NPR

Psychologist Craig Bryan: Treating Vets For PTSD

Marines wait outside a building to take psychological tests in September 2009. The military assesses troops in search of clues that might help predict mental health issues. (AP)

The rate of U.S. Army suicides has doubled since 2004. In June, a study released by the Army indicated that nearly as many American troops at home and abroad committed suicide in the first six months of 2006 as the number who had been killed in combat in Afghanistan during the same time period.

The Army has begun investigating its mental health programs. But one hurdle to improving services is that many soldiers fail to ask for help because of a culture that prides itself on mental toughness.

"Unfortunately, in the vast majority of cases, when a veteran comes forward for help, it's usually when they're in extremely bad shape," says psychologist Dr. Craig Bryan. "The military culture is not quite amenable in going and asking for help from others. ...  Right now in the military, depending on the branch of service, about three-quarters of service members who kill themselves never come into a mental health provider [and] never reach out and ask for help. They're out there somewhere but most of us don't know where they're at."

Dr. Bryan, who studies suicidal behaviors and prevention strategies, advises both the Air Force and the Department of Defense on PTSD prevention and treatment research. He joined Terry Gross for a discussion about combat stresses, the growing number of military suicides and his role as a psychologist who has treated both active-duty service members and returning veterans. From February to August of 2009, he directed the Brain Injury and Combat Stress Center in the primary Level III trauma hospital in Iraq, where he studied mental resiliency and combat stress.

"The most eye-opening experience I had when I was deployed was what service members were most concerned about -- their most pressing needs on a day-to-day basis -- actually wasn't the traumatic events," he says. "It wasn't the combat, seeing the dead bodies, shooting people, being shot, being injured. Yes, those were definitely important but what most service members talked about the most was the day-to-day benign stressors. It was the not being able to sleep in a comfortable bed, not having access to warm, cooked food, not being able to communicate with loved ones easily. Those day-to-day stressors slowly degrade their mental resources and their resiliency so that when big things happen -- the explosions occur, when the gun battles happen -- they don't have as much energy in their battery to get through that and that's where we started to see more of the problems."

Bryan and his colleagues started working with combatants on dealing with their day-to-day stressors: how to make sure they were sleeping well and maintaining physical health in order to keep them mentally fit on the battlefield.

"Back here in the States, when you're working with a service member with PTSD or some other combat-related stressor or injury, it usually happened months or years in the past," he says. "Whereas, when I was in Iraq, the explosion happened yesterday, so I was seeing them in the hospital when they were getting the shrapnel removed from their bodies. We were doing [assessments] very quickly and providing interventions geared towards preventing long-term problems that we often talk about and see here in the United States."

For his contributions to primary care behavioral health and military suicide prevention, Dr. Bryan was recognized in 2009 by the American Psychological Association's Society for Military Psychology with the Arthur W. Melton Award for Early Career Achievement. He is an assistant professor in the department of psychiatry at the University of Texas Health Science Center and the lead risk management adviser for the $25 million Department of Defense funded Strong Star Consortium, focused on PTSD prevention and treatment research.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

(Soundbite of music)

TERRY GROSS, host:

This is FRESH AIR. Im Terry Gross.

The suicide rate of military service members and veterans has been rising since the start of the Iraq War. My guest, Dr. Craig Bryan, is on the front line of suicide prevention. He is the lead consultant to the U.S. Air Force for psychological health promotion initiatives as well as the U.S. Marine Corps' Suicide Prevention Program. He also treats active-duty serviceman and veterans for PTSD, and works with those at risk for suicide. He served in the Air Force and in 2009, was deployed in Iraq and directed the Brain Injury Clinic at the Air Force Theater Hospital in Balad. Dr. Bryan is an assistant professor in the Department of Psychiatry at the University of Texas Health Science Center.

Dr. Craig Bryan welcome to FRESH AIR. In the documentary "Wartorn," which is about post-traumatic stress disorder, the mother of a vet who killed himself says, the Army taught him how to kill to protect others; they didn't teach him how to stop having that instinct. Has she managed to sum up a serious issue -what happens to you after you come home, when you've been taught to kill?

Dr. CRAIG BRYAN (Assistant Professor, Department of Psychiatry, University of Texas Health Science Center): Well, I think it is a pretty remarkable insight into sort of the paradox of working with service members. You know, part of being an effective warrior, an effective service member, and having an effective military is training our individuals to no longer fear death, to use violence and aggression in controlled manners, and then an individual's return from war zones, combat zones, using those skills. And they're not necessarily taught how those skills fit within, you know, the culture and the context of the United States, where violence and aggression have a very different role to play within daily basis in contrast to a combat zone.

