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The buddy system

Veterans help veterans combat PTSD

On a stifling hot morning in April 2008 in the Kirkuk Province, specialist Jayson Early left his military base and headed to a nearby Iraqi police station on his first field assignment.

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Veterans Jayson Early, left, and Erik Ontiveros.

During the subsequent 14 months he served in the country, Early worked both as a military policeman training Iraqi police forces and as a gunner manning the turret atop a Humvee. But for this assignment, he was sent on an innocuous-sounding public affairs errand to photograph a burned-out truck parked at an Iraqi police station.

“I was 19 years old,” he says, telling the story six years later, now a father of two and living where he grew up, in the small town of Hughson, near Modesto in California’s Central Valley. “I walk up to the truck with my camera thinking there is nothing there.” Then he looked inside.

“There were body parts, coagulated blood, hair all over,” he says, pausing. “I just wasn’t expecting it.” An Iraqi family had been executed in the vehicle, presumably by insurgents. Early had gone through intense military training to prepare for moments like these. He blocked any emotions. He followed orders, clicked the camera and moved on. It wasn’t until years later that he realized just how permanently those images, and many more like them, had burned into his brain.

Like so many of the 2.6 million Iraq and Afghanistan war veterans who have returned home over the past decade, Early brought his combat training back with him to the States. The hypervigilance, the emotional numbness; the training that kept him alive on the battlefield didn’t serve him well in civilian life. The absence of the adrenaline high of battle and the closeness to combat buddies left him detached and lonely. Anxiety in crowds and flashbacks triggered by fireworks or screaming children led to isolation and self-medication with alcohol and cocaine. He had severe post-traumatic stress disorder but he didn’t know it.

“You went through hell essentially and made it out visibly unscathed,” he says, remembering when his deployment first ended and he was shipped to Germany, then home. “I was young. I just wanted to go home and have a normal life. I didn’t even realize PTSD was a real thing.”

For years, he pushed away family and friends who tried to help. “I coped by drinking large, copious amounts. I’d have trouble sleeping. I’d get angry and just drink that away.”

When he finally sought help for depression, PTSD and multiple addictions, it wasn’t a psychiatrist or a psychologist or a licensed counselor who broke through to him. It was his fellow veterans.

“Friends might say they understand but they don’t,” Early says. “It means a little more when a vet reaches out and says, ‘Hey I know what it’s like.’”

Troubled and hard to reach

The need to connect the waves of veterans recently returned from the war zones of Iraq and Afghanistan with mental health services has grown more urgent as the disturbing mental health statistics rise. Roughly 40 percent of the returning veterans report having difficulty adjusting to civilian society, according to a recent Pew Research Center study, and an estimated 22 veterans commit suicide each day, according to the Department of Veterans Affairs. Twenty percent of veterans— almost half of whom won’t seek treatment — suffer from clinical PTSD or major depression often leading to addictions and self-isolation, research by the RAND Corporation found.

Because the stigma associated with seeking out mental health care is particularly strong within the military, veterans are one of the most difficult populations for mental health-care professionals to reach.

“It’s wicked difficult to treat anyone with moral injuries from combat in the traditional medical model,” says psychiatrist Jonathan Shay, MD, an expert on PTSD, who coined the term “moral injury” to refer to the psychological, cultural and spiritual aspects of combat trauma. “It destroys the capacity for trust. What it leaves is despair, an expectation of harm, humiliation or exploitation, and that is a horrible state of being.

“The traditional medical model — in an office with the door closed — is the last thing they want. I’m convinced that’s where peers come in. Peers are indispensable. It takes a community to heal these wounds.”

To bridge this care gap, researchers at the Stanford University School of Medicine and the Veterans Affairs Palo Alto Health Care System have designed a pilot program based on veterans supporting veterans. Psychiatrist and researcher Shaili Jain, MD, has spearheaded the effort, aptly called the Peer Support Program, hiring and training two veterans as certified peer support providers who travel to VA health clinics in Sonora, Modesto and Stockton — rural and underserved areas in California that are home to many returning veterans. The program, supervised by Bill Boddie, a licensed clinical social worker, was modeled after the VA’s use of peer support providers for the treatment of the seriously mentally ill.

Peer support providers connect with veterans in ways that other mental health professionals can’t, Jain says. Through phone calls and on-site support groups, they give advice on how to survive the day-to-day challenges of readjusting to civilian life based on their personal experience. Their role isn’t to provide psychiatric treatment, but to help break down the barriers that are blocking other veterans from getting the care they need. With thousands of veterans across the country suffering from PTSD relying on the Department of Veterans Affairs for care, integrating peer support into treatment is growing in popularity, Jain says.

