Army Surgeon Shares PTSD Struggles to Help Others

By Lisa Daniel

American Forces Press Service

WASHINGTON, Sept. 27, 2012 – As the Army conducts a worldwide stand-down today to draw attention to preventing suicide within the force, those who have survived attempts to take their own lives may take notice. One is Dr. Tara Dixon.

Army leaders and military officials, overall, say there are multiple reasons why service members commit or attempt suicide. Some are combat-related, but at least half are not. Many involve personal problems with love, money and the law, some that simmered for years before they even entered the military. The problems are complicated by each person’s coping abilities, or resilience, and other factors, they say.

Dixon’s story is less complicated; it is the story of one soldier’s struggle with post-traumatic stress disorder that eventually left her feeling so hopeless that death seemed the only way out.

Dixon, 38, of Georgia, was in her medical residency to become a trauma surgeon when she enlisted in the Army Reserve in 2004 after hearing that the military needed surgeons in the wars in Iraq and Afghanistan. She deployed as a trauma and critical-care surgeon to Iraq with forward-deployed units in 2008 and 2010 -- “me and some guys in a tent,” she said as part of a Sept. 13 panel discussion at the annual Warrior-Family Symposium, sponsored by the Military Officers Association of America and the National Defense Industrial Association.

“We got bombed routinely,” she said. “This was not a Geneva Convention war. We had to take the big red cross off the top of our tent because that’s where [insurgents] aimed.”

Dixon described the stress of treating “the guy I had breakfast with that morning” for critical injuries, and of having to make split-second decisions about whether to amputate a limb or risk transporting a soldier hours away to a Baghdad hospital. Then there were the abused Iraqi children brought in as decoys for insurgent attacks on the unit and the female soldiers who needed treatment for sexual assaults -- crimes she was legally bound not to report at the victims’ request, she said.

Dixon said she coped with the stress through the only outlet she had: running, sometimes 80 miles each week.

Still, she said, “It messes with your mind a bit.” And even though she felt the strain of post-traumatic stress from her first deployment, she soon returned for a second one.

Dixon returned to the United States in the fall of 2010, but the war was still with her. Among the many problems, she said, was returning as a reservist to a city without a military base and no means of support. “I was very much an outcast, and I felt very much alone,” she said.

She described the frustration and embarrassment of post-traumatic stress, of dropping her bags and running to pick up patients at the sound of a helicopter, only to realize she was at her local grocery store.

“It was very embarrassing and frustrating to me that I was nervous in crowds, that helicopters bothered me,” she said. “When you get back to a normal place, somehow your body and your brain don’t shut off” from the survival instincts of war.

“If we didn’t hit the ground when we were in Iraq, if we didn’t duck when someone shoots at us, we would be dead,” she said.

Even when she was fully aware of being thousands of miles from the war, Dixon said, she couldn’t stop from reacting instinctively. “If someone drops the communion plate in church and you hit the ground, that one part of your brain knows you’re in church, but you’re still going to react,” she said.

Dixon said she sought counseling, but her problems seemed only to get worse. Six months after returning from Iraq, she tried to end her life with an overdose of pills.

“I felt lost,” she said. “I was without hope.”

After struggling to find an inpatient facility through TRICARE and the Department of Veterans Affairs, Dixon said her family found a private treatment center where she would spend the next nine months recovering from PTSD. “They gave me my life back,” she said. “They gave me hope back.”

Today, Dixon says she is much improved. She has learned to understand PTSD as “a normal reaction to an abnormal situation.” And she has learned important tactics in treating flashbacks, skills known as “dissociation” and “reorienting.”

“In treatment, they teach you to look around,” she said in an interview with American Forces Press Service from Ocala, Fla. “Here in Florida there are big, beautiful oak trees. There are no oak trees or anything lush in Iraq.” Similarly, she said, “If you hit the ground and you look around and see Starbucks, you know you’re not in Iraq.”

Dixon is processing out of the reserves, and is using some of her medical skills as a veterans service liaison for The Refuge -- A Healing Place, in Florida, where she works with veterans and their families and helps them find treatment. She gets lots of calls for help, she said, including Vietnam War veterans who still struggle with flashbacks and nightmares and even a World War II veteran whose post-traumatic stress surfaced more than 60 years after he left the battlefield.

“Sometimes it helps knowing others have been through the same thing,” she said.

Dixon said she hopes her work will prevent the 9/11 generation of war fighters to not repeat the hard times so many Vietnam War veterans have had with post-traumatic stress.

As for her own struggles, Dixon said, “I’d like to say it’s curable and it’s done and it’s fine,” but she said she doesn’t know when she might stop reacting to things like fireworks.

“I know it’s a lot better,” she said.

Dixon is proud of her work in combat. “I never lost a coalition force in two tours,” she said. But the PTSD has made her career as a surgeon uncertain.

“I really enjoyed what I did,” she said. “It’s something I was very good at. That part is sad to let go. We’ll just have to see how time progresses.”

