Posttraumatic Stress Disorder and War-Related Stress (PTSD)

Posttraumatic StressDisorder Posttraumatic Stress Disorder and War-Related Stress (PTSD)

PTSD Posttraumatic Stress Disorder (PTSD) and War Related Stress PTSD

The National Centre for War Related Posttraumatic Stress Disorder’s most recent publication, Posttraumatic Stress Disorder (PTSD) and War Related Stress provides a description of the nature of PTSD and related conditions in lay terms.

Written by Mark Creamer and David Forbes from the National Centre for War Related PTSD and Grant Devilly from the University of Queensland the book incorporates a considerable number of insights from veterans with PTSD, their partners and counsellors from the Vietnam Veterans Counselling Service.

It also offers commonsense hints for coping better with the condition and a description of what formal treatment may entail.

Typefaces: Bodoni, Goudy Old Style and Times New Roman

Frontpiece

Ivor Hele Private John White 1941 crayon with charcoal 56 x 37.8 cm AWM.28483

All Photos and Artwork used with the permission of the Australian War Memorial

ISBN: 0–642–41460–2 PTSD

Posttraumatic Stress Disorder (PTSD) and War-Related Stress

Information For Veterans And Their Families National Centre for War-Related Posttraumatic Stress Disorder

The National Centre For War-Related PTSD. Locked Bag 1, West Heidelberg, Victoria 3081.

Tel: (03) 9496 2922 Fax: (03) 9496 2830 Email: [email protected] Web: www.ncptsd.unimelb.edu.au

The National Centre is a collaborative project between the Commonwealth Department of Veterans’ Affairs, The University of Melbourne, and the Austin and Repatriation Medical Centre.

Posttraumatic Stress Disorder & War-Related Stress i MESSAGE FROM THE MINISTER

Message From The Minister For Veterans’ Affairs

In recent years, we have seen an increasing awareness of the emotional and psychiatric effects that traumatic events may precipitate. Such events may occur in civilian life, in the form of assaults, accidents, and Bruce Scott traumatic bereavements. They may occur in the work context, particularly in high-risk occupations such as the partners and families in helping them emergency services, overseas aid to understand their loved one’s reac- agencies, and financial institutions at tions and in knowing how to respond. risk of armed hold-up. Perhaps the most Specialised treatment programs are obvious examples, however, are the now available in every state of traumatic events that the men and Australia. If you are suffering from the women of our Defence Forces face on kinds of problems described in this our behalf. book, you may wish to think seriously The stress of military service has about getting some professional help. been identified under many names over Call your local VVCS Office or the the years, including shell shock, war National Centre for more information neurosis, and battle fatigue. In more (see the contact details at the back of recent times, the term posttraumatic this book). stress disorder, or PTSD, has been In the meantime, I hope you will adopted and considerable effort has find the information and advice con- been devoted to assisting veterans and tained in this book to be helpful and currently serving personnel suffering supportive. from this debilitating disorder. The Department of Veterans’ Affairs, through the National Centre for War-Related PTSD, has taken a lead role in helping veterans to recover from the stress of their military experiences. The Hon. Bruce Scott MP This booklet provides sound advice Minister for Veterans’ Affairs and practical suggestions to assist veterans who are experiencing PTSD Minister Assisting the Minister or related problems. It is useful also for for Defence

Posttraumatic Stress Disorder & War-Related Stress iii HOW TO USE THIS BOOK

Then move on to the next section. You How To Use will gain much more from the book if you read it slowly and carefully. If you This Book have a partner or close friend, you may wish to read it with him or her. Take it in turns to read a section and then discuss it – does it apply to you and your relationship? If so, is there anything you can do about it? When you have finished the book, This book was developed by mental you may decide that you would like health professionals with considerable to obtain some extra professional help. experience in the area of posttraumatic By then you will have a good know- stress. Although it is directed primarily ledge of traumatic stress and the at veterans and their families, the infor- kinds of things that treatment may mation is equally applicable to survivors involve. In the meantime, we hope that of other kinds of trauma. the information in this book will help A large amount of information and you understand your problems and how advice is contained in these pages and to begin the process of recovery. we recommend that you do not try to Remember, there is much that you can master it all in one go. Read a small bit do to improve your quality of life, your at a time and, if necessary, re-read it relationships, and the way you feel. several times until you understand it. Good luck!

Light Horse Signallers at Tiberius (WW1) – AWM.B00277 iv Posttraumatic Stress Disorder & War-Related Stress ACKNOWLEDGEMENTS

tance in the production of this book- Acknowledgements let. Staff and veterans from the PTSD treatment program at the Austin & Repatriation Medical Centre, and staff and veterans from VVCS Posttraumatic Stress Disorder: Queensland, for their suggestions on Information for Veterans and Their early drafts of the manuscript. Wes Families was produced by the Kilham and Ros Woodward from National Centre for War-Related VVCS Head Office for their critiques PTSD. It was written by Mark and comments. Staff from the Creamer and David Forbes (National Younger Veterans Program of the Centre), and Grant Devilly Department of Veterans’ Affairs for (University of Queensland). their assistance with the practicalities. The National Centre would like And, finally, Joanne Cesario and to thank several people for their assis- Terry Lewis from the National Centre for a host of other things.

“The Original 11th Battalion, 3rd Brigade AIF, Egypt 1915 – AWM.A02875

Posttraumatic Stress Disorder & War-Related Stress v CONTENTS

vi Posttraumatic Stress Disorder & War-Related Stress CONTENTS

Contents

How To Use This Book iv

Acknowledgements v

Background 4

What is PTSD? 5 What is a traumatic event? 6

Common Symptoms of PTSD 8 Intrusive symptoms 8 Avoidance symptoms 9 Arousal symptoms 10 Why do traumatic stress symptoms develop? 11

Associated Problems 14 Anxiety 15 Depression 15 Alcohol and Drugs 17 Impact on Relationships and Work 18 Family functioning 18 Occupational functioning 20

Coping 22 Coping yourself 22 Coping within a family 26 Sleeping better 28

Posttraumatic Stress Disorder & War-Related Stress 1 CONTENTS

Contents

Treatment 30 Stabilisation and engagement 31 Education and information 33 Symptom management 34 Exposure therapy: confronting feared situations 37 Exposure therapy: confronting the memories 38 Cognitive restructuring 40 Psychodynamic psychotherapy 41 Relapse prevention 42 Alternative and adjunctive treatments 42

Resources 43 The Vietnam Veterans Counselling Service 43 The National Centre for War-Related PTSD 44 Accredited PTSD treatment programs 45 Support groups 45

AWM.8257

2 Posttraumatic Stress Disorder & War-Related Stress BACKGROUND

BACKGROUND

Ivor Hele Australian Soldier, Libya 1941 oil on canvas 58.4 x 48.2 cm AWM.28474 Posttraumatic Stress Disorder & War-Related Stress 3 BACKGROUND

has no simple answer. However, we Background know that between 12 and 15 percent of war-zone veterans – including peace-keeping forces – will go on to experience a chronic condition known as Posttraumatic Stress Disorder Whether in the military or as a (PTSD), while a further 12 to 15 civilian, at some point during our lives percent will experience at least some nearly all of us will experience a of the symptoms associated with this traumatic event that will challenge our condition. This booklet is aimed at view of the world or ourselves. providing information for veterans who Depending upon a range of factors, have developed some of the more com- some people’s reactions may last for just mon symptoms of PTSD. It is designed a short period of time, while others may to provide some suggestions as to what experience more long-lasting effects. veterans can do to help themselves and The question of why some what they can expect in the way of people are affected more than others treatment for this condition.

