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The power of peer support

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Working out operational stress injuries—posttraumatic stress disorder in particular—finds success in a circle of soldiers

 

By Linda Hossie

 

Since warfare began, soldiers have come home from battle with psychological injuries. The first written record of a battle stress reaction was written by the Greek historian Herodotus in 490 b.c. He described the fate of an Athenian soldier who had not been physically injured but had been struck blind after seeing a fellow soldier die.

The historic evidence that these injuries exist and are real has not helped most of history’s soldiers. The tell-tale symptoms of panic, confusion and flashbacks have long been a source of shame, things a “real” soldier wouldn’t feel. Sufferers and their families have tried for the most part to hide the affliction.

The military was no better. Hundreds of soldiers were shot for cowardice and desertion in the First World War, many of them suffering from psychological injuries of war. The military’s attitude was made notorious by Lt.-Gen. George S. Patton, commander of the Seventh U.S. Army, who on Aug. 3, 1943, slapped a soldier who was hospitalized for psychoneurosis, accusing him of cowardice. The incident almost ended Patton’s career, but his gesture reflected generations of thinking about battle stress disorders.

Only in 1980 were these injuries—variously called shell shock, battle fatigue, soldier’s heart—included in psychiatry’s Diagnostic and Statistical Manual of Mental Disorders as posttraumatic stress disorder (PTSD).

Since then, slowly but surely, the medical and military communities and the world at large have started to take PTSD more seriously as a treatable medical condition. Using MRIs, doctors can now see that soldiers returning from war with PTSD have physical markers in their brains that explain the condition’s behavioural symptoms.

PTSD is a serious chronic condition that can predispose sufferers to violence, addiction and suicide. There are soldiers with PTSD who haven’t left their basements in years, one who in desperation over his emotional state ploughed his SUV into a garrison building, another who woke up to find his hands around his wife’s throat. Soldiers’ families sometimes disintegrate under the pressure of trying to cope with the range of disabling symptoms.

In 2008, retired Lt.-Gen. Romeo Dallaire, who commanded the UN forces in Rwanda, described a 1997 flashback to a parliamentary committee in Ottawa.

“I was travelling with my family in Prince Edward Island,” he said. “We were driving down a road where they had clear-cut the sides of the road where there had been principally spruce trees. The large branches had been piled along the roads with the ends facing the road and the leaves or the quills had all rusted and turned brown.

“As I drove down that road I immediately fell into a trance in which it seemed to me like I was right back in Rwanda and what was piled beside the roads were the bodies of dead and decaying Rwandans. It was so overwhelming that I in fact had to stop, and for a considerable amount of time took a lot of support from the family to be able to re-establish myself.”

Dallaire has referred to PTSD as “by far the most prevalent injury of our timeframe,” but statistics are difficult to come by. Some soldiers return with symptoms. In others, the signs show up months or even years later. Many never seek help and are neither diagnosed nor counted. Depending on how they are calculated, estimates of the prevalence of PTSD range from two to 30 per cent of the active military population.

Canadian Lt.-Col. Stéphane Grenier, who served in Rwanda with Dallaire, is one of the soldiers who returned with PTSD. After a period of depression and despair in which he narrowly avoided suicide, he was helped to come to terms with it by a sympathetic superior officer.

Grenier uses the term “cultural permission” to describe an acknowledgment within the military that PTSD is a real injury and that treatment is required. He received that permission from a former boss, Col. Chris Corrigan, who told him that he had been through a rough patch and needed to take some time to care for himself.

The empathy shown by Corrigan opened up a vision for Grenier of the benefit soldiers could receive from peer support, and he proposed a program within the military to provide it.

That program is the Occupational Stress Injury Social Support Program (osiss), set up in 2001 and now available in every province. Until 2006, it was run by Grenier, who said in an interview that he had to “advocate, argue, confront, disagree and go against the grain to get this project up and running.”

“The fact of the matter is that when a colonel comes out and admits they have PTSD and depression and that they are going to do something to help soldiers and families who are falling through the cracks left, right and centre, you do not make friends.”

“What do soldiers do?” he asked. “They follow orders.” Calling their stress injury a disorder “is like a slap in the face with a two-by-four.”

Political tensions with his political overseers eventually led to Grenier losing his job at osiss in 2006. He was posted to Afghanistan and returned in 2007 to another mental-health assignment: setting up training for soldiers to help reduce the stigma for those with stress-related injuries. He has since left the military.

The training program he designed in his last military job was based on leadership principles and behaviours and included “granular, tangible” discussions, he said. Experienced veterans were recruited to provide the training and by the time they declared their own psychological struggles at the end of the day-and-a-half-long sessions, they had demonstrated their credibility as soldiers. Grenier calls it “leveraging people’s lived experience” to lessen stigma.

Grenier said the stigma is still there, but is significantly reduced from what it was 12 years ago, when he went public with his difficulties. Then, he said, it was a “minus 30 chill.” Now it’s like a “cold fall wind.”

