May is Mental Health Awareness Month, an opportunity to raise awareness of the millions of veterans – and Americans – battling mental health challenges, and perhaps more importantly, to discuss what should be done to ensure these men and women can live great lives – filled with meaning, purpose, connection, and growth.
When it comes to the subject of mental health and veterans, there is no doubt that much is done to raise awareness of their plight. However, far too little is done when it comes to talking about and taking action on the second part of the story — the journey from struggle to strength, pain to purpose, tragedy to triumph.
As a 21-year US Navy service-disabled combat veteran, and the Chairman of the EOD Warrior Foundation and Boulder Crest, which owns and operates two privately-funded wellness centers – Boulder Crest Retreat Virginia and Boulder Crest Retreat Arizona – as well as the Boulder Crest Institute for Posttraumatic Growth, I have a unique perspective, from considerable personal and professional experience, on the struggles of veterans and their family members, and on their opportunities to grow in the aftermath of trauma.
In March of 1989, I was severely injured in a military parachuting operation. I broke my back in two places, dislocated my shoulder, and was knocked unconscious, suffering a severe concussion. I was told that my military career was over. In December of the same year, I was back to full active duty primarily thanks to my personal motivation and a private medical resource – a chiropractor. You see, the Navy assigned me an E-3 physical therapist and bottles of pain killers and Motrin 800mg. I am convinced that if I would have stuck to the Navy’s regime, I would have been discharged. I went on to do a full 21-year career and ultimately retired as a Master Chief Petty Officer, the Navy’ s senior enlisted rank.
In 1989, Chiropractors were looked upon as “witch doctors.” This is not the case today. My hope is that we can transform the mental health community like we have physical therapy and pain management and further hope that it doesn’t take 30 years!
On that front, I am heartened by the language included in S.785 related to Posttraumatic Growth, and I am grateful for the opportunity to share some of what we are learning on our journey.
Boulder Crest Retreat Virginia
In September 2013, we opened Boulder Crest Retreat Virginia – the nation’s first privately-funded wellness center dedicated exclusively to combat veterans and their families. Our vision was to create a place — and programs – where service members and veterans could transform struggle into strength and growth and receive what they required to be as productive at home as they were on the battlefield. For our first nine months, we invited innovative nonprofits to use Boulder Crest Retreat Virginia, for free, as a platform to deliver their programs. These programs ran the gamut – from 1-15 days, clinical to non-clinical, focused on everything from Military Sexual Trauma (MST) and Posttraumatic Stress Disorder (PTSD) to relationship and familial challenges.
It soon became clear to us that these programs would not be sufficient to allow us to achieve our ambitious vision. Every program we witnessed struggled with four key challenges:
First, the programs were, by their very nature, catch-and-release. Participants would come for 1-15 days, experience the program, and receive a pat on the back and warm wishes that everything would be different now. How to cope with their “new normal’. Rarely was that the case. Second, there was no curriculum related to these programs – no sense of what was being done, or how one could scale effective programs. Third, there was little to no evaluation being conducted into efficacy of these programs. While we know that, in the words of Irwin Bernstein, “the plural of anecdote is not data,” far too often, these programs relied on anecdotes to demonstrate effectiveness. Lastly, those who provided care or delivered programs were often “wounded healers,” people struggling with their own mental health issues and challenges, that significantly impaired their ability to connect with and guide others.
In May 2014, leveraging all we had learned thus far, I began a journey to understand what actually worked when it came to mental health, PTSD, and suicide. I was committed to ensuring that my brothers and sisters could live great lives and thrive in the aftermath of trauma. I traveled around the country and met with leading psychiatrists, psychologists, social workers, life coaches, and trauma experts. Time and time again, when I asked them, “What works to allow people to live great lives in the aftermath of trauma?” – I was told, “Nothing.”