Ivor Hele, Meteor Jet, 1952, oil on canvas on plywood, 40.4 x 45.6 cm – AWM.40326

4 Posttraumatic Stress Disorder & War-Related Stress WHAT IS PTSD?

ed with PTSD during combat. In the What is PTSD? Vietnam War, this became known as a “combat stress reaction”. Some of these people continued on to develop what became known, in 1980, as PTSD is a psychological response to Posttraumatic Stress Disorder. the experience of intense traumatic Traumatic stress can be seen as part events, particularly those that threaten of a normal human response to intense life. It can affect people of any age, experiences. In the majority of people, culture or gender. Although we have the symptoms reduce or started to hear a lot more about it in disappear over the first few months, recent years, the condition has been particularly with the help of caring fam- known to exist at least since the times ily members and friends. In a of ancient Greece and has been called significant minority, however, the by many different names. It is referred symptoms do not seem to resolve quick- to often in literature and the work of ly and, in some cases, may continue to Shakespeare provides several good cause problems for the rest of the per- examples - some of these appear in this son’s life. It is also common for symp- book. In the American Civil War it toms to vary in intensity over time. was referred to as “soldier’s heart”, in Some people go for long periods with- World War I it was called “shell shock”, out any significant problems, only to while by World War II it was known relapse when they have to deal with as “war neurosis”. Many soldiers were other major life stress. In rare cases, the labelled as having “combat fatigue” symptoms may not appear for months, when experiencing symptoms associat- or even years, after the trauma.

VJ Day Melbourne – AWM.AO3637

Posttraumatic Stress Disorder & War-Related Stress 5 WHAT IS A TRAUMATIC EVENT?

the individual has experienced a What is a Traumatic threatening event that has caused them Event? to respond with intense fear, helplessness, or horror. For military veterans, the trauma may relate to direct combat duties, being in a dangerous war-zone, Trauma is a very personal thing. or taking part in peacekeeping missions What traumatises one person can be under difficult and stressful conditions. of less significance to others. This For civilians, the trauma can stem from variation in peoples’ reactions occurs either man-made events (such as physi- because of their individual personality, cal assault, sexual assault, accidents, beliefs, personal values, and previous and witnessing the death or injury of experiences (especially of other trau- others) or natural disasters (such as matic events in their life). It occurs also fires, earthquakes, floods, and because each person’s experience of the cyclones). Overall, there are no hard incident is unique. However, in all cases and fast rules to define trauma.

Vichy surrender 1941 – AWM.8997

6 Posttraumatic Stress Disorder & War-Related Stress COMMON SYMPTOMS OF PTSD

COMMON SYMPTOMS OF PTSD

Ivor Hele Briefing room 1953 oil on canvas on plywood 40.3 x 45.5 cm AWM.40320

Posttraumatic Stress Disorder & War-Related Stress 7 COMMON SYMPTOMS OF PTSD

Common Symptoms of PTSD

PTSD is characterised by three main groups of problems. They can be classi- fied under the headings of intrusive, avoidant and arousal symptoms.

‘Jericho’ – AWM.B1477 Intrusive Symptoms:

Memories, images, smells, sounds, and muscle tension when things hap- and feelings of the traumatic event can pen which remind them of the inci- “intrude” into the lives of individuals dent. Overall, these “intrusive” symp- with PTSD. Sufferers may remain so toms cause intense distress and can captured by the memory of past horror result in other emotions such as grief, that they have difficulty paying attent- guilt, fear or anger. ion to the present. People with PTSD report frequent, distressing memories of the event that they wish they did not have. They may have nightmares of the event or other frightening themes. Movement, excessive sweating, and sometimes even acting out the dream while still asleep may accompany these nightmares. They sometimes feel as though the events were happening again; this is referred to as “flashbacks”, or “reliving” the event. They may become distressed, or experience physical signs such as sweating, heart racing, New Guinea. 1944 – AWM.016593

8 Posttraumatic Stress Disorder & War-Related Stress COMMON SYMPTOMS OF PTSD

often try not to think about, or talk Intrusive Symptoms of PTSD: about, what happened, and attempt w to cut themselves off from the painful Distressing memories or images of feelings associated with the memories. the incident In their attempts to do this, they often w Nightmares of the event or other withdraw from family, friends, and soci- frightening themes ety in general, and begin to do less and less. This may help them to shut out w Flashbacks (reliving the event) the painful memories, but it can also w Becoming upset when reminded lead to a feeling of not belonging to the of the incident rest of society and no longer taking part w Physical symptoms, such as in activities they used to enjoy. In this sweating, heart racing, or muscle way the person can become “numb” to tension when reminded of the their surroundings and not experience event normal everyday emotions such as love and joy, even towards those close to them. Such reactions can lead to depression, feelings of isolation and problems within the family. They can also lead to severe problems with moti- Avoidance Symptoms: vation – people with PTSD often find it hard to make decisions and get themselves going. They may have difficulty making the effort to help Memories and reminders of trau- themselves or even to do things that matic events are very unpleasant and they would previously have found usually lead to considerable distress. enjoyable or easy. This can be very hard Therefore, people with PTSD often for family and friends, who often think avoid situations, people, or events that that the sufferer is just being lazy or may remind them of the trauma. They difficult.

9th Division, 1942 – AWM.41991

Posttraumatic Stress Disorder & War-Related Stress 9 AROUSAL SYMPTOMS

for long, getting only a small amount Avoidance and Numbing of work completed in a few hours, Symptoms of PTSD: easily distracted). Disturbed sleep is very common. w Trying to avoid any reminders of Anger is often a central feature in the trauma, such as thoughts, PTSD, with sufferers feeling irritable feelings, conversations, activities, and prone to angry outbursts with places and people themselves, others around them, and the world in general. Many veterans w Gaps in memory – forgetting feel let down, abandoned, and judged parts of the experience by others. They may have a sense of w Losing interest in normal activi- betrayal about the way they were treat- ties ed by a range of people on their return w Feeling cut-off or detached from to Australia or about things that have loved ones happened since. These feelings of betrayal often result in bitterness and w Feeling flat or numb anger. Some people only express their w Difficulty imagining a future anger verbally (which can still be very damaging). Others become physically aggressive and violent to property or people, even to those who are closest to them. Often veterans feel unable to control their anger. The power of their anger may be frightening for them and Arousal Symptoms: they often feel considerable remorse afterwards. Such symptoms frequently cause major problems at work, as well as with family and friends. Often people who have experienced a trauma have been confronted with their own mortality. Their assumptions and beliefs that the world is safe and fair, that other people are basically good, and that “it won’t happen to me”, may be shattered by the experience. After the event, these people often see danger everywhere and become “tuned in” to threat. As a consequence, they may become jumpy, on edge, and feel constantly on guard. This can lead to being overly alert or watchful and to having problems concentrating (for

example, not able to read a book Gulf of Oman. 1990 – AWM.P1403.48

10 Posttraumatic Stress Disorder & War-Related Stress WHY DO TRAUMATIC SYMTOMS DEVELOP?

Aust. Spitfire, Millingimbi 1942 – AWM.60732

a mass of new information that is hard Arousal Symptoms of PTSD: to accept or understand. It doesn’t fit with our view of the world or ourselves w Sleep disturbance – the way we think things are or should w Anger and irritability be. Human beings have a natural tendency to try and make sense of w Concentration problems things that happen around them. w Constantly on the look-out for When people experience a trauma, the signs of danger event keeps coming back into their w mind in an attempt to make sense of Jumpy, easily startled what happened. This is a natural way of trying to deal with, or come to terms with, difficult experiences and seems to work well for many stressful life events. However, due to the high level of distress associated with memories of Why Do Traumatic more severe trauma, the thoughts and Stress Reactions feelings tend to be pushed away to protect the person from this distress. Develop? The result is that, whilst the memory may go away for a while, the need for it to be dealt with has not been addressed and it keeps coming back. It is important to understand where The movement backward and forward the signs and symptoms of PTSD come from intrusive thoughts and feelings from. One of the leading clinicians in about the trauma to avoidance and the area, Mardi Horowitz, described numbing can then continue almost trauma as an experience that is, by its indefinitely unless the cycle is very nature, overwhelming. It contains addressed in some way.