GROSS: Now you've said that, you know, soldiers are trained to face death with fearlessness. But does that training also make it easier to take your life?

Dr. BRYAN: We think in some ways, that it is. Yes. We do know that one protective factor for suicide is fear of death. If someone is afraid to die, they tend not to kill themselves. And so when you have a group of individuals who have been conditioned to overcome that fear, in many ways they sort of have what it takes to kill themselves.

Now, of course, you know, fearlessness about death is not enough. A person also has to want to kill themselves. You know, just because you know how to, or youre capable of killing yourself ,doesn't necessarily mean that you're going to do it because if you dont ever desire suicide, you know, suicide never becomes an option. So it's a little bit more complex than just pure capability.

GROSS: So what are some of the things that you've come across from vets who you've worked with, that have made them think about or succeed in taking their lives?

Dr. BRYAN: Yeah. Well, I guess first I would say that there is no such thing as succeeding in taking one's life. And they kill themselves and they have a fatal outcome, but...

GROSS: Yeah. I was so sorry about that word when I used it. Yeah.

Dr. BRYAN: ...there's no such thing as a successful suicide. What we do know about some of the factors that contribute to those who die as a result of self-inflicted injury, there tends to be intense psychological and mental suffering. There is an extremely high level of agitation. Oftentimes, there's mood disturbance, a sense that things are never going to get any better. We see what we call cognitive constriction within the clinical field, which is - it's sort of like tunnel vision - an inability to solve problems and to kind of think of options, and select a solution that would be optimal.

When I work with suicidal service members, I often, you know, tell them if you are able to solve this problem effectively, you know, suicide wouldn't even be an option. It would be obsolete, in many ways. And so what we often find with the service members is they just - they're suffering intensely. It's an agonizing suffering, and they haven't been able to figure out how to eliminate that suffering in a way that doesn't require them to die.

GROSS: At what point do vets come to you for help?

Dr. BRYAN: Unfortunately, in the vast majority of cases, if a veteran comes forward for help, it's usually when they are in extremely bad shape. The military culture is not quite amenable to going and asking for help from others, particularly from a medical standpoint. Medical personnel are often seen as outsiders.

You know, when someone comes in for any sort of medical problem, you know, we might profile them, we might temporarily restrict their duty - which is, of course, a necessary condition for them to recover. But in a culture in which being able to sort of grit your teeth, endure, press on, where that's sort of the norm and that's valued, you know, coming in and asking for help poses a risk to the service member. And so unfortunately, those who do come in for help are usually in - very, very distressed at that point in time, and it's a much more complex and difficult process to help them out.

Right now in the military - depending on the branch of service, there's some fluctuation - but on a, you know, overall, about three-quarters of service members who kill themselves never come into a mental health provider, never reach out and ask for help. And so it's - they're out there somewhere, but most of us don't know where they're at. The treatment providers don't know how to get to them, to provide them the help that they need.

GROSS: Are you currently seeing people in active duty, or mostly people who are no longer in the service?

Dr. BRYAN: Right now, most of the patients I'm working with are active duty still.

GROSS: So if they come to you, it's an admission that maybe they're not combat-ready anymore - that they're maybe not, you know, up to being in the military anymore, and they're afraid that that would be a blot on their record? Is that what you're saying?

Dr. BRYAN: Right. Yeah. There's a significant fear. That's actually the number-one barrier to accessing mental health services within the military - is that there is a concern that it will have some sort of negative impact on their career. You know, the number one fear is, of course, they will be kicked out of the military, or they will be deemed no longer fit for duty. Some of the other, you know, less important reasons that people provide are, of course, they might - they believe that there will be some sort of limitation to promotion, to special-duty status, to particular career fields that require very high levels of health standards.

Now, of course, most of these beliefs - if not all of them - are false. We know -actually, very well - studies have been done showing that interestingly enough, when service members come in for treatment, their likelihood of being retained on duty, and maintaining their deployability status, actually increases, and actually remains very high. But you know, that's a perception that unfortunately, is quite prevalent within the military right now.

GROSS: You know what I'm thinking must be difficult for you as a psychiatrist -I mean, in the civilian world, I think any kind of therapist tries to help their patients exercise their own free will in the most productive way that they can. But free will is a little bit limited when you're in the service and, you know, the Pentagon has decided that, you know, you are going back for another deployment - and you don't want to.