In principle this is true because it is not what our mental health system – broadly speaking – is focused on accomplishing. The mental health system is nearly exclusively focused on one thing when it comes to its clients and patients – managing and mitigating the symptoms associated with times of struggle; often through a combination of medication and talk therapy. This approach is not working for far too many people – something made obvious by the highly distressing statistics around veteran’s mental health, and also by the words of one of the world’s most esteemed medical journals, the Journal of the American Medical Association (JAMA).
In August 2015, JAMA called for a new and innovative approach to PTSD for veterans. In January 2017, JAMA Psychiatry declared that, “These findings point to the ongoing crisis in PTSD care for service members and veterans. Despite the large increase in availability of evidence-based treatments, considerable room exists for improvement in treatment efficacy, and satisfaction appears bleak based on low treatment retention…we have probably come about as far as we can with current dominant clinical approaches.”
The first glimmer of hope I encountered on my journey would be found at the University of North Carolina, Charlotte, in the person of Dr. Richard Tedeschi. Dr. Tedeschi, along with his colleague, Dr. Lawrence Calhoun, coined the term Posttraumatic Growth (PTG) in 1995 to describe the ways in which people reported growth in areas of their life in the aftermath of traumatic events and experiences.
I asked Dr. Tedeschi if he was interested in partnering with us to develop a training-based program for combat veterans that would, for the first-time ever, be designed to cultivate and facilitate Posttraumatic Growth in those who were struggling. Dr. Tedeschi agreed, and since 2014, we have been hard at work at the development and delivery of Warrior PATHH.
Warrior PATHH and PTG
Warrior PATHH is an 18-month program that begins with a 7-day intensive and immersive residential initiation. The 7-day initiation is supported by Boulder Crest’s custom-built myPATHH technology platform, which connects and supports students through the remaining 77 weeks — providing ongoing training, connection, and accountability.
Warrior PATHH trains combat veterans through the proven framework of PTG: educating them about the value of struggle and what stress and trauma do to the mind, body, heart, and spirit; teaching proven non-pharmacological techniques designed to regulate thoughts and emotions; creating an environment of trust and safety to facilitate disclosure of past challenges from combat and pre-combat experiences, which is supported by a delivery team composed primarily of combat veterans; beginning to craft a new story that harnesses the lessons of the past and looks forward; and a renewed commitment to service – to one's family, community and country – here at home.
In January 2016, after more than two years of research, development, piloting, and success, the Marcus Foundation funded the development of the first-ever curriculum effort designed to cultivate and facilitate Posttraumatic Growth. The curriculum effort included Student and Instructor Guides, a Journal, Syllabus, and Schedule; four pilot programs; and an 18-month longitudinal study.
The 18-month study, led by Dr. Tedeschi and Dr. Bret Moore, was completed in January 2019, focused on exploring the impact of Warrior PATHH in three key areas: Symptom Reduction, Quality of Life improvement, and Posttraumatic Growth experienced. With responses at the pre, post, 1, 3, 6, 12, and 18-month marks and the use of 24 well-respected and bespoke measurement tools, this effort represents one of the most robust evaluations of a mental health effort ever initiated. The evaluation effort included 8 Warrior PATHH Programs (49 students) and a response rate of 95 percent. Key highlights include:
- 54% sustained reduction in PTSD symptoms
- 52% sustained reduction in depression symptoms
- 41% sustained reduction in anxiety symptoms
- 39% sustained reduction in Insomnia
- 44% sustained reduction in drug use
- 24% sustained improvement in positive emotions experienced; and 25% sustained reduction in negative emotions experienced
Quality of Life Improvement:
- 14% sustained improvement in Couples Satisfaction
- 33% sustained reduction in stress reactivity
- 11% sustained improvement in physical activity
- 26% sustained improvement in nutrition
- 12% sustained improvement in financial wellness
- 56% sustained improvement in personal growth (PTG)
- 78% growth in Spiritual-Existential Change
- 69% growth in Deeper Relationships
- 58% growth in New Possibilities
- 36% growth in Personal Strength
- 26% growth in Appreciation for Life
- 32% sustained improvement in ability to change perspective/psychological flexibility
- 23% sustained improvement in capacity to integrate problematic life experiences.