Posttraumatic Stress Disorder & War-Related Stress 11 WHY DO TRAUMATIC SYMTOMS DEVELOP?

Throughout this, alternating bet- battle or other situations of threat. It ween short bursts of painful memories hypes us up and promotes our survival – and periods of avoidance and numbing, it may often be an adaptive way to the sense of feeling keyed-up persists. respond to a life threatening situation The traumatised person has been and certainly better than being immo- through an event that potentially bilised with fear. Again, however, it is threatened their life, or the life of no longer useful for our survival once someone else, so the mind and body stay on alert to make sure that it won’t the danger has passed. In fact, as we miss any sign in the future that such an all know, it starts to cause serious event may recur. It is safer to get it problems in our day to day lives. wrong by overestimating potential Traumatic stress reactions are threat than to risk the possibility of therefore sensible and adaptive both as missing any future threat. The persis- part of survival during the trauma and tent activation of this threat detection in attempts to come to terms with the system, however, leaves the traumatised trauma afterward. Once we recognise person feeling keyed-up or on edge where these symptoms come from, it is much of the time. In addition, easier to understand the typical trau- the threat detection system is so matic stress reactions. sensitive that it is constantly going off when there is no danger, in a way that The difficult part is letting go of aspects interferes with the person’s capacity to of these reactions that have ceased to live a normal and happy life. provide benefit and are A similar explanation exists with primarily interfering with the trauma- regard to anger. Anger was useful in tised person’s quality of life.

El Alamein 1942 – AWM.13660

12 Posttraumatic Stress Disorder & War-Related Stress ASSOCIATED PROBLEMS

ASSOCIATED PROBLEMS

Ivor Hele Private John Growns 1952 crayon with charcoal 56 x 37.9 cm AWM.40410

Posttraumatic Stress Disorder & War-Related Stress 13 ASSOCIATED PROBLEMS

are thought to be the result of people Associated trying to control either themselves and their symptoms (such as alcohol and Problems drug abuse) or their environment (such as avoidance behaviour and angry outbursts). Also, many of the signs are directly related to stress (such as skin PTSD is not the only psychological complaints and general aches and response to trauma. People may pains). Overall, the most commonly develop a range of other problems that associated problems in PTSD are those can affect their quality of life, their relating to anxiety, depression, and ability to relate to other people, and alcohol or drug use. These can be very their capacity for work. These prob- disabling to the person suffering from lems may occur on their own, or as part them, and may affect family members of the PTSD. Many of these problems and work colleagues.

“Ajana” – AWM.PB0084

14 Posttraumatic Stress Disorder & War-Related Stress ANXIETY

Anxiety: Common Symptoms of Anxiety:

w Apprehension, fearfulness, or terror Anxiety is best described as a state of apprehension and worry that some- w Shortness of breath and tightness thing unpleasant is about to happen. in the chest It is often accompanied by a range w Palpitations and increased heart of physical symptoms which are, in rate themselves, very frightening. Sometimes people experiencing these w Sweating symptoms believe that they are going to w Shaking, trembling, or dizziness die from a heart attack or go crazy. w Anxiety can be specific to certain situ- Fear of losing control or going ations (such as social events, crowded crazy places, or public transport), or it can be w Excessive worry a general state of worry about many w Feeling restless and on edge things in our lives. It can become very disabling, as people tend to avoid a w Muscle tension wide range of situations that make w Physical disorders (e.g., skin them anxious. The symptoms are very complaints, stomach upsets, unpleasant and may cause a great deal aches and pains) of distress. Some of the common anxiety and stress symptoms are shown at right.

AWM.75924

Posttraumatic Stress Disorder & War-Related Stress 15 DEPRESSION

Depression: Common Symptoms of Depression: w Feeling low, down in the dumps, Depression is a general state of low miserable mood and a loss of interest or pleasure w in activities that were once enjoyed. Feelings of worthlessness, help- Life becomes flat and grey, and lessness, and hopelessness nothing seems fun, exciting, or enjoy- w Lack of energy, easily tired able anymore. These depressed states w Lack of enthusiasm, difficulties can be very intense, leading to a total with motivation withdrawal from others and a state of numbness, or they can be lower in w Loss of interest and pleasure in intensity – just feeling “down in the normal activities dumps”. They may last for as little as a w Lack of appetite and weight loss few hours or as long as months or even w years. In more severe cases, the person Loss of sexual interest may believe that life is no longer worth w Difficulty sleeping or sleeping living. Around 50% of people with too much chronic PTSD also have significant w Poor concentration, memory, problems with depression. Some of the and decision making common signs of depression are shown at right. w Thoughts of suicide / death

Sergeant R. Simes – AWM.23118

16 Posttraumatic Stress Disorder & War-Related Stress ALCOHOL AND DRUGS

Depression is often associated with guilt. People with PTSD often report Alcohol and Drugs: strong feelings of guilt, shame, and remorse. This may be about the fact that they survived while others did not; In an attempt to cope with the it may be about what they had to do to unpleasant symptoms, many people survive; it may be related to things they turn to alcohol or other drugs. Around did about which they now feel 50% of males and 25% of females with ashamed. The nature of war is such that chronic PTSD also have major prob- there are often no acceptable or “good” lems with alcohol and drugs; the figures options: all options are bad (for for veterans are even higher. In example, kill or be killed). Sometimes Australia, the most common problem the guilt results from trying to apply drug is alcohol but many people also civilian, or peacetime, standards to a abuse other illicit drugs (for example, combat situation. If we judge our marijuana) or prescription medications. actions then by our standards now, we Drug and alcohol abuse impairs the per- may end up feeling guilty and ashamed. son’s ability to function effectively and For some veterans, those feelings can to relate to other people. It can cause be very damaging and can get in the great difficulties in areas such as rela- way of recovery. They are hard to work tionships, work, finances, and can cause on, but it is important to try and reduce violent behaviour. the intensity and strength of guilt by challenging the thoughts and beliefs associated with those feelings.

Housie, Empress Japan 1942 – AWM.3999

Posttraumatic Stress Disorder & War-Related Stress 17 IMPACT ON RELATIONSHIPS AND WORK

Impact on Relationships and Work

Traumatised people can become “consumed” or overwhelmed by their feelings. They may become preoccupied with survival in situations that they perceive as threatening. This may lead others to believe that individuals with PTSD are selfish, thinking only of themselves. This “egocentric” behaviour, together with the symptoms of PTSD, can impact on relationships Sth Vietnam 1967 – AWM.EKN 67/130/VN with family and friends, as well as on the person’s ability to function at work, hobbies, or other life areas.

ly intimate. On the other hand, feelings Family Functioning: of worthlessness, anxiety, and depression may result in a complete loss of interest in sex and difficulties becoming aroused. This tends to compound PTSD can directly affect family life feelings of inadequacy or guilt and their on a number of levels. A common sign partner may become resentful and hurt. of PTSD is inability or difficulty feeling Traumatised people often feel a and expressing emotions (for example, more general sense of detachment – love and enthusiasm). This may lead feeling generally “cut-off” from other partners, family members, and friends people. This often leads to reduced to feel “pushed away” and rejected. participation in activities and hobbies This, in turn, can leave the sufferer that they used to enjoy before the feeling isolated and unloved. In an trauma. This absence of shared enjoy- attempt to reassure themselves that able activities makes it difficult to have they are normal, traumatised people a normal family life. The partner is sometimes become sexually demanding, often left with the full burden of yet still find it difficult to be emotional- running the family. In some cases, a

18 Posttraumatic Stress Disorder & War-Related Stress FAMILY FUNCTIONING

great deal of time is spent focussing on to act in controlling ways toward fami- the veteran’s problems at the expense ly members in attempts to protect them of the partner’s needs. from perceived dangers. Traumatised people are often tired, Over a period of time, these due to disturbed sleep and depression, problems with family and friends can and can become cranky and irritable. severely erode trust and intimacy. Being worn-out by nightmares and an Eventually, it may become too much inability to get a good night’s sleep for those close to the individual. frequently means that the person Following trauma, the likelihood of simply has less energy to offer the separation and divorce is considerably relationship. They may say hurtful increased. things without really considering the implications of what they are saying. Traumatised people may try to compensate for their feelings of fear The feelings of detachment, and vulnerability by using anger to difficulty in expressing emotion, and pre-empt any perceived potential persistent irritability, which are threat. As one veteran stated “the best frequently part of PTSD, can all form of defense is attack”. This fear impact negatively on relationships can also motivate traumatised people with the family.