Dr. BRYAN: Right.

GROSS: You dont have a choice there. So then what becomes your role as their psychiatrist, when they don't have a choice, and they're being told to face death and to face the possibility of having to kill when they feel like, I'm done with that; I can't do that anymore.

Dr. BRYAN: Right. First off, I'm a psychologist, not a psychiatrist.

GROSS: Okay. Thank you for correcting me.

Dr. BRYAN: So just a quick clarification. I know that sometimes we play similar roles, but slightly different training. But as a psychologist, I'll do mostly, you know, behavioral therapy - sort of the classic talk therapy. And the way I approach that - because you do find that interesting dynamic within the military quite often, not necessarily related only to deployment but many aspects of military life, in that a huge part of it is to help service members understand that actually, they do have a choice. They do have the ability to exercise free will, although maybe the options that they have available to them are more limited than it would be if they were, you know, not in the military.

And kind of to illustrate this, or to provide an example is, if you had a service member like this who doesn't want to deploy again but yet, you know, they have received orders to deploy overseas, what I would work with or talk with that individual about is, you know, why did they join the military? And oftentimes, I will pose to them - it's like, well, fine then, don't deploy. You don't have to deploy. And, of course, they usually say I'm crazy and say - or I'll - well, I'll end up in jail. If I don't do it, I'll be a deserter, and I'll end up in jail. And then I point out to them, so there you go. So your choice is deployment or jail. And it's not a good choice, by any means.

And then what we do is, we start talking with them about their ideals, their principles, what is it they value in life, you know, what type of a person do they want to be, why did they join the military. And of course, what you usually get from these individuals, you get themes like, well, I stand for honor, integrity. I care about my family. You know, I want to provide for my spouse or for my children. You know, you get these - you get them connected with what they consider to be important, and who they want to be.

And then once we've identified that, you really kind of pose that choice to them again and say, you know, youve made a commitment to the military. And part of that commitment is a sacrifice of some of your individual autonomy. And so as you consider whether or not you're going to deploy with the military or go to jail, which of these two options will help you to be the man or woman of honor, integrity, a good parent, a good spouse - you know, all of those ideals.

And when you frame it in that way, usually people start to realize that okay, I do have a choice and I don't like it - and I never ask a service member to like the choice. I'm just asking them to make the choice that will help them be the person that they want to be so that, you know, they feel comfortable with all of the decisions that they've made in life even when they're not the decisions they want to be making.

GROSS: And I'm going to tell you - listening to that, I know that the correct answer is supposed to be: So I will deploy and continue with my military responsibility - as opposed to going to jail. But really - like, if you pose that choice to me, I might think: Maybe I'll go to jail because probably I won't get killed there.

Dr. BRYAN: Mm-hmm.

GROSS: ...whereas if I go to Iraq, I might get killed and then my children might not have a father and, you know, my spouse might not have a spouse and...

Dr. BRYAN: Right.

GROSS: Do you know what I'm saying? It doesn't - I'm not sure that that choice makes it - would make it any easier for me.

Dr. BRYAN: Mm-hmm.

GROSS: I'm not in that position, so I can't say.

Dr. BRYAN: Yeah. And, you know, if a service member were to respond with that, you know, I certainly can't force you to make one choice or another. And what we would do is engage in a conversation about what the consequences are associated with okay, I'll go to prison instead. Say, okay, so how does that help you become, you know, all of these things that you want to be? And if that's your choice, then that's your choice.

And, you know, I certainly cannot force your mind, in many ways. All I can do, as a psychologist, is help you to understand the ramifications of the decision you make and hopefully, help you to make the decision that is in your best interest, and that sort of most matches and aligns with who you are as a person because really, that's the pathway to, you know, reduced suffering in life.

GROSS: My guest is psychologist Dr. Craig Bryan. He's a consultant to the Department of Defense on suicide and mental health. We'll talk more after a break. This is FRESH AIR.

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GROSS: My guest is Dr. Craig Bryan, a psychologist who treats veterans and active-duty service members who have PTSD, and he works with those at risk for suicide.

Now, from February to August of 2009, you were in Iraq, in Balad, and you were the director of the Traumatic Brain Injury Center for the 332nd Expeditionary Aerospace Medicine Squadron. And you were working to improve mental resiliency, and to manage combat stress. What are some of the things that you saw there, that helped you understand in a very first-person kind - in a very firsthand kind of way the kind of stresses that soldiers face, that can leave them feeling permanently scarred?