“Peer support is key to reaching veterans living with PTSD and addictions,” says Jain. A 2008 study in Psychiatric Services led by Matthew Chinman, PhD, a scientist at the VA Pittsburgh Healthcare System, found that supplementing traditional mental health care with peer support reduces many hurdles to helping people with serious mental illness. More recently, Jain conducted a literature review and found support for this approach specifically for PTSD. That review, published in the September 2013 Journal of Traumatic Stress Disorders and Treatments,showed that “integrating peers into the treatment of adults with PTSD improves access to mental health care.”

In addition to conducting research, Jain works as a clinician, providing psychiatric treatment to veterans in her small, closed-door office at the Menlo Park VA. “The very nature of the disorder makes veterans really mistrustful. The last person they may want to see is, well, somebody like me sitting in an office who comes from an entirely different world.”

A good connection

In the years after his deployment to Iraq ended, Early found daily life a constant struggle. He tried to live a “normal” life. He got married, had two children. But flashbacks, sleeplessness and guilt consumed him. He turned to drinking and drugs. A minor stroke during his posting to Fort Riley, Kan., from Germany, ended his career in the military, and he moved back home to California, bringing his young family with him. It was his dad, also a veteran who had struggled with PTSD, who first broke through to him.

Concerned about Early’s self-isolation, his anger and drinking, his father introduced Early to one of the two certified peer support providers working in Modesto, former U.S. Marine Staff Sgt. Erik Ontiveros.

“One day my dad grabbed me and said, ‘Get dressed. We are going to Erik’s support group,’” Early says. The two drove to the Modesto VA clinic and joined the Friday morning support group. “I didn’t talk the first few sessions. I was still in that denial phase. I was thinking, ‘This is just a bunch of bull. I don’t need this, I’m fine.’ Then the other vets started talking about some stuff, and it was like ‘Holy crap!’”

Sitting in a circle with a small group of other Iraq and Afghanistan veterans, a light bulb finally began to flicker in Early’s brain. Maybe those 14 months in Iraq of piecing together the body parts of Iraqi civilians blown to bits, of constant adrenaline-pumping fear, of near-death experiences, bullet dodging, bomb scares — maybe all that and more could have caused some mental wounds. Maybe death and violence upfront and personal could trigger years of anger, depression, drinking and drug use even if he hadn’t been physically wounded. Maybe he did need help.

This is where Ontiveros, a fellow veteran who had been through similar experiences and received help for his own PTSD, stepped in. Ontiveros has 10 years’ experience as a Marine with three deployments to Iraq. He had been through treatment and was four years in recovery when Early joined his support group. Ontiveros knows how hard it can be for a veteran to ask for help.

“A lot of these vets don’t know there’s anything like this kind of support out there,” Ontiveros says. “They just sit alone in their garage drinking beer. I know what that’s like. I used to just sit at home drinking. I wouldn’t get off the couch. I’d go days without shaving, without taking a shower.”

Ontiveros, 33, went from being a combat vet to a stay-at-home dad virtually overnight. He left the Marines in 2009 and returned to the States for the birth of his first child. Back home he began experiencing unexpected flashbacks, anxiety, guilt. He found he missed the Marines intensely. In 2010 he admitted himself into the psychiatric ward at the Palo Alto VA for depression, PTSD and alcohol abuse, then attended the PTSD residential rehabilitation program at the Menlo Park VA for five months. When he got out, he worked as a volunteer with other veterans still in the program as part of his own therapy. That’s where Jain found him, trained him and hired him.

“I always share my own personal struggles, some of the processes I use to deal with them,” Ontiveros says about how he leads group sessions in Modesto and Stockton. “We’re just focusing on the here and now, our everyday lives — whether that may be getting out of the house, or talking to civilians, or navigating resources within the VA. It’s about adjusting to being outside the military. We have to learn how not to be military.”

It’s the shared experiences that make it work, he says. Veterans come from a military culture that the outside world doesn’t understand. They innately trust each other.

Trauma healer, trauma scientist: Shaili Jain, MD, directs the VA Palo Alto Health Care System’s PTSD peer support services.

Validation

The number of vets who have been reached by the program’s peer support providers — Ontiveros in Modesto and Stockton, and Guy Holmes in Sonora — is evidence that the program is working, Jain says.

“Veterans are voting with their feet,” she says. Nearly 200 at-risk veterans, those who are traditionally the hardest for mental-health providers to reach, have enrolled in the program since its inception nearly two years ago. Participant feedback has also been positive, with 75 percent of veterans reporting the service as helpful.

“We’ve been publishing on the concept of peer support in general and on the specific program,” says Steven Lindley, MD, PhD, associate professor of psychiatry at Stanford and the program’s leader. As Jain’s mentor during her fellowship at the Veterans Affairs National Center for Post Traumatic Stress Disorder in Menlo Park, he was familiar with her interest in advancing the research of peer support and involved her when the Michael Alan Rosen Foundation became interested in funding the Peer Support Program.