Receiving mail – AWM.11303/25

Posttraumatic Stress Disorder & War-Related Stress 19 OCCUPATIONAL FUNCTIONING

from working effectively at all. Occupational The decision to stop work is a diffi- Functioning: cult one. The veteran needs to weigh up the personal cost of remaining in the workforce against the benefits of trying to continue work, perhaps with reduced hours or responsibility (for The traumatised veteran may have example, sense of belonging, achieve- difficulty coping with pressure at ment, self esteem, and financial well- work. Irritability, jumpiness, mood being). Although the benefits of a regu- swings, poor concentration, and mem- lar pension and retirement from the ory problems may lead to disputes in the workforce may seem very appealing, workplace and frequent job changes. this is not a decision that should be They may be intolerant of other peo- taken lightly. ples’ inefficiency, comparing “civvy street” with the organised, military way. Some veterans with PTSD adopt a workaholic pattern, shutting Problems such as irritability, mood themselves away in their work and swings, poor concentration, and mem- putting in very long hours. This seems ory disturbance can often interfere to be part of the avoidance component with the veteran’s capacity to work of PTSD – keeping very busy helps to effectively. Alternatively, the veteran prevent the memories and unpleasant may use a “workaholic” pattern as a thoughts coming back. Other veterans way of attempting to avoid the find that their problems prohibit them unpleasant memories.

Sydney, NSW, C. 1918? – AWM.H11576

20 Posttraumatic Stress Disorder & War-Related Stress COPING

COPING

Ivor Hele Flight Lieutenant Peter Middleton 1952 oil on canvas on plywood 45.5 x 40.5 cm AWM.40328

Posttraumatic Stress Disorder & War-Related Stress 21 COPING

Some people who develop PTSD Coping seem to recover completely and are left with little or no on-going distress and impairment. For others, the symptoms may persist and the individual must learn to manage and cope with them in It is not very helpful to think of order to minimise the effects on their “curing” PTSD in a black-and-white, lives. There is much that people with all-or-nothing manner. Everyone who PTSD can do to help themselves deal experiences trauma will be affected by with the disorder. it. Some of those changes may be positive – for example, the survivor may become stronger in some ways, perhaps more caring and understanding of other’s misfortune. They may find that Coping Yourself: the experience has made them better equipped to deal with future life stress. Unfortunately, some of the changes will be negative, especially in cases of PTSD, The following is a list of tips that and coping with even the smallest some people have found to be useful. frustrations and difficulties becomes a Many of them are basic common sense, major challenge. but that does not mean they are unim-

Salvation Army Hut – AWM.93717

22 Posttraumatic Stress Disorder & War-Related Stress COPING YOURSELF

portant. On the contrary, if you can do may be able to find programs in your the basics (which is not easy) you will local community or VVCS (such as go a long way to successfully managing Heartsafe, Gutbusters, and Lifestyle your PTSD symptoms. Programs) to assist with some of these Do not try to do everything at once. areas. When you have read the following sections, you may wish to stop for a w Eat healthy meals. This sounds so while and work out a “plan of action”. simple, but how many of us actu- Which strategies sound particularly ally do it? A poor diet will useful for you? Which ones are you pre- increase your stress levels – if in pared to try? We suggest that you select doubt, talk to your general only one or two to begin with. Work practitioner or a dietician. out a plan to achieve them, one at a time, and set yourself some realistic w Get regular aerobic exercise like goals for the next week. At the end of walking, jogging, swimming, or the week, review your progress: modify cycling. You might want to your goals if necessary and/or try some take the opportunity to go for reg- additional strategies for the following ular walks with your partner. week. Over time, you will gradually Exercise is vital in effectively develop a range of coping strategies and managing stress. If you have changes to your lifestyle that will help PTSD, your body is almost you to feel more in control of your constantly geared up for “fight or symptoms and get more out of life. You flight”. Exercise helps to burn up those chemicals (like adrenalin) that are hyping you up and will help you to become more relaxed. w Get enough rest, even if you can’t sleep. Rest will help to increase your reserves of strength and energy. You may wish to try some kind of meditation, yoga, or relaxation exercises. (See also the section on “Sleeping Better” later in this booklet). w Establish, and try to stick to, daily routines (e.g., go to bed at a set time, get out of bed at a set time, plan activities for the day). Routine is very important in helping us to feel in control and to function effectively.

Firebase – AWM.CRO-68-579/VN

Posttraumatic Stress Disorder & War-Related Stress 23 COPING YOURSELF

w Set small, realistic goals to help a defined period (perhaps 30 min- tackle obstacles. At first, things utes each day between 6:00 and may seem insurmountable but 6:30pm). If unwanted thoughts broken down into small steps come into your mind at other they are manageable. Some times, gently remind yourself that people like to keep lists of tasks you will be thinking about it later to accomplish when they feel in the day. capable, crossing them off as they are completed. This can be very w Ask for support and help from rewarding, helping you to your family, friends, church, or acknowledge that you are achiev- other community resources when ing something. you need it. This is not a sign of w weakness. In general, other peo- Redefine your priorities and work ple are very keen to help as long out what is, and is not, achiev- as you let them know what you able. Try to be realistic – expect want. neither too much nor too little of yourself. Then focus your energy w Join or develop support groups– and resources on those priorities. sharing experiences with others w To help stop the constant stream who understand is often useful. of worrying and anger-producing Good starting points would be thoughts, set aside a specific time the veterans’ organisations (e.g., each day for thinking. Give RSL, VVAA, VVF, etc.) or the yourself permission to reflect and Vietnam Veterans Counselling deal with issues related to the Service (VVCS) despite the trauma (e.g., corresponding with name, they welcome inquiries the DVA) at appropriate times for from veterans of all conflicts).

SEYMOUR, VIC. 1944-11-25.

LT T.C. DERRICK, VC DCM (right) SHAKING HANDS WITH LT R.W. SAUNDERS (left), AS THEY CONGRATULATE EACH OTHER FOLLOWING THEIR SUCCESSFUL GRADUATION FROM THE OFFICERS' CADET TRAINING UNIT AT SEYMOUR. LIEUTENANT SAUNDERS WAS THE FIRST ABORIGINAL COMMISSIONED IN THE AUSTRALIAN ARMY.