Frontline Psych with Doc Bender: How Well You Perform Physically May Depend on How Fit You are Mentally

By Dr. James Bender, DCoE clinical psychologist

“Winning is 90% mental, the other half is physical.”

     — Yogi Berra

Dr. James Bender is a former Army psychologist who deployed to Iraq as the brigade psychologist for the 1st Cavalry Division 4th Brigade Combat Team out of Fort Hood, Texas. During his deployment, he traveled through Southern Iraq, from Basra to Baghdad. He writes a monthly post for the DCoE Blog on psychological health concerns related to deployment and being in the military.

When most people hear the words “psychologist,” “mental health” or “shrink,” they think “mental illness.” After all, why should you talk to those guys unless you have posttraumatic stress disorder (PTSD) or depression? It’s unfortunate that some people think that way, because in addition to helping with serious conditions like PTSD and depression, behavioral health specialists can offer much more. A big part of psychology concerns itself with improving physical performance.

All service members are called upon to perform physically throughout their careers. Everyone has to pass a physical training (PT) test, infantry soldiers need to shoot and run, Navy rescue divers need to perform physically in harsh environments, security forces troops have to stay sharp while protecting flight lines and perimeters, and the list goes on. When I was in Iraq, I told my soldiers to think of themselves as athletes because they are.

Anyone who’s endured endless PT knows that the military is very good at training your body to perform, but that’s only part of the solution. A huge part of your physical performance depends on your mindset, and that’s where behavioral science comes in. During the next few months, I’ll spend some time blogging about the mental aspects of human performance. Hopefully, you’ll learn some things that will improve your execution on the job.

Getting Worked Up

 We’ll start by talking about arousal, or how keyed up, excited or motivated you get while executing an action. This has to do with being alert, both physically and mentally. Weightlifters and football players will often psych themselves up before an event and almost work themselves into frenzies, while a concert violinist may breathe deeply or meditate to calm down and lower their level of arousal before a performance. A lot of things happen when you’re at a high level of arousal or “really psyched.”

Generally, we want to be very keyed up, with adrenaline flowing, when we’re trying to perform a simple task that doesn’t require much thought or complex action. Running and doing pushups and sit-ups are activities where you want a high level of arousal. While in this state, you tend to feel pain and fatigue less and blood and oxygen are carried to your major muscles quickly. On the other hand, when you’re performing an action that requires concentration and fine motor skills, like shooting or land navigation, you want less arousal. Being too keyed up will actually decrease performance because the parts of your brain responsible for concentration, visual-spatial skills and creative thinking become less active, essentially shutting down.

How Do You Perform Best?

 Another point to consider is your personality type. Extroverts or thrill-seeking people generally perform better when they’re more aroused while introverts tend to perform better when they’re calmer, or less aroused. So, it’s important to find your optimal level of arousal based on the task at hand and your personality type.

Things get interesting when you have to switch from high-intensity activities to low-intensity activities very quickly. Snipers are good at this. During training, they sprint and then drop to the ground and fire rounds into a target. They perform an activity (running) where a high level of arousal is needed and then suddenly transition to an activity (shooting) where a lower level of arousal is needed. Being in good physical condition lets them sprint without needing too much arousal, and breathing deeply before shooting lets them lower their heart rate and calm down, allowing them to shoot accurately.

Thanks for reading and please post any comments or questions you may have.

Join Doc Bender for a live chat on Twitter to ask questions about the mental aspects of human performance from 11:30 a.m. to 12:30 p.m. (EDT) Sept. 18. Follow DCoE at twitter.com/dcoepage.

Hidden in Plain Sight … A Perspective on Suicide

Posted by U.S. Public Health Service Cmdr. Sarah Arnold, DCoE program manager for performance enhancement

Cmdr. Sarah Arnold is a physician trained in family medicine and preventive medicine. She served in the Navy for 14 years and completed two tours in Iraq. Five years ago, she lost her friend to suicide and was compelled to write about it, in part because she was the last person to see her colleague and friend before she died and also for her own healing.

Two police officers stood at my front door. As I invited them in, they asked if I knew the whereabouts of my friend Dawn (name changed) because she was missing from the hospital. Dawn, a Navy nurse, and I, a Navy doctor, at the time, worked together. We went our separate ways, as we all do in the Navy after a tour is over. I was now in a residency program, and she was stationed at another clinic. That’s why I was surprised to see her one day at the hospital where I was working.

A couple of days before the police showed up on my doorstep, I had lunch with Dawn in the food court at the hospital. That was the last time I saw her. I still had the receipt from Taco Bell — it was my treat. One of the officers said, “It looks like you may have been the last person who remembers seeing her, because shortly after, she was reported missing from the hospital. We were given your name because she has to sign in and out from the ward and tell the staff who is with her.” The officers left me a business card with instructions to call if I saw or heard from her.