“We’ve shown that there’s more of a bonding with the peer support specialists than with psychologists or psychiatrists,” says Lindley, director of outpatient mental health for Veterans Affairs Palo Alto Health Care System. “They’re providing the glue that helps these clients stay in treatment.”

Jain has spent the five years since she left a private practice in Wisconsin and traveled cross-country to start the PTSD fellowship researching, writing and publishing on peer support. It was the discovery of her own father’s hidden story of loss and trauma during the 1947 partition of India that changed her career trajectory and set her on a path committed to advancing the science of PTSD.

“It just moved me that I am from people who have had their lives torn apart because of traumatic incidents,” she says. “Now, as a doctor and a scientist, I have this platform. Doesn’t it make sense that I use it to help others torn apart by trauma?”

Peer support as treatment for individuals with PTSD isn’t a new concept, Jain says. But there has been little published in the scientific literature to support it as evidence-based care. She has set out to help change that, to add to the body of evidence that would encourage the use of peer support nationwide. The goal is to eventually test the effectiveness of the Peer Support Program in a controlled study, Jain says.

Another Stanford PTSD expert and psychiatrist, David Spiegel, MD, helped write the definition of the disorder for the DSM-IV and DSM-V, the handbook of mental health diagnosis for health-care professionals. He is not involved with the Peer Support Program, but is not at all surprised by its success. He saw how peer support helped Vietnam War veterans during the 1970s when he worked at the Palo Alto VA.

“The very thing that alienates these vets from society is their ticket to peer counseling,” Spiegel says. “They feel they don’t fit. The very thing that makes them feel excluded on the outside is an instant bond and connection with other vets. That’s a powerful thing.”

The importance of being understood

That bond with other veterans is exactly what kept Early coming back to the support group in Modesto. But he was still struggling.

“At first, Jayson was just sitting back and hearing everybody else’s stories,” Ontiveros says. “Then he started opening up and talking about his feelings. His big thing was adjusting to civilian life and communicating with his wife.”

After about a month of support group sessions led by Ontiveros, Early says he began to realize that he wasn’t the only veteran struggling to deal with civilian life, a realization that helped break down his own barriers to the possibility of getting additional psychiatric help.

“Those other vets in the group around my age, they were opening up,” Early says. “They were talking about day-to-day hassles. Dealing with crowds at the grocery stores or dealing with somebody that’s incompetent at the drive-thru. Your fuse is so short to begin with, something so minor sets it off. Normal hassles that a normal person wouldn’t get upset about. I’m the kind of guy, at the grocery store if somebody bumps into me, and doesn’t say sorry, I’m going to slam into their cart and just walk away.”

Early felt a connection with Ontiveros, who told the group about his own daily struggles to communicate with his wife, to control outbursts of anger, to be willing to ask for help. Ontiveros informed the group about the other mental health services available to them. He gave tips on how to navigate the VA bureaucracy, on how to open up and trust someone other than another veteran.

“That first year back in civilian life, I really battled myself,” says Ontiveros who was a platoon leader when he left the Marines. “I felt like shit because I left my Marines. They were my family. I felt like I abandoned them. Sometimes I would phone some of them and break down and cry and say that I was sorry that I failed them as their leader, as their platoon sergeant, that I was sorry that I couldn’t be there for them.

“A lot of them understood, and they assured me that it was a good choice. That I had to be there for my family, that I had to move on.”

And Ontiveros understood what it was like for Early when, one night in March, he finally hit bottom.

“I had a really bad night,” Early says. “I drank a bottle of whiskey, and a lot of beer. My wife spoke to my dad about me getting help because she knew I would listen to him more than I would to her. He said, ‘Look, you are going to get help or the marriage is going to be done.’”

The next day, Early checked into the Menlo Park PTSD residential rehabilitation program, the same one where Ontiveros stayed for five months. Ontiveros visited him there, and encouraged him to stick with the program early on when he wanted to drop out.

“It sucks every time you sit there and say, ‘I need help,’” Early says. “I fought the program for 50 days thinking, ‘This is bogus, none of this applies to me.’” On day 51, the light bulb turned on and stayed on. Early stayed in the program for 115 days. He was released in June.

“Things don’t get completely better but every day life gets easier to cope with from the tools I learned while at the Menlo Park VA,” Early says. “That was a big realization for me. I never would have made it through the program without Erik.” Ontiveros says he told Early what he tells all his vets, what he learned the hard way.

“That label that we give ourselves of not being normal — that stigma — doesn’t allow us to accept who we are. I tell them we have been in a situation that only 1 percent of the rest of the population has been in. What we have seen, the rest never do. It’s who we are.” 

Audio interview with Shaili Jain.

Tracie White is a science writer for the medical school’s Office of Communication & Public Affairs. Email her at tracie.white@stanford.edu.

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