- 22% sustained improvement in self-compassion
- 40% sustained increase in reading
- 9% sustained decrease in disruption to core beliefs
In short, we developed a program that achieved the vision that we set forth – to ensure combat veterans could be as productive at home as they were on the battlefield, and live great lives – filled with passion, purpose, growth, connection, and service – at home. In response to this unparalleled success, we are now working with partners so that Warrior PATHH can be scaled to ten locations across the country.
Solving the Bigger Problem
Regarding PATHH as merely a program, however, is to miss the larger point. What we are learning along our journey about what did and didn’t work transcended the normal divide between so-called clinical and non-clinical efforts. We had the opportunity to talk to and be guided by not just experts in the psychological and psychiatric community, but the very veterans we are seeking to help. What they told us speaks volumes about what would represent the new and effective approach that so many are calling for. They aren’t interested in being pathologized or reduced to a diagnosis or set of symptoms. They aren’t interested in accepting that times of struggle, despair, or trauma serve as limiting factors to a great life. They aren’t interested in accepting their “new normal,” a life where they must grow accustomed to a diminished life, that is a fraction of what it once was. They aren’t interested in being permanently medicated, and living a life filled with a constant sense of numbness and disconnection that inhibits joy, connection, and purpose.
What veterans are interested in is learning how to maximize the value of their struggle, training, and experiences. What they insist upon is training, support, accountability, direction, and forward movement. What they deserve is the opportunity to grow and live great lives.
The experts are saying we must have a new and innovative approach; and the veterans – voting with their feet – are too. We know that half of all veterans who might benefit from mental health will never go. That of those who do, between 50-80 percent will drop out of treatment before the protocol is finished. That of those who complete the protocol, only 40 percent will experience meaningful benefits – often just a minimal and short-lived reduction in symptoms.
In a May 2017 editorial entitled “Changing Mindsets to Enhance Treatment Effectiveness,” JAMA noted that “…growth mindsets are also proving critical in health care. While more research is needed, what is clear is that instilling a growth mindset in patients about their belief in the capacity to change is an important precursor to health and healing.” The editorial also stated that, “Effective communication and the patient physician relationship are central – not superfluous – aspects of medical care.”
The work that Boulder Crest has done over the past six years in applying, cultivating, and facilitating PTG is at the heart of the new and innovative approach that is required. It speaks to a philosophical and systemic approach that looks beyond current struggles, and towards a future that is authentic, fulfilling, and purposeful. This attitudinal distinction, combined with robust program evaluation and decades of research into PTG, serves as the foundation for such an approach, and has the potential to not only deliver results in PATHH programs, but to substantially enhance the effectiveness of current approaches. In large part, this is due to the recognition and strong evidence base demonstrating that patient education can be as or even more effective than therapeutic treatment.
PTG and Veterans Mental Health
Something must change when it comes to mental health and veterans. For years now, we have done the same thing over and over again and expected a different result. As a bomb disposal technician, I cannot abide this. I come from a field where you don’t get the chance to make a mistake twice; a career field with the motto, “Initial Success or Total Failure.”
We must work towards new and innovative approaches – leveraging the legions of well-meaning mental health professionals, organizations, and peers – to drive better outcomes, and instill a sense of hope, possibility, and agency in veterans who struggle. The focus of our efforts must be in line with what drove my wife and I to open Boulder Crest Retreat Virginia, nearly six years: to ensure that our nation’s veterans can live great lives. This means our focus must be far beyond preventing suicide or marginal improvements in outcomes; our focus must be on ensuring we are training struggling veterans to understand and experience Posttraumatic Growth in their own lives because the opposite of suicide isn’t prevention, its creating a life worth living.