Dr. BRYAN: I think what, you know, the most eye-opening experience that I had when I was deployed was what service members were most concerned about, their most pressing needs on a day-to-day basis. Actually, it wasn't sort of the traumatic events. It wasn't, you know, the combat, seeing dead bodies, shooting people, being shot at, being injured. Yes, those were definitely important. But what most service members sort of talked about the most was sort of the day-to-day, just benign stressors. It was the, you know, not being able to sleep in, you know, a comfortable bed; not having access to warm, cooked food; not being able to communicate with loved ones easily or being on - you know, during that one phone call you get in two weeks, home to the family - just happens to be the time when some insurgent, you know, launches a mortar. And the mortar lands on the phone line and basically kills the phone line, and so now you're not going to be able to talk to your family for who knows how long.

And it was sort of just those, you know, everyday, little stressors that just grate on the nerves of service members, that I think slowly degrade their mental resources and their resiliency so that when big things happen - when the explosions occur, when the gun battles happen - they - sort of - it's like they don't have as much energy in their battery to kind of get through that. And that's where we started to see more of the problems.

And so what we started doing - when I was deployed - to start working with combatants on just how to deal with day-to-day stressors, how to make sure that you're sleeping as well as possible, maintaining physical health so exercising regularly, engaging in meaningful activities - all geared toward keeping them mentally fit so that when the big stuff does happen, you're able to respond to it much more effectively, and you're not as limited or as impaired as a result.

Once we did find those individuals who came in, who were having more significant combat stress reactions, the biggest difference that I found deployed was, of course, once I - you know, back here in the states, when you are working with a service member with, you know, post-traumatic stress disorders or some other combat-related illness or injury, is that it usually happened months or years in the past. Whereas, when I was in Iraq, you know, the explosion happened yesterday. And so I was seeing them in the hospital while they were getting their, you know, the shrapnel removed from their body. We were doing the evaluations very quickly and providing interventions, you know, sometimes even within hours of an event, geared towards preventing long-term problems that we often talk about, and we see here in the United States.

GROSS: And do you think that's helpful, to immediately have some kind of psychological counseling after a traumatic event, after you've been hurt?

Dr. BRYAN: I think if it's done in certain ways. There's certainly some evidence, you know - like critical incident stress debriefing or management -that's been found to be harmful when delivered immediately following a trauma.

GROSS: Like what - and why is it harmful?

Dr. BRYAN: What seems to be the reason why it's harmful is because in that particular model, individuals are forced to undergo some sort of a psychological intervention in which they relive the account. And the fear - we don't know for sure, but the theory seems to be - is that it interferes with the natural grieving and processing - you know, process over time. And so, there's just a natural reaction. You know, if someone tries to kill you, you know, it makes sense to be a little afraid and on edge, and to have nightmares and dreams about it. The issue is, how does that individual sort of consolidate those memories and create meaning associated with it? And if you get in too early and disrupt that process by forcing them to undergo certain interventions, you can basically - yeah, you can mess it up. Whereas, what we were finding is that when you allow the individual to voluntarily engage in early interventions, we get much more success.

GROSS: Were you in a position of having to decide whether somebody should be taken out of active duty because of PTSD, or whether just some counseling would help them perform their job better?

Dr. BRYAN: Yeah, I mean, all military psychologists and psychiatrists certainly are in that position to do it. While I was deployed, I was not necessarily making decisions about whether or not someone be retained on active duty. The decisions I was making on a daily basis were whether or not they should be air-evaced out of the country for more - for higher levels of care, or whether I could adequately treat the conditions there in Iraq.

GROSS: Were those hard decisions to make?

Dr. BRYAN: Yeah. I mean, there were certainly - you know, some cases are definitely more difficult than others. I think the most difficult decisions I had to make - and I can, you know, I still remember the cases very vividly. There were some where I recommended, you know, the service member be returned to the United States for treatment. And they did not want to go back. And you know, they begged me. They pleaded. They were very distressed, and it was an extremely, you know, emotional and a difficult process for me. Because on the one hand, I know the reason I'm deployed to Iraq is to maintain a fighting force. And so in that sense, I want to keep as many people in the fight as possible. That's certainly what the patient wants - is, they don't want to be, you know, sent back to the United States. They want to finish their mission. And so in that sense, I'm violating this relationship aspect with my patient.