AWM.083166

24 Posttraumatic Stress Disorder & War-Related Stress COPING YOURSELF

w Continue to educate yourself and us – make an effort to do this from your family about reactions to time to time. trauma. A good understanding of w Acknowledge unresolved issues PTSD and related disorders is and be honest with yourself: important in coming to terms what do you still feel hurt or with your experiences and begin- frightened or angry or guilty ning to deal with your problems. about? Recognising, and admit- ting to, the issues is an important w Look after your partner, if you first step to recovery. Use the hurt have one. Try to clarify your feel- and pain as a motivator to make ings and assumptions about him the necessary changes to heal or her, and check out whether (i.e., if you don’t want to contin- those feelings and assumptions ue feeling like that, what can you are accurate. Many problems are do about it?). caused by one partner jumping to w Talk to your children. Try to be conclusions or assuming that they supportive and patient. Obvious- know what the other is thinking. ly, this is not always easy, but Remember that men and women losing control and getting angry tend to react differently. Women only makes things worse. Set an tend to be caretakers and put oth- example by expressing your feel- ers first. Men tend to have more ings gently, controlling your difficulty acknowledging and anger, and showing problem expressing feelings of helplessness solving skills in dealing with and sadness and believe in family difficulties as they arise. “toughing it out”. We all like our (What exactly is the problem? partners to say and do things that Let’s work out a plan to handle it show that they value and care for and see how we go).

VJ Day Balikpapan – AWM.113723

Posttraumatic Stress Disorder & War-Related Stress 25 COPING

w When you’re feeling rotten, remember that those around you Coping Within A are probably also under stress. Family: w Focus on your strengths and coping skills. It may not feel like it at times, but you have many Partners and close friends are often strengths and strategies to deal at a loss as to how to help someone with with difficult times. PTSD. There are several things that loved ones can do to help the w Try not to use your PTSD or your traumatised person and you may find war experiences as an excuse for the following suggestions useful. hurting yourself or others. There is no excuse for being violent, w If possible, listen and empathise aggressive, or otherwise mistreat- when the traumatised person ing other human beings. It is wants to talk. Remember that it important that you take responsi- may be very hard for them to bility for your own behaviour. express what they’re going through. A sympathetic listener w Remember that you are not is important in minimising the alone. Lots of other veterans over tendencies of people with PTSD the centuries have experienced to withdraw and “shut down”. It these kinds of problems. There is is best not to say “I understand always hope. what you’re feeling” (you probably don’t, since you haven’t been Often some simple strategies through the same experiences). and healthy habits can go a long Instead, show your empathy by way to better managing your symptoms. The little things can make a difference in the way you look after yourself!

Returning Prisoner of war 1945 – AWM.108005

26 Posttraumatic Stress Disorder & War-Related Stress COPING WITHIN A FAMILY

comments such as “it must be and that you want to understand really difficult for you; I can see and assist them. that it upsets you; is there any- w thing I can do to help?” Re-assure them that they are now safe. w Spend time with the traumatised w Care about each other. Give person. There is no substitute for hugs. Tell each other how much personal presence. Just keep they are appreciated. Offer praise. doing the usual things that peo- Make a point of saying something ple do together. Do not feel that nice to each other every day. you have to talk about the trauma Good relationships are charac- or be their counsellor. Just being terised by lots of positive interac- with people who care about them tions, but they take a lot of hard is very important for traumatised work. individuals. Equally, try to respect w the person’s need for privacy and Don’t be afraid to suggest that private grief at times. they see a clinical psychologist, psychiatrist, or counsellor, or that w they seek support from peer Don’t tell survivors that they are groups. (But remember to do this “lucky it wasn’t worse” or to “pull in a tactful and caring manner – themselves together and get over not in the middle of an argu- it”. They are not consoled by ment!). such statements. Tell them, instead, that you’re sorry they w Laugh. Use humour (although were involved in such an event, not about the traumatic event).

35th Infantry in Captured Punt, New Guinea 1944 – AWM.73274

Posttraumatic Stress Disorder & War-Related Stress 27 SLEEPING BETTER

meal within a couple of hours of Sleeping Better: going to bed w Starting a gentle exercise routine and losing a bit of weight often helps with sleep Sleep disturbance is very common in PTSD and in depression. Medication w Don’t do anything in bed except sometimes helps, but it should be used sleep (and, perhaps, sex): don’t with caution and only as directed by watch TV, read, do crosswords, or your medical practitioner. There are think about worrying things. several simple “non-drug” strategies you Reserve bed for sleeping. can try that can be very helpful in w Get into the habit of doing some- improving sleep: thing relaxing before bed: listen w Get into a regular routine. In par- to a relaxation tape or some ticular, get up at the same time relaxing music, have a warm each morning even if you haven’t bath, slow down! slept well w Try not to worry about not sleep- w If you are not asleep within 30 ing: the more you worry about it, minutes, get up for a while before the less likely you are to drop off returning to bed. If you don’t drop to sleep. You can survive without off within 30 minutes, get up much sleep, even though you will again and so on be tired w Try to avoid caffeine (coffee, tea, w Sleep, like any habit, takes a cola, chocolate) from 6 pm while to change. Try to stick to onwards. Avoid alcohol and, if the above guidelines for at least possible, cigarettes from dinner- two weeks before deciding time onwards. Try not to eat a whether or not they help

VJ Day Melbourne – AWM112854

28 Posttraumatic Stress Disorder & War-Related Stress TREATMENT

TREATMENT

Ivor Hele Untitled 1949 crayon with charcoal 37.9 x 56 cm AWM.40383

Posttraumatic Stress Disorder & War-Related Stress 29 TREATMENT

Treatment for PTSD often involves Treatment several stages: 1. Crisis stablisation and engagement 2. Education about PTSD and related conditions Obtaining appropriate treatment for PTSD is not always as straightforward as 3. Strategies to manage the symp- one might think. First, the person has to toms (such as anxiety, anger, accept that there is something wrong depression, alcohol abuse, sleep and see the benefit of seeking help. problems, and relationship prob- Getting help is often frightening – for lems) many, it is a leap into the unknown – 4. Trauma focussed therapy (con- but without this first step, progress is not fronting the painful memories possible. Secondly, it is not always easy and feared situations) to find a helping professional who 5. Cognitive restructuring (learning understands PTSD and to whom you to think more realistically and re- can relate and trust. Sometimes it may evaluating the meaning of the be necessary to try a few different event) sources of help until you find the right one for you. As one starting 6. Relapse prevention and on-going point, contact details for some useful support organisations are provided in the back of this booklet. Alternatively, try asking It is important to remember that your general practitioner, community treatment can be painful and hard health centre, or veterans’ organisation work. Unfortunately, there is no easy for advice. There are many different way to get rid of the memories or aspects to treatment and many different make them less distressing. There is no approaches. However, this section will magic wand and no “sweet oblivious deal predominantly with the most antidote”. But the long term gains can common forms of treatment and the be enormous: effective treatment can ones that have been shown to be effec- dramatically assist your recovery, tive. Most require the services of an helping you to live a normal life once experienced mental health professional. again.

Vichy Surrender – AWM.8997

30 Posttraumatic Stress Disorder & War-Related Stress STABILISATION OF A CRISIS

Stabilisation Of A Crisis And Engagement In Macbeth consults a doctor about Treatment: his wife being troubled with thick coming fantasies that keep her from rest. He demands of the doctor:

“Cure her of that: PTSD symptoms are not usually Canst thou not minister to a mind constant in their intensity. Rather, they diseas’d; tend to fluctuate and there may be Pluck from the memory a rooted times when they “flare up” or worsen. sorrow; Although this can occur at any time, it Raze out the written troubles of is most likely to be triggered by things the brain; such as anniversaries or other reminders And with some sweet oblivious of the trauma and stressful life events antidote (such as family arguments, problems at Cleanse the stuff’d bosom of that work, death of a friend or relative). perilous stuff Crises can occur at any Which weighs upon the heart?” time of the day or night. Several 24- The doctor replies: hour telephone counselling services are “Therein the patient must minister available (for example “Veterans’ Line” to himself” – see the back of this book under Shakespeare: Macbeth “Resources”). Although talking on (Scene 1, Act 5) the telephone to someone you do not know may not sound like much help, it can often be very effective. At least it may help you get through the night or weekend until other support is available. During especially difficult times it may be necessary for the veteran to attend hospital as an inpatient. During his or her stay, the crisis may be treated with medication, psychotherapy, and general counselling. As well as stabilising the symptoms, a brief inpatient stay also provides a “time-out” period for both the veteran and their family to refocus on their direction. It is important that any current life crises are resolved, or at least put “on AWM.P516.05.03 hold”, before the real treatment of