To that end, Boulder Crest has partnered with the VA in an effort to train clinicians, peers, and front-line staff in the principles and practices related to PTG. But more must be done – and done quickly. As the leading organization focused on PTG in this country, and with a strong track record of success within the military and veterans community, we strongly support the language in S. 785, calling for the VA to enter into partnerships with nonprofit mental health organizations to facilitate Posttraumatic Growth among veterans. This language – and the possible impact – represents a strong start to exploring differential, and more growth-oriented approaches to times of struggle, and to the mental health crisis surrounding our nation’s veterans
- 785 is also noteworthy for its call for greater collaboration between the Department of Defense and VA, another important gap in current approaches. The truth is that while the focus tends to be on VA when it comes to the subject of veterans, DoD plays a critical role, particularly when it comes to transition. While we believe that the transition language included in S. 785 would lead to meaningful improvements related to community support, we also think that it is too narrow to be transformative.
The current transition approach is myopically focused on helping veterans get a job; a laudable and important next step, but not a panacea. If it were the answer – at a time of miniscule veteran’s unemployment – we would see dramatic improvements in mental health statistics. But we are not.
Transition is challenging for the vast majority of service members — as demonstrated by VA data showing that the largest mental health challenge for transitioning service members is not PTSD, it is depression. More notably, as Mobbs and Bonanno wrote in the Clinical Psychology Review:
Recent population survey studies have suggested that 44% to 72% of Veterans experience high levels of stress during the transition to civilian life, including difficulties securing employment, interpersonal difficulties during employment, conflicted relations with family, friends, and broader interpersonal relations, difficulties adapting to the schedule of civilian life, and legal difficulties (Morin, 2011). Struggle with the transition is reported at higher, more difficult levels for post-9/11 veterans than those who served in any other previous conflict (i.e. Vietnam, Korea, World War II) or in the periods in between (Pew Research Center, 2011). Crucially, transition stress has been found to predict both treatment seeking and the later development of mental and physical health problems, including suicidal ideation (Interian, Kline, Janal, Glynn, & Losonczy, 2014; Kline et al., 2010).
The military does a tremendous job when it comes to bringing people into the service in a relatively short period of time. The Marine Corps Museum boasts of how the Corps “transforms ordinary civilians into Marines.” When it comes time for the transition, we subject our transitioning service members to a week of “death by PowerPoint.”
We have had countless instances of a veteran who has transitioned poorly, self-medicated in response, damaged relationships in the process, and found themselves in a mental health office. They are then mis-diagnosed with PTSD, medicated, turn to disability payments, and become unproductive, unfulfilled, unworthy, and suicidal. What was a temporary issue of adjustment became a permanent diagnosis. We can and must do better to prepare transitioning service members not just for a post-military job; we must prepare them for a post-military life. Critical elements of our program, particularly focused on education, could be used to that end, and a clear-eyed look of how transition goes wrong is critical to understanding how veterans end up at the brink of suicide.
In short, we cannot simply wait for veterans to get to the point of crisis or fail to acknowledge what the data and the veteran are telling us — whether you served for four years or forty, getting out is hard. We must do a better job of getting “left of boom.”
As a retired disabled combat veteran and a retired CEO, I know the power of military experience and the challenges associated with combat experiences and long deployments. I also know that I am the man I am because of the United States Navy. More than two thousand years ago, the Athenian general and philosopher Thucydides said it best: “We must remember that one man is much the same as another, and that he is best who is trained in the severest school.”
Rather than focusing on suicide prevention and more of the same in terms of mental health services, we should be focused on ensuring veterans can live great lives at home – lives filled with joy, passion, love, service, and purpose. We should ensure my fellow veterans can use the great military training they receive as a launching pad for a productive and purposeful life as a Warrior at home. We must ensure that, to paraphrase the words of a good friend and USMC General officer, their time in the service cannot be the greatest accomplishment of their lives. Doing so requires an integrated and collaborative approach, and we look forward to being a part of the solution and any questions that arise from this written testimony.