Stigma still keeps some soldiers from seeking peer support. One such man is a retired major who agreed to tell CrossCurrents his story. He has been diagnosed with PTSD but he resists that diagnosis for himself. He will admit to depression and anxiety because depression and anxiety can occur regardless of military service.

Admitting to PTSD, he believes, would be admitting that he “can’t take” what military life demands. He would be one of the people his generation of soldiers was taught to look down on, excluded from a community that has been like a family to him for most of his life. His father was also a soldier, a veteran of the Korean War, which makes the family connection even stronger.

Putting the emphasis on the word “injury” rather than “disorder” was Grenier’s innovation. He coined the term operational stress injury, and the logic for it comes from his knowledge of the military culture.

“What do soldiers do?” he said. “They follow orders.” Calling their stress injury a disorder “is like a slap in the face with a two- by-four.”

The osiss program’s key rationale is that those who understand the chaos and disruption visited on soldiers with PTSD are best placed to help them come to terms with it. Its success has prompted international interest, and speakers from osiss have made presentations in Europe, at NATO and in the United States. Dallaire was recently invited to the American Psychiatric Association’s annual conference to discuss changing its term—posttraumatic stress disorder—to posttraumatic stress injury.

 “I never dreamed in 1,000 years that it would potentially become a clinical term,” Grenier said.

One group on the front lines with Canada’s soldiers is their wives. These women often recognize the importance of peer support because they see the way their husbands behave at home before and after deployments. One said that meeting other soldiers through therapy was “the most helpful thing” she and her husband had encountered.

“I mean, he is such good friends with these people now,” she said. “Phones them all the time, they talk and they all know what each other’s talking about. And that is huge—huge therapy for him. It may be better than having a counsellor who has no clue.”

The woman’s story, and that of five other military wives, was included in a PhD thesis in counselling psychology by Holly Beth McLean, submitted to UBC. The husbands of the women were all part of a non-military support group called the Transition Program for Canadian Soldiers.

To date, 6,300 soldiers have taken advantage of osiss services. While the number seems small, Grenier pointed out that in its first year, the program had only four support workers and the numbers increased slowly in subsequent years.

“In the six years I managed the program, 70 per cent of our active cases were extremely unstable individuals [but] soldiers and families who availed themselves of the program have moved on and have embarked on the road to recovery.”

The program offers peer support for families—for anyone living with a soldier “who has an operational stress injury,” said Maj. Carl Walsh, osiss national manager.

In actual meetings between peer support workers and a soldier with an operational stress injury, he said, one of the important jobs of the peer support staff is to “model” recovery for the soldier—“this is where you could be” once your symptoms are dealt with.

Peer support workers are hired, trained by “a PhD psychologist” and work under ongoing supervision, Maj. Walsh said.

The program also has staff people available on site. Soldiers who are returning from tours go through what is called “third location decompressions,” with staff advising them of the services available for a range of possible needs.

Grenier pointed out that whether a soldier needs osiss help depends on the peer support available to him outside the program. Many commanding officers and units are very supportive of a soldier going through difficulties, he said. “What we inherit are the people who fall through the cracks.”

But he also pointed out that the current program has dropped its “seven or eight tier self-care protocol.” Because the peer support job is so demanding, under Grenier’s management, support workers were actively encouraged to follow detailed plans to look after their own mental health. Now a worker with difficulties is simply referred to the employee assistance plan, he said.

A point made by a number of soldiers is that the nature of modern peacekeeping is partly responsible for the disorder. Canadians have an honoured tradition as peacekeepers, but modern peacekeeping operations can involve situations of extreme violence and human rights abuse. After the civil war in the Balkans, in which more than 130,000 people were killed and war crimes committed on a massive scale, the 1999 Croatia Board of Inquiry concluded that stress was the likely cause of the high number of illnesses experienced by Canadian peacekeepers there.

Not only are soldiers in combat situations, but the combat is between civilian forces, and peacekeepers have stringent limits on their use of force. “The ethical and moral and legal dilemmas” in that situation, Dallaire has said, “have been added onto what the old combat stress used to be.”

Lt.-Col. Alexandra Heber, a psychiatrist with the Canadian Forces’ Operational Trauma and Stress Support Centre in Ottawa, doesn’t agree. Although record keeping was not good enough during the Second World War to allow comparisons with that period and the PTSD rate of modern peacekeepers, she said two men can be standing right beside each other in a violent conflict and one will develop PTSD and the other will not.

For those who do, the peer support program can be a lifesaver. A peer support worker told journalist Randy Turner that in osiss, “the important thing is that everybody has a common denominator. We all served in some sort of way. It doesn’t matter if you’re an officer or a junior rank. It doesn’t matter if you’re male or female. What matters is you went through a trauma, and we’re here to help bring you back.”

PTSD by the numbers

A 2011 Library of Parliament research paper made an effort to provide numbers, based on “the only major scientific study on PTSD in Canadian soldiers… based on a special sampling developed by Statistics Canada as part of the 2001 census,” which included 8,441 active service personnel.

