and the truck broke down and they're like, you got to stay with the truck.

731
00:51:05,280 --> 00:51:06,640
He goes, why do I have to stay with it?

732
00:51:06,720 --> 00:51:07,520
Well, you're the new guy.

733
00:51:07,600 --> 00:51:08,320
You stay with the truck.

734
00:51:08,400 --> 00:51:09,280
We'll be back in two hours.

735
00:51:09,440 --> 00:51:10,720
They didn't come back until the next day.

736
00:51:10,800 --> 00:51:12,320
He spent the night up in a tree.

737
00:51:14,720 --> 00:51:17,520
This is a guy who had been in hand to hand combat.

738
00:51:17,840 --> 00:51:26,080
His first day as commanding officer was killed by close range fire in a market, standing right in front of him.

739
00:51:27,680 --> 00:51:32,400
He had seen several people in firefights killed next to him.

740
00:51:32,960 --> 00:51:33,920
Big, strong guy.

741
00:51:34,480 --> 00:51:35,440
What bothered him?

742
00:51:36,560 --> 00:51:37,920
Being forgotten overnight.

743
00:51:39,520 --> 00:51:49,360
And he was, another psychiatrist, a relatively well known psychiatrist, you know, referred to me and said, this is the worst case of PTSD I've ever seen.

744
00:51:50,160 --> 00:51:55,280
And it was, it was because of that, that event.

745
00:51:55,520 --> 00:52:01,760
And so doing the treatment with him was a little bit harder because his reaction was intense.

746
00:52:02,240 --> 00:52:10,400
Like he left one day and there was some people fighting out front of his shop and he didn't notice them until he heard something break.

747
00:52:11,120 --> 00:52:14,560
And oh man, he, he went back into battle mode.

748
00:52:16,080 --> 00:52:37,680
He unfortunately wasn't arrested, but he ran a barbershop, but there were people in the hospital afterwards and that was his motivation to come into treatment because, you know, he's trying to start a business and he's beating the crap out of customers in front of his place who were, who, he didn't think he was that affected until he saw that.

749
00:52:37,920 --> 00:52:47,120
So that was a very hard case because when the person doesn't realize, when they hear it from their spouse, they hear it from other people, they might not be motivated.

750
00:52:47,440 --> 00:52:54,080
When he put those two people in the hospital, then he realized, I'm not in control anymore.

751
00:52:54,560 --> 00:52:55,760
And that's scary.

752
00:52:56,000 --> 00:52:59,600
But remember, loss of control is a symptom of PTSD.

753
00:53:00,320 --> 00:53:02,640
And that was it.

754
00:53:02,800 --> 00:53:06,880
We were able to help him with the exposure treatment, with going through it over and over again.

755
00:53:07,040 --> 00:53:07,920
What does he avoid?

756
00:53:07,920 --> 00:53:10,640
He avoided going to the movies in seven years, that type of thing.

757
00:53:13,280 --> 00:53:18,800
So, so these cases do come back to you when you have a case, a hard case.

758
00:53:19,040 --> 00:53:19,920
They're the ones you remember.

759
00:53:20,640 --> 00:53:23,040
Most of the people get better when they start doing this.

760
00:53:23,200 --> 00:53:25,920
They, they naturally are action oriented.

761
00:53:26,080 --> 00:53:26,880
They get better so fast.

762
00:53:26,880 --> 00:53:28,640
It's like, okay, let's help the next person.

763
00:53:29,040 --> 00:53:30,080
And you help yourself.

764
00:53:30,160 --> 00:53:33,440
And here's how we always teach people what they did.

765
00:53:34,240 --> 00:53:35,840
We don't want them relying on us.

766
00:53:36,240 --> 00:53:38,000
They might say, I heard your voice in my head.

767
00:53:38,160 --> 00:53:41,040
I was going to, you know, I was going to take the elevator, but I took the stairs.

768
00:53:41,200 --> 00:53:45,280
I was going to go to Walmart when it was almost closed, but I said, screw it.

769
00:53:45,360 --> 00:53:45,760
I'll go now.

770
00:53:45,840 --> 00:53:47,920
And it's busy just to get a workout in.

771
00:53:48,080 --> 00:53:49,680
Like they call, we call it workouts.

772
00:53:49,840 --> 00:53:51,360
I get my extra workout in.

773
00:53:52,080 --> 00:53:52,160
So.

774
00:53:53,040 --> 00:53:53,280
Dr.

775
00:53:53,360 --> 00:53:54,960
Ron Ciano, we're out of time.

776
00:53:55,040 --> 00:53:56,240
Thank you so much for being with us today.

777
00:53:56,480 --> 00:53:57,440
Really appreciate your insights.

778
00:53:57,440 --> 00:53:58,320
I appreciate the opportunity.

779
00:53:58,640 --> 00:54:00,320
Thank you for letting me talk on and on.

780
00:54:00,560 --> 00:54:01,120
No, no, no.

781
00:54:01,280 --> 00:54:06,640
I appreciate you putting a big spotlight on it just so people are aware.

782
00:54:06,640 --> 00:54:08,240
And so I really appreciate that personally.

783
00:54:08,640 --> 00:54:09,280
Thanks so much.

784
00:54:09,520 --> 00:54:10,240
No, thank you.

785
00:54:10,320 --> 00:54:11,440
I'm Chris Meek.

786
00:54:11,440 --> 00:54:11,920
We're out of time.

787
00:54:12,000 --> 00:54:12,640
We'll see you next week.

788
00:54:12,880 --> 00:54:13,760
Same time, same place.

789
00:54:14,000 --> 00:54:17,120
Until then, stay safe and keep taking your next steps forward.

790
00:54:21,760 --> 00:54:24,560
Thanks for tuning in to Next Steps Forward.

791
00:54:24,800 --> 00:54:34,720
Be sure to join Chris Meek for another great show next Tuesday at 10 a.m. Pacific time and 1 p.m. Eastern time on the Voice America Empowerment Channel.

792
00:54:34,960 --> 00:54:37,840
This week, make things happen in your life.