Posttraumatic Stress Disorder & War-Related Stress 31 STABILISATION OF A CRISIS

PTSD can begin. It is not possible to treatment team if you are taking part devote the necessary concentration, in a group program). You will need to time, and energy to your recovery if spend some time getting to know each you are constantly worried about your other, and building trust, if you are to job, your relationship, your children, work on the difficult issues. We call or other important life areas. That is this process “engagement”. For many not to say that you have to be able to veterans with PTSD, this is a very dif- solve all those problems before you ficult process – it may have been a can work on your PTSD, but you will long time since they really trusted need to be able to put them to one side another person, particularly someone for a while to concentrate on your who is not a veteran. In many cases, treatment. Therapy is hard work – you will need to tell your therapist there is no easy way to do it – and you about experiences and feelings that will need to devote all your personal you have never discussed with anyone resources to the task. before. We need to recognise that this The first part of treatment will is a difficult process that will take a lot often be devoted to developing a rela- of courage, but it will be worth it and tionship with the therapist (or the it is the only way to recovery.

Japanese Swords, Labuan 1945 – AWM.109724

32 Posttraumatic Stress Disorder & War-Related Stress EDUCATION AND INFORMATION

it happened. This is because, when we Education And are under threat, our attention is very Information: focussed on the source of the danger and we do not take in all the other things that are happening around us. We may end up with a distorted and confused memory of the Trauma can sometimes feel like an experience, so that it becomes difficult incomprehensible cloud that hangs to understand and make sense of the over all areas of the person’s life. The event. This confusion often stops us first step in treatment is to understand from being able to put the experience exactly what trauma is, why we have behind us. For this reason, your the symptoms we do and, therefore, therapist may help you to find out more why it is treated the way it is. In this about what happened during the event. regard, it is hoped that the current (Although we have put this under the booklet is a first step in understanding heading of “Education and the disorder. You need to know what Information”, it is actually something the common signs and symptoms are, that may happen at several stages and you need to recognise that you are throughout treatment). This process is not alone – many people who have important in being able to “put the experienced traumatic events have pieces of the jigsaw puzzle together” responded in exactly the same way as and make sense of your experience. A you have. You need to understand why good understanding of exactly what the symptoms have appeared – the happened and why it happened often fact that they were very useful for facilitates recovery. Unfortunately, of survival while the traumatic events course, this is not always possible. were happening but that they are Sometimes we may never find out no longer useful. They have become exactly what happened or, more com- “maladaptive” and now only serve to monly, why it happened and we have to create problems and distress for you. learn to live with that uncertainty. You need to understand what treatment will involve and how it may affect you. It is very important that you feel able to ask your therapist questions about the nature of your problems and the process of treatment. He or she will not have all the answers, but together you will reach a better understanding of what has happened and how you will recover. Sometimes, people who have been through a traumatic event have trouble understanding what happened and why AWM.73274

Posttraumatic Stress Disorder & War-Related Stress 33 SYMPTOM MANAGEMENT

w Techniques to help you organise Symptom Management: your time effectively, scheduling enjoyable and productive activities and providing some structure As already noted, PTSD has many to your days symptoms that interfere with the traumatised person’s daily functioning. Anger Management: Techniques to Part of treatment usually involves reduce levels of anger and irritability providing the person with strategies to with others is always an important part cope with and manage these symptoms. in helping the PTSD sufferer. Not only Medication will often play a part in this does it help them to be more relaxed, stage of treatment. Unfortunately, such but it assists them in relating to others strategies rarely make the symptoms go and being part of normal society. away altogether. However, they help Strategies that are commonly used sufferers to carry on with their day- include: to-day functioning, no longer being w Education to understand the “helpless victims” of the symptoms. A nature and purpose of anger range of strategies may be used and w some of the more common are outlined Methods of identifying early below. However, it is important to keep warning signs of stress and in mind that the following is just a irritability guide; an experienced and qualified w Methods of identifying high risk therapist can help you accomplish these situations and how to prepare for techniques. them w Methods of realistically re-evalu- Anxiety Management: Techniques ating the situation, keeping it in aimed at reducing levels of anxiety and perspective arousal are an important part of treat- w ment. These techniques may include: Strategies to reduce arousal and stay calm in difficult situations w Relaxation training to reduce w overall levels of anxiety Effective communication methods (verbal and non-verbal) w Breathing techniques to reduce w panic-like symptoms Differentiating assertive from aggressive behaviour w Thought stopping methods to w break the tendency to ‘ruminate’ Problem solving strategies to or think excessively about the effectively deal with disagree- past ments w w Rational self-talk to help manage Distraction and removal tech- high anxiety situations and niques to avoid ‘flare-ups’ depressing thoughts w Practice in imagined and real-life situations

34 Posttraumatic Stress Disorder & War-Related Stress SYMPTOM MANAGEMENT

Management of Depression: As Medication Self-Management: mentioned above, people with PTSD Medication is frequently used to help frequently develop symptoms of manage severe PTSD symptoms depression. Therefore, strategies to (although, on its own, it will not reduce and manage depression are change the underlying problems and frequently employed as part of treat- should be combined with other treatment. Strategies may include the fol- ments). To minimise unintended diffi- lowing: culties associated with medication, the following strategies are frequently used: w Increasing positive, enjoyable events and scheduling these into w Education about the use and daily living effect of the drug w Education about possible side- w Methods of understanding the effects and activities or sub- underlying assumptions and stances to avoid beliefs about the self (e.g., “I’m a worthless failure”) or the world w Methods of keeping track of (e.g., “Nobody cares about me”) medication use that can lead to feelings of w Discussing the effects and desire sadness and depression to change medication with your psychiatrist w Identifying patterns of depressive thoughts on a day-to-day basis w Methods of reducing and stopping medication intake w Realistically evaluating and challenging negative beliefs and thoughts w Rational, realistic coping self-talk

Gulf War, I. Parrot – AWM.P1403/47

Posttraumatic Stress Disorder & War-Related Stress 35 SYMPTOM MANAGEMENT

Substance Abuse: As mentioned, Relationship Difficulties: People who many people with PTSD attempt to have been traumatised often lose track cope or “self-medicate” with excessive of who and what they can trust in the amounts of alcohol and inappropriate world. This often has a major impact drug use (including prescribed drugs). on relationships. To address the diffi- Treatment for alcohol or other drug culties that can occur between couples use can include: and family members, PTSD sufferers are frequently taken through a range w Education about the use and of strategies to improve relationships. effect of the substance Some of the methods used may w Decisions regarding total absti- include active listening (how to really nence versus controlled use of listen to your partner or children), the drug communicat-ion training (how to say w Recording “danger” times and effectively what you need and feel), identifying patterns of use and problem solving (how to solve everyday problems without fighting). w Developing coping strategies for Some of this may occur with the vet- high risk times eran alone and some with their part- w Assertiveness training for when ner. Separate support and counselling others are applying peer pressure for the partner is often beneficial. w Sometimes family therapy is provided, Planning and scheduling activi- where the whole family meet to ties not associated with the address their issues, with the aim of substance developing a healthy environment for w Response prevention – methods all. of resisting the ‘urge’

Sleep Disturbance: Many sufferers of PTSD report disturbances of sleep. Several strategies may be useful in addressing the difficulty of going to sleep, waking repeatedly throughout the night, or waking early in the morning. It is common for therapists to assist clients in developing a healthy sleep routine in line with the suggestions provided above. Other strategies, including medication, may be adopted when those are not prov- ing effective. (See the earlier section on Sleeping Better). Sergeant J. Trease, Vietnam – AWM.FOD.71254/VN