  • When PTSD is narrowly defined to exclude other psychiatric conditions such as major depression, the report said, the incidence is about 2.3 per cent.
  • When soldiers are included who have taken part in combat, the incidence of PTSD doubles; when soldiers who have witnessed atrocities are included, the rate jumps to almost 10 per cent.
  • The report also notes that the lifetime risk of PTSD for those groups is two to four times higher, meaning many may go on to develop the disorder.
  • A later and more specific Canadian Forces study, in 2011, Cumulative Incidence of Post-Traumatic Stress Disorder (PTSD) and Other Mental Disorders (http://forces.gc.ca/health-sante/ps/mh-sm/osi-bso/default-eng.asp) estimated that eight per cent of soldiers who had deployed to Afghanistan had been diagnosed with PTSD. The study involved medical record reviews of a sample of 2,045 personnel.

PTSD: It’s a family affair

Last year, Kelly Thompson was eagerly awaiting the return of her soldier husband from a tour of duty in Afghanistan. In the first 40 nights he was home, however, the two of them slept in the same bed for only five.

“Mark’s body is so tense that once he falls asleep, his legs move non-stop,” she wrote in a blog for Chatelaine magazine in January, 2011. ”He kicks, flails and quite literally bruises my shins.… And when I gently wake him up, he mumbles something about fighting the Taliban or killing the monster from the Predator.”

The longer Mark was home, however, the more peacefully he slept. He and Kelly could look forward to resuming comfortable nights together.

Not all military families are so lucky. When a soldier returns home with full-blown posttraumatic stress disorder (PTSD) or develops it later, families are in the cross-hairs of a chronic and deeply debilitating condition. Not all of them survive.

The soldiers may have symptoms that range from mistrust, sleeplessness, anger and addictions, as well as loss of sensuality and sexual drive. Their spouses, trying to cope with the stranger who came home to them, also suffer anxiety, depression, social withdrawal and sleep problems. Those are only some of the symptoms.

“I… feel I am walking on eggshells, saying what he wants to hear,” said one woman. “There are some times now when I feel a little afraid. During those instances, I just leave the room and walk away.”

She was one of the subjects in a study of PTSD wives conducted by Holly Beth McLean for a PhD in counselling psychology at the University of British Columbia.

“Joe was taught as a soldier to show no signs of weakness and to react to things that are threatening with maximum violence, maximum aggression,” said another. “I wasn’t getting that full force, but it was there, just barely under the surface, and it really scared me.”

Not all PTSD wives feel that kind of fear. Jane, the wife of a major who did three peacekeeping tours in violent war zones, said that she and her husband have never suffered any alienation from each other as a result of his psychological symptoms. In an interview at their sunny, pleasant home, he called her “my best friend,” and said that without her, “I wouldn’t be here.”

That’s not to say they have it easy. A retired major, her husband has been diagnosed with PTSD, although he doesn’t accept the diagnosis. He does have many of the symptoms, though, including trouble sleeping. He’s jumpy, they both agree. He’s deeply depressed. He has sought treatment for depression and anxiety, including electric shock therapy.

For a time he had such problems with his memory that he had to take a cellphone when he left the house—he got lost, even in the small central Ontario city where he lives. Jane goes with him to every medical appointment to fill in the holes in his memory.

“It’s been a long haul,” she said.

Children, too, suffer when a parent has PTSD. Attention has been focused on the symptoms children exhibit while a parent is away on duty. They have nightmares and anxiety about the parent’s safety.

But living with PTSD once the soldier is home presents its own challenges, as the Mood Disorders Society of Canada made clear in a report this year to the Government of Canada, quoting Deborah Harrison, a sociology professor at the University of New Brunswick.

“It changes their life and it completely changes the situation at home,” she said. “It’s a crisis like any other kind of major illness or violence in the home.”

One veteran with PTSD who took part in a study with the University of Western Ontario said he recognized the degree to which his condition affected his children.

“It really had a profound effect on my oldest son because… the relationship with him changed. He has a lot of anger and hurt. He was basically abandoned… unable to understand why I have these mood swings and anger.”

Even in families where violent behaviour or addictions are not an issue, a spouse may be left doing all of the family work, as well as working outside the home, in order to keep the family functioning.

“My job now is very well suited to my situation because I have alternate weeks working and being off and I can do my job and be at home more,” one woman told McLean. “I am home every day to get the kids ready in the morning for school. All Luke has to do is put them in the truck and take them to school. And I am home every day for lunch and I am home right after five. I am home to take care of everything at lunch, make sure everybody eats and everything is taken care of and go back to work and come back home… so I got very, very lucky to get this job.”

Even in these difficult stories there is a ray of light. All of the women in McLean’s study report strong memories of the life-loving, funny and healthy men they sent off to duty and all of them, in spite of the stresses they described, remained loyal to their husbands and stayed married. In the UWO study, only one of 10 Canadian peacekeepers who took part had experienced a separation and divorce.