But at the same time, in the back of your mind, you realize that in order to maintain a fighting force, they need to be healthy. And you have to recognize your limits in a combat zone, on what you can treat and what you cannot treat effectively. Because, you know, in a combat zone, if someone is not concentrating, if they're not sleeping well, you know, their reaction time is slowed down. That's a difference between life and death. And it's not just for that patient, but it's for all the other service members in their platoon, everybody else who is affected by that one individual's decision-making process. So it's - there are many days where it was a pretty clear, straightforward, you know, decision. But there were several times where it was extremely, extremely difficult in figuring out what should be done.

GROSS: My guest is psychologist Dr. Craig Bryan. He's a consultant to the Department of Defense on suicide and mental health.

We'll talk more after a break.

This is FRESH AIR.

(Soundbite of music)

GROSS: My guest Dr. Craig Bryan, a psychologist who treats veterans and active-duty service members who have PTSD, and he works with those at risk for suicide.

Some people will tell you that, you know, everyone in a war zone gets post-traumatic stress disorder of one degree or another - that it's not possible to be in war and to be shot at, or to shoot at, without being scarred by it and without suffering some kind of, you know, psychological trauma. Would you agree to that?

Dr. BRYAN: Well, I wouldn't say that everyone has a degree of PTSD because they've been deployed. I would agree that everyone is affected by life experiences. And I think this is one of the areas that I've certainly been working on - is that, you know, we assume that in all cases, 100 percent of the time, deployment must be bad for that very reason. And if you've been shot at, if you've been in a life-threatening situation, there is going to be a toll or a - consequences that have to be paid, and it can't possibly be good. I think what that fails to recognize, however, is that it's also possible for the very same experience to have both positive and negative qualities. And when you talk with service members, overwhelmingly, that's what they will report. You know, even when you look at some of the prevalence estimates of PTSD, you know, coming out of OEF/OIF, about 15 percent are estimated to have likely PTSD. But what that -what people kind of overlook is that that means 85 percent of deployed service members are doing reasonably well.

You know, yes, they've probably been affected in some way by their experience. But it can be - we can have both positive and negative life experiences from the very same thing. We use skills that we learn in combat zones. We, you know, learn how to interact with others in new ways. We find a sense of purpose and meaning. There's a clarity, oftentimes, that comes to what is my, you know, mission in life - that oftentimes, people come back and they feel like they've sort of learned something about themselves, and they're a better person because of it.

GROSS: I think it's fair to say that we know now that post-traumatic stress disorder always existed, even though we didn't have a name for it until pretty recently. When you look back to the era of like, battle fatigue and you know, other names that were used to describe what we now call PTSD, can you see a similarity of symptoms and - but different ways that the military dealt with it in the past? And do you feel like you are able to learn from things that historically were done wrong, in terms of coping with it?

Dr. BRYAN: Yeah, I think so. And I mean, you can go as far back as the ancient Greeks, and you can see within their writings some hints of descriptors that would suggest, you know, the possibility of PTSD. So, you know, as long as there has been military and there has been war, and humans have used violence against each other, we have known that the consequences associated with that are sleepless nights, nightmares, memories, agitation, being on edge. And that's - as long as we've had written language describing battle, we have seen those descriptions.

I think what has changed is that within the past several decades, of course, we have brought science to bear in understanding this problem. So it's not so much just - kind of opinions and ideas about what's happening now, but now we actually have, you know, empirical evidence to know - you know, how does PTSD affect people? And more importantly, I think the most important advance within this arena is, of course, the treatments. Thirty, 40 years ago, we didn't know nearly as much about how to treat PTSD. And we didn't have what, you know, now I mean, you know, we talk about prolonged exposure and cognitive processing therapy, as those are the treatments for PTSD; that's front line. Those didn't exist 30, 40 years ago, at least in their current state. Although, you know, people were talking about it and the ideas were there, we didn't have it organized in a natural treatment package, and then prove that it actually works.

GROSS: Dr. Bryan, thank you so much for talking with us.

Dr. BRYAN: Oh, thank you for having me.

GROSS: Dr. Craig Bryan is a consultant to the Department of Defense on suicide and mental health. He is an assistant professor at the University of Texas Health Sciences Center in San Antonio.

You can find links to NPR's coverage of PTSD and suicide in the military on our website, freshair.npr.org, where you can also download podcasts of our show.

(Soundbite of music)

I'm Terry Gross.

(Soundbite of music) Transcript provided by NPR, Copyright NPR.

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