36 Posttraumatic Stress Disorder & War-Related Stress EXPOSURE THERAPY

had this experience in a range of Exposure Therapy – situations, such as going to a shopping Confronting Feared centre or watching a movie about war. Very often people believe that if they Situations: do not leave the situation they will “lose control”, “go crazy”, “have a heart attack”, or have some other dire consequences. At the very least, they are Anxiety frequently causes people to likely to believe that the unpleasant stay away from the frightening situa- feelings will be intolerable. Exposure tion. It is quite normal for people to therapy aims to show that this is not the want to escape or avoid situations, case by helping the person to thoughts, memories, or feelings that are confront the feared situation. This is painful or distressing. However, this is done in a very controlled and gradual one of the major impediments to fashion, overseen by therapists who are recovery. Avoidance and escape pro- experienced with the procedure, so that vide temporary relief – the anxiety discomfort is kept to a minimum. By reduces. Unfortunately, the next time building upon repeated successes in the person encounters that situation facing these feared situations, the again, he or she is likely to become person is eventually able to confront anxious long before it is planned to them without anxiety and they are no occur. We call this “anticipatory longer avoided. anxiety”. The more the situation is In many ways, this approach is avoided, the more the person continues common sense. Let’s take an example of to believe that it is dangerous. Further, a little boy who is standing on the even if the person does not avoid, the beach when a big wave knocks him anxiety may continue to build once over. He becomes very frightened of the they are in the situation. You may have sea and refuses to go to the beach the

VJ Day Balikpapan – AWM.113723

Posttraumatic Stress Disorder & War-Related Stress 37 EXPOSURE THERAPY

next day. How would his mother or father help? In order to overcome the Exposure Therapy – fear, his parents may take him for a walk Confronting The along the beach, staying away from the sea, holding his hand and Memories: reassuring him. Gradually, they walk closer and closer to the water’s edge. Eventually, the boy is able to go into A form of exposure therapy is also the sea again unaided. This is a simple used to treat distressing memories of the example, but exactly the same process trauma. In cases of PTSD, the applies to treating more severe and memories are the “feared situation”. complex fears in adults. These memories are so frightening, and In conducting exposure treatment, cause so much distress, that the person your therapist will work with you in tries to avoid or escape from them by constructing a hierarchy – a list of blocking them out. Often, exposure feared situations in order of difficulty. treatments are used to assist in Treatment involves tackling each item, confronting the memories. Exposure is one at a time, and moving on to the only one term used to describe this next only when you are confident to process. Some people talk about “trau- do so. More difficult items may be ma focus work”, “working through the broken up into several steps. Exposure trauma”, “coming to terms with the treatment can be difficult and painful, experience” or simply “confronting the but it is the most effective way of treat- memories”. There are many analogies ing many anxieties. used to explain this process to PTSD sufferers before treatment commences. The following analogies may help you to understand the process. “Very often, after a trauma we tend to pack the event away into a box. We try to file away what happened, putting it to the back of our mind. We then use a little strength to keep the lid tightly closed and try to leave it undisturbed. However, over time, two things happen. Firstly, our strength begins to wane and it becomes more of an effort to keep it sealed. Secondly, due to the pressure, the box begins to lose its shape and small cracks begin to appear. What we experience as symptoms (such as memories of the trauma, and having nightmares and disturbed sleep) is like Sth Vietnam 1967 – AWM.EKN 67/130/VN the content of the box spilling out

38 Posttraumatic Stress Disorder & War-Related Stress EXPOSURE THERAPY

through these cracks. This is usually fine for a few weeks or months, but the very frightening, so we try to avoid problems would keep coming back as anything that reminds us of the trauma. the tooth continued to deteriorate. We try to stop thinking and talking Instead, they spend some time drilling through what happened and how we and scraping, cleaning out all the decay felt. In this way the content of the box before putting the tooth back together. becomes a “ghost” which we have This is a very unpleasant and painful learned to fear. As part of therapy, we process, but we know it is worth going are going to open the box and inspect through this short term pain for the the content for what it really is. In long term gain. Traumatic memories are this way we can talk through what a bit like tooth decay. We need to make happened and how you felt. We will be sure that we have confronted all aspects inspecting the “ghosts” that have been of the trauma before we try to put the created and throwing away any mal- event behind us. We need to give our- adaptive and distressing beliefs you may selves time to face up to even the worst have about the event. We find that parts of the experience so that there are once the trauma has been dealt with in no skeletons in the closet to come and this manner the symptoms become haunt us in the future. Like the dentist’s much less severe and less frequent.” drilling, it is a painful process but an Another analogy talks about the important part of recovery”. dentist: A final analogy comes from the “When dentists work on a decayed work of Edna Foa, one of the leading tooth, they don’t just slap the filling on experts in the treatment of PTSD: top of the decay. If they did, it may be “Suppose you have eaten a very large and heavy meal that you are unable to digest. This is an uncomfort- able feeling. But when you have digested the food, you feel a great sense of relief. Flashbacks, nightmares, and trou- blesome thoughts continue to occur because the traumatic event has not been adequately digested. Treatment will help you to start digesting your heavy memories so that they will stop interfering with your daily life”. Exposure based treatments are not for everybody. In some cases, if the memories are not causing too much of a problem, it may be best not to drag everything up again. You may wish to talk to your therapist about whether this approach would be beneficial for you. Somalia, 1993 – AWM.MSU93/138/14

Posttraumatic Stress Disorder & War-Related Stress 39 COGNITIVE RESTRUCTURING

In a similar vein, people often Cognitive believe that certain events cause specif- Restructuring: ic reactions. For example, one may believe that being in a crowded shopping centre causes panic, as if there is some automatic connection between Following a traumatic experience, shopping centres and panic. However, people may be left with a range of the anxiety that people feel is not the negative interpretations or beliefs about result of the event itself. An inanimate what happened, as well as about them- object such as a shopping centre cannot selves and the world. For example, they make someone anxious by its own may think that they are bad or evil for doing. It is our interpretation about the acting in the way they did; they may situation that creates the anxiety, and think that what happened was their this interpretation is based upon beliefs fault; they may see themselves as weak we hold. In the above example the or inadequate; they may think that the active belief may be that one is in dan- world has become a dangerous place ger of being trapped. Therefore, when and that other people are nasty, cruel, the person is in a shopping centre they and out to take advantage. Sometimes, may have thoughts such as “I’m there may be elements of truth in these trapped, I can’t escape, I’m going to lose thoughts. Often, however, they are control”. It is these thoughts that cause completely untrue or, at least, grossly the feelings of panic. exaggerated. This kind of thinking Cognitive restructuring is a proce- leads to all sorts of unpleasant emotions dure whereby people’s thoughts, such as depression and guilt, anxiety beliefs and interpretations about past and fear, and anger. Sometimes therapy experiences are identified and mistakes will be aimed at helping the person to in thinking are highlighted. (Cognition identify those maladaptive thoughts, to is just a technical word for thoughts). challenge and dispute them, and to For example, it may be that the replace them with a more realistic view person is thinking in “black and white of themselves and the world. terms” – seeing things as all good or all