I tried to remember earlier conversations to figure out where she could be. Dawn wouldn’t tell me why she was in the hospital, so I thought something must have happened at her clinic. All I knew about her medical history was that she had a traumatic brain injury in the past; I think from a car accident. When we were working together, she did OK. She was a hard worker and lived by herself while her husband and two children lived about an hour away. She didn’t like her job, but most of us didn’t like our jobs at the clinic because we were always understaffed because of deployments or nervous about being taken out of our clinic to deploy. There was no shore duty anymore, except for training programs like the one I was in. She always seemed lonely and kept to herself. Dawn was also very thin; I hardly saw her eat. In fact, the strange thing about having lunch with her that day was she actually ate her entire meal in front of me.

The next few days after meeting with the police officers were uneventful. I was really busy with my training program and still hadn’t heard from Dawn. Then, I checked my email. My heart sank as I read an email from a mutual friend saying Dawn was found hanging from a tree in a park near the hospital. My mind immediately went back to the words from the police officer — “You may have been the last person who remembers seeing her” — words I haven’t forgotten. After all, I am a primary care physician, Dawn was my friend and colleague, and I missed it — and I live with that every day.

As suicides in the military continue to gain media attention, we must remember the friends and family left behind. While suicide prevention programs are necessary and powerful tools, it’s also important to realize that sometimes the messages can be overwhelming to people who lost a friend or loved one to suicide. Messages like, “all suicides are preventable” are a strong call to action but can leave these folks feeling guilty and ashamed, which is no consolation after a tragic death.

Though it’s critical to recognize the circumstances of a potential suicide, we must also be sensitive to the needs of those who lost friends and loved ones. We can help by directing them to resources. If you're grieving and interested in talking to someone, explore the bereavement counseling options through resources such as Vet Centers, Tragedy Assistance Program for Survivors and Give an Hour. DCoE also has a fact sheet that can help you understand some of the emotions you’re experiencing.

If you’re a service member in crisis, or know someone who may be showing signs and symptoms that suggest they may need help, contact Military Crisis Line at 800-273-8255 (press 1 for military) for 24/7 information and confidential crisis support.

In Times of Doubt, Find Healing in Pastoral Care

By Jayne Davis, DCoE Strategic Communications

The soldiers were pinned down, taking heavy fire and casualties from what they determined was a lone gunner behind a protective wall. Finally, one soldier broke from the group, made his way to the wall and in a fervent burst of gunfire took the sniper out — it was an 11-year-old boy.

Later, that scene in the soldier’s head kept him from sleeping, played on his spiritual beliefs and made him question his moral compass. He felt unworthy of his religion, unworthy of his family. He knew he needed to talk to someone. He went to see a chaplain.

“Chaplains are often the first line of defense for service members wrestling with issues of moral and spiritual concerns,” said chaplain and Navy Cmdr. Raymond Houk, who related the sniper story. Houk is assigned to Pastoral Care at Walter Reed National Military Medical Center and works at the National Intrepid Center of Excellence.

“The unique relationship between chaplain and service member creates a pocket of trust wherein we can help with issues like forgiveness, grief, survivor’s grief and inner moral conflicts — issues that stay with people after experiencing difficult situations and making life and death decisions. Often what’s needed is for them to accept that they made the best decision under the circumstances,” said Houk. “In those cases, we offer support and compassion to help them forgive themselves.”

Chaplains can be in the unique circumstance of having to counsel a service member on both spiritual and psychological loss — and be able to distinguish differences.

In many parts of the world where deployed units are on smaller ships or isolated outposts, behavioral or psychological health care providers are not commonly attached to the units, but most often chaplains are. That puts them in the position of also being the first line of defense for service members having psychological concerns, such as posttraumatic stress. Although some behaviors are common to both spiritual and psychological concerns, chaplains are trained to identify symptoms of posttraumatic stress disorder (PTSD). “We’re trained to know when the service member needs to seek behavioral health care so we’re very familiar with sleeplessness, intrusive thoughts, nervousness and anger issues,” said Houk. (Read this post about one chaplain’s personal experience with PTSD.)

A spiritual assessment is often the first step for a chaplain faced with helping service members showing signs of PTSD. An assessment helps identify spiritual needs important to their psychological health care, said Houk. “It may include faith practices or beliefs that give their life purpose, meaning, depth and value — beliefs that can impact their behavioral health,” said Houk.

At military treatment facilities chaplains can read, make notes to and include the spiritual assessment in electronic records. “Knowing that a spiritual assessment is not separate from treatment but an integral part of the healing plan encourages the patient to be more forthcoming about their spiritual beliefs, and raises their awareness that their beliefs can be a source of strength and healing during the recovery process,” said Houk.

Houk pointed out that it’s critical for the patient to understand that the chaplain is part of the medical team. Historically, chaplains have had close relationships with medical personnel. “From my perspective, the process of moving service members from spiritual counseling to provider care is handled well, but chaplains still need to be intentional about keeping proactive relationships with health care providers,” said Houk. “Providers need to be aware of chaplains’ capabilities and trust them to make solid referrals.”

Chaplains can find support and resources in this fact sheet and through the Chaplain Working Group hosted by Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Contact the group for details.