Discussion: Combating Post traumatic Disorder
Discussion: Combating Post traumatic Disorder
An Innovative Approach to Treating Combat Veterans with PTSD at Risk for Suicide
HERBERT HENDIN, MD
Suicide rates among military personnel had a signiﬁcant drop in 2013, but there is no evidence of a drop among veterans. The problem of suicide among combat veterans with posttraumatic stress disorder (PTSD) remains a source of concern. The Department of Defense and the Department of Veterans Affairs are now calling for innovative treatment approaches to the problem. A short-term psychodynamic therapy presented here may be able to ﬁll that need by dissipating the guilt from veterans’ combat-related actions that leads to suicidal behavior. The treatment showed promise of success with veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates that it may be equally successful in treating them. Basic aspects of the psychodynamic approach could be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide.
A 7-year research and treatment project with combat veterans of the Vietnam War with posttraumatic stress disorder (PTSD) and at risk for suicide at a Veterans Administration (VA) Medical Center laid the groundwork for the material in this article (Hendin & Pollinger Haas, 1984a,b). Comparable research being performed at the Michael E. DeBakey VA Medical Center in Houston, Texas, which includes veterans of the wars in Iraq and Afghanistan as well as Vietnam, is building on this work (Hendin, Al Jurdi, Houck, Hughes, & Turner, 2010).
PTSD AND THE RISK FOR SUICIDE
Vietnam veterans with PTSD are four times more likely to die by suicide than veterans without PTSD (Bullman & Kang,
1994). Although PTSD is the disorder most associated with suicide among veterans, most veterans with PTSD are not at risk for suicide. Veterans at risk for suicide who do not have PTSD have very different problems than veterans at risk for suicide who do. This study only addresses the problems of veterans with PTSD. The study of Vietnam combat veterans with PTSD provided insight into the factors associated with suicide among them. Persistent severe guilt over combat experiences was found to be the major factor differentiating veterans who had attempted suicide and those who were seriously preoccupied with suicide from those veterans who were neither (Hendin & Pollinger Haas, 1991). Nineteen of 100 combat veterans with PTSD had attempted suicide at least once since returning from Vietnam. Guilt related to combat actions was signiﬁcantly marked in all 19 of the suicide attempters, but in only 32 of the 66 nonsuicidal veterans (v2 = 14.24, df = 1, p < .001). Fifteen had been seriously preoccupied with suicide since they left the service. Guilt was also marked in 12 of these 15 veterans compared to the 66 nonsuicidal Discussion: Combating Post traumatic Disorder
HERBERT HENDIN, Suicide Prevention Initiatives, New York, NY, USA and New York Medical College, Valhalla, New York. Address correspondence to Herbert Hendin, Suicide Prevention Initiatives, 1045 Park Avenue, New York, NY 10028; E-mail: hhendin@ spiorg.org
582 Suicide and Life-Threatening Behavior 44(5) October 2014 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12135
veterans (v2 = 3.71; df = 1, p = .05). Although anxiety, survivor guilt, and depression marked those at risk for suicide, combat guilt outperformed the other three predictors, including depression, when all four were entered into a logistic regression simultaneously. The combat experiences of the suicidal veterans were examined for possible determinants of their guilt. The chaotic nature of guerilla warfare in Vietnam, the uncertainty about who was the enemy, the emphasis on body counts, and the Viet Cong’s use of women, children, and the elderly as combatants contributed to combat actions about which veterans felt severe guilt. The Viet Cong would strip American soldiers they had killed and hang their naked bodies from a tree with their genitals stuffed into their mouths. Such tactics, designed to frighten soldiers, also tended to infuriate them and contributed to atrocities on both sides. A more common provocation was rage precipitated by experiencing the death of close comrades (Hendin & Pollinger Haas, 1991; Shay, 1995).
MEANING OF COMBAT
How each veteran experienced combat events; that is, the meaning of the combat experience to the veteran, was integral in determining the nature of the guilt and the risk for suicidal behavior. The term meaning of combat refers to the subjective, often unconscious perception of the traumatic event, and includes the affective state of the veteran before the event took place, when it took place, and the affects experienced subsequently. Nightmares and other re-experiencing symptoms are cardinal symptoms of PTSD. Both are valuable tools in determining the meaning of the experience to the veteran. The following case example is illustrative (Hendin & Pollinger Haas, 1984a). (Informed consent was obtained from all project participants and some cloaking was performed with case presented).
Throughout his tour, Greg L. thought he would be killed in action. The thought was comforting to him because it would enable him to avoid having his friends, family, and ﬁancee discover that he had lost control of his anger and killed without reason in Vietnam. During the last two weeks of his tour, when he learned that he was not going to be assigned to any more combat missions, he tried to kill himself with an overdose of drugs. He had been an artillery spotter in Vietnam. He was preoccupied with a memory of a friendly village that he and his sergeant had helped to destroy in a contest designed to see who could call in the best coordinates. Through his binoculars, Greg had watched with excitement as the shells landed. As the village was being destroyed, he saw an old woman with betel nut stains on her teeth running in his direction. She was shaking her arms trying to get him to stop the shelling. As she ran toward him, she was killed by an artillery round. After he returned to the United States, Greg was tormented by a painful recurring nightmare that expressed his intense guilt over the destruction of the village. In the dream, he is captured by South Vietnamese villagers, strung on a pole like a pig carcass, and paraded around the village so that everyone could throw stones at him, hit him, spit on him, and curse him. The old woman with the betel nut stained teeth is taunting him. The villagers hold him responsible for all the death and destruction in their village. He knows they are going to kill him. Greg made a second suicide attempt during a re-experiencing event in which he thought he saw the villagers covered in blood. He cut his wrists and described feeling a sense of relief as the blood spurted out. Both the nightmare and the reliving experience express his sense of guilt and need for punishment. The nightmares of most veterans with PTSD correspond closely with the combat experiences, and the terror over being killed that they engender. Veterans who have severe guilt over their actions in Discussion: Combating Post traumatic Disorder