CWA Volunteers – AWM.89251

40 Posttraumatic Stress Disorder & War-Related Stress PSYCHODYNAMIC PSYCHOTHERAPY

bad – when in reality the world holds much that is “grey”. It may not be per- Psychodynamic fect, but it’s not all bad either. The per- Psychotherapy: son may be overgeneralising (e.g., “no- one can be trusted”) or over-focussing on the negatives and minimising the positives in most situations. They may see one negative thing as confirmation Therapists working with a psycho- that they are not coping, while ignoring dynamic approach attempt to integrate other evidence that they are, in fact, the person’s traumatic experience with coping quite well. Once these erro- his or her life as a whole. They do not neous thoughts and patterns are discov- focus on symptoms alone, but seek to ered, it is the goal of cognitive therapy make connections between the trau- to replace these with more adaptive, matic experience and vulnerabilities in realistic and flexible beliefs. This, of the person’s earlier life. They try to course, includes re-evaluating our expe- understand how current situations riences and, in particular, the traumatic evoke traumatic responses even event. It is a difficult process that can though the original trauma is past. The take a lot of hard work, but it can be psychodynamic approach seeks to very effective in minimising and man- understand the way in which the indi- aging unpleasant emotions. vidual continues to interpret the world in distressing and often self-destructive ways. Disruptive and traumatic experience earlier in life can predispose the individual to more deeply troubled responses to trauma later in life. So, for example, even though he would not have been responsible, a young boy may feel that he caused his parents’ relationship to break-up, leading to divorce. Later in life, as a young man, he may feel responsible for the death of his comrade in the war, even though in fact he would have been powerless to prevent his friend’s death. Psychodynamic psychotherapy can bring to light connections between such experiences. By means of this process, it may free the individual from excessive and unreasonable guilt (for example), once these experiences have Vietnam: Kevin A. “Dasher” Wheatly – AWM.4438 been worked through.

Posttraumatic Stress Disorder & War-Related Stress 41 TREATMENT

However, the focus of the therapy is have of doing something about it. Skills on current life experience and persist- acquired during treatment can then be ing difficulties. The past is re-visited applied to cope with the recurrence of only to the extent that it is being symptoms. At times, additional help replayed in the present, often in may be required – do not hesitate to self-defeating ways. Psychodynamic seek professional assistance if you think therapy is usually a longer term therapy you need it. Possible sources of help in and is not suited to all people. case of relapse should be identified as part of treatment so that you know where to seek help quickly if you require it. Relapse Prevention:

In some people, even following Alternative and treatment, PTSD can be a chronic disorder with lapses from time to time. Adjunctive Treatments: Preventing a recurrence of symptoms is most important for veterans with PTSD. Times of stress (for example, There are a host of other treatment family or work problems, bereave- techniques ranging from homeopathy ments, and financial difficulties) may to hypnosis that, while not being “run lead to a recurrence of symptoms in of the mill”, can help some people. It is some people. When this happens, it is our suggestion that these alternative important to remember that it was techniques are used only when more expected and not to feel that you are mainstream methods have proved back to square one. As long as it is not ineffective or as an adjunct to those too severe, and does not last too long, treatments when appropriate. Everyone you can deal with it. is different in their reaction to therapy As part of treatment, it is common and, occasionally, some treatments may to provide specific help directed do more harm than good, especially in towards maintaining the gains made the hands of inexperienced practition- during therapy and, as far as possible, ers. Therefore, we suggest that, before avoiding relapse. In order to do this, the embarking upon these treatments, the coping strategies listed above are inte- sufferer discuss the possibilities with a grated into all areas of the person’s life skilled mental health professional who in order to minimise causes of is knowledgeable in all available stress and it’s intensity. Education and resources for the treatment of PTSD. discussion to identify the early warning signs of a relapse is important – the earlier you recognise that things are going wrong, the more chance you

42 Posttraumatic Stress Disorder & War-Related Stress RESOURCES

RESOURCES

Ivor Hele Digger Walking 1941 crayon 65.5 x 39 cm AWM.21896

Posttraumatic Stress Disorder & War-Related Stress 43 RESOURCES

Resources

This section lists some of the resources available to veterans (and families of veterans). These are in addition to standard health and mental health services. To find out what is available in your local area, you may wish to talk to your general practitioner Sth Vietnam 1967 – AWM.EKN 67/130/VN or community health centre. The following organisations provide more spe- cialist assistance and advice:

include: crisis counselling (face to face or telephone, and an emergency after hours toll-free telephone service); individual, family and group counselling; country outreach programs for rural Australia; education and information resources (including a library); case The Vietnam Veterans management roles; referrals to other Counselling Service treatment services. (VVCS): Contact details:

The VVCS is a free and confidential VVCS is available in all states - see service provided by the Department of the phone book under Vietnam Veterans Affairs. Despite the name, vet- Veterans Counselling Service for your erans of any conflict are welcome to nearest office. A 24-hour emergency attend and you do not need to have a free-call service is available on 1800 043 war-related disability or entitlement 503 in Sydney, Lismore and Newcastle, from the Department of Veteran’s and 1800 011 046 in all other areas. Affairs. Those who may use the services The postal address for VVCS is: of the VVCS include Australian veterans of all conflicts and peacekeep- VVCS National Office ing operations, as well as their families. GPO Box 21 VVCS will also see people with Woden, ACT 2606. concern for a veteran’s welfare who wish to seek advice. Services offered Tel: (02) 6289 6168

44 Posttraumatic Stress Disorder & War-Related Stress RESOURCES

Accredited PTSD Support Groups: Treatment Programs:

There are various support groups, run by veterans themselves or by In every state of Australia there are associations related to the well-being hospitals and/or community facilities of veterans. Some of these are which have been accredited by the nationwide while others are based only National Centre to provide treatment within certain states. As the list of for veterans with PTSD and related organisations available can be different problems. These facilities provide a in various states, we suggest that range of program options including interested veterans (or their partners inpatient/outpatient models, day hospi- and families) contact either the VVCS tal programs, and less intensive or your local DVA office for available community based treatments. These organisations in that area. treatment programs are carefully evaluated and new programs are continually becoming available. For an up-to-date list of accredited programs contact the National Centre or visit their web pages.

Cambodia 1992 – AWM.PO2570.027

46 Posttraumatic Stress Disorder & War-Related Stress DISCLAIMER

Disclaimer:

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowl- edgement of the source and no commercial usage or sale. Reproduction for the purposes other than those indicated above, require the prior written permission from the Commonwealth available from Ausinfo. Requests and inquiries concerning reproduction and rights should be addressed to the Manager, Legislative Services, AusInfo, GPO Box 1920, Canberra ACT 2601, Australia. The National Centre shall not be responsible for the results of any actions arising out of the use of any information in this publication nor for any errors or omissions contained therein. The publisher, the National Centre, the Department of Veterans’ Affairs, and the authors expressly disclaim all liability to any person in respect of anything and of the consequences of anything done or omitted to be done by any such person in reliance, whether whole or partial, upon the whole or any part of the contents.

Cambodia 1992 – AWM.PO1748.100

Posttraumatic Stress Disorder & War-Related Stress 47 THE NATIONAL CENTRE FOR WAR-RELATED PTSD

The National Centre For War-Related PTSD:

The National Centre was formed to improve services to veterans and cur- Contact details: rently serving personnel with PTSD and related disorders. The mission of The National Centre For the National Centre is to advance War-Related PTSD. knowledge about PTSD, improve Locked Bag 1, treatment of the condition, and West Heidelberg, prevent the disorder. The goals of Victoria 3081. the National Centre for War-Related PTSD include: Tel: (03) 9496 2922 Fax: (03) 9496 2830 w Facilitating the development of effective treatment services for Email:[email protected] veterans suffering from PTSD Web: www.ncptsd.unimelb.edu.au and related problems w Training health professionals in the recognition, assessment and management of PTSD w Educating the general and veteran community, the defence forces, and health professionals about PTSD and related conditions w Collaborating with the Australian Defence Forces on prevention and early interven- tion in traumatic stress w Encouraging and directing research into PTSD w Collaborating with international agencies with similar objectives

Posttraumatic Stress Disorder & War-Related Stress 45 Lance Coporal Albert Jacka VC

ISBN: 0–642–41460–2