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View “The Reality of War”,
a short exerpt from Michael
Kamber’s essay “Shooting
the Truth”, from The Good
Men Project anthology, now
Mark Pollack, MD, is the director of the Home
Base Clinical Program. Home Base is a
partnership between the Red Sox Foundation
and Massachusetts General Hospital dedicated
to improving the lives of veterans who deployed
in support of the conficts in Ìraq and Afghanistan
and live with deployment- or combat-related stress
and/or traumatic brain injury.
Click the link to learn more about Treating PTSD.
MATLACK: Thank you Dr. Pollack. Ì came to
MGH to hear your lecture and heard about how
your brother has served our country and how that
was one part of your motivation to head up the
Home Base program. So maybe we can start with
the numbers. Ìs it 300,000 men and women who
are affected at this point, we think?
POLLACK: 300,00 is the ballpark. Obviously
there are more men affected than women. There
are more men serving. But it can affect both men
MATLACK: There’s no evidence to indicate that
men are more inclined to post-traumatic stress
MATLACK: And just so Ì understand, 300,000
includes both post-traumatic stress and
brain injury, or is it just post-traumatic stress?
POLLACK: Ìt's 300,000 just PTSD. Ì'd say there
are about two million people who've served. Ìf 30
percent of people are affected by PTSD or TBÌ÷
traumatic brain injury÷that's about 600,000, and
so it's about 300,000 with PTSD or PTSD and TBÌ,
and the same amount of TBÌ and/or PTSD.
MATLACK: Traumatic brain injury occurs when
soldiers are near explosions that rattle their
POLLACK: Right. So an ÌED, an improvised
explosive device, that goes off would be a common
provocation for traumatic brain injury. Sometimes
shock waves, as an explosion would, or if a bomb
or missile or something like that goes off nearby,
that kind of thing.
MATLACK: What are the symptoms of each?
POLLACK: Well, individuals with post-traumatic
stress disorder have experienced a situation or a
trauma that involves a threat of loss of life or severe
bodily harm to themselves, or witnessing such an
event to somebody else. Coupled with that, people
will typically experience a variety of different kinds
of symptoms, from sort of three large categories of
symptoms. One is re-experiencing type symptoms,
so things like fashbacks or nightmares, or re-
experiencing symptoms of arousal or anxiety, fear,
if provoked by coming in contact with a situation
that reminds them of the original trauma. So a car
backfring might be evocative of the explosion; the
person'll have a fashback and feel like they're
back in a combat situation. Or an individual who's
assaulted in a dark alley, if they walk by a dark
alley, that might start to make them feel aroused
The second major category of symptoms is
withdrawal symptoms, so things like feeling
depressed, feeling a lack of future, a tendency to
kind of withdraw themselves. This is also often very
painful for spouses and children. The individual
doesn't seem quite the same anymore.
And then the third major category are a
hyperarousal which leads to irritability, anger,
panic attacks, sleep disturbance.
Now, it’s not uncommon after a trauma for people
to have some of these kinds of symptoms normally.
Ìf you've ever been in a bad car accident, it's not
uncommon to be anxious, aroused, or have sleep
disturbance for days afterwards. But the diagnosis
of PTSD is made when these persist for a month
or more afterwards, with the idea that, for many
people, these may kind of fade over time. And for
some people these might not occur immediately
after a trauma, but it might occur months or
sometimes even years down the road.
MATLACK: And how about brain injury? What are
POLLACK: For traumatic brain injury, the
symptoms include things like memory disturbance,
dizziness, lightheadedness, a variety of physical
upset, lightheadedness, word-fnding diffculties,
depression, anxiety, irritability, those kinds of things.
Often people who have traumatic explosions and
stuff like that might both develop TBÌ because of
the physical force of the blast, but also develop
PTSD as a result of having been exposed to a
MATLACK: So it seems like one of the biggest
challenges is the self-diagnosis÷ veterans who
are suffering to actually come forward.
POLLACK: The evidence is that probably less
than half of people who are suffering with this are
seeking any kind of treatment. That may, in large
part, be due to stigma around psychiatric issues. Ìt
may be a desire, in some cases, for people not
want to call attention to themselves in a way that’s
going to get them pulled out of the situation and
away from the other soldiers. They don’t want
to feel like they’re abandoning them, so they’ll
minimize their symptoms from TBÌ, and even with.
And then, when home, often people may avoid
seeking treatment, either because
people just want to put the whole thing behind
them, again because of the stigma, and because
of a desire to avoid getting involved in any sort
of screening or treatment that might delay their
ability to return home.
MATLACK: Ì don't know if you're aware of Seb
Junger, who writes for Vanity Fair a lot. He spent
a year in Afghanistan in really one of the worst
locations. And one of his things is that the guys in
the most dangerous situation choose to be there,
and so he's asking the question why would they
choose to do that. Do you think once you kind of get
to a point of having experienced so much trauma
that you kind of get into this cycle where it’s kind
of the only thing that you know, and that there’s
some level of post-traumatic stress that’s actually
kind of going on constantly, that pushes you to re-
experience that by being in that adrenaline-flled
POLLACK: Ì think people have all sorts of
different pathways for being there. Ì think what is
clear is that, once people get into those situations
they are very connected and committed to each
other. There really is a lot of truth to the idea that
people go to war for their country, but they fght
for their buddies. And Ì think once there, they
are committed to staying there. Ì've heard some
returning veterans talk about the fact that the
work there felt really meaningful, and that what
they do on a day-to-day basis here, while it can
be sort of pleasant or fll needs, isn't flled with the
kind of saliency and meaning that the work there
was, where they were literally fghting for their
lives, fghting to protect their friends. That is part
of what’s going on when people stay, and when
they go back. Just last week we were in Walter
Reed and saw some very impressive men who
had been badly wounded, and they’re anxious to
go back. They certainly have enough injuries that
they wouldn’t have to go back, but they want to go
back because their guys are still there.
MATLACK: As part of this Good Man Project,
one of the guys we've profled is Michael Kamber,
who’s the number-one war photographer for the
New York Times.He’s covered twelve wars, and
when he comes back, he’ll say, “Nothing here
seems to matter. Ì need to take pictures that are
going to show the truth, the real truth, of what’s
going on in the wars that are going on in this world,
and that’s somehow become this passion, but a
lot more than that.
POLLACK: Many people are searching for
meaning in their lives, and when they fnd
something that makes sense to them and gives
them a sense of fulfllment, people are willing to
put themselves in harm’s way to do it.
MATLACK: So tell me a little bit about Home
POLLACK: The Red Sox won the World Series, in
2004 and then 2007, and they went to Washington
in '07 to meet the President. Because one of
the team docs was in the military, they went to
Walter Reed with the idea that that would be a
nice thing for the soldiers down there, especially
Red Sox fans. Tom Werner and a number of the
owners really were very moved by what they saw
down there, and decided they wanted to make a
commitment to doing something, and eventually
agreed to underwrite, along with MGH, for a
program designed to help take care of soldiers,
returning veterans, and their families.
So Home Base is a program that helps provide
care focused on combat stress-related disorders,
PTSD, depression, anxiety, and traumatic brain
injury, and also helping provide education,
support, and treatment for family members. They
also sacrifce, not having their family member
there for months or sometimes even years. You
can imagine what the impact would be on a kid
[in] these formative years with parents not there
for long stretches of time.
A third piece is education. We're providing
education to the general public, but we’re going
out to yellow ribbon events for returning veterans,
providing education around family issues,
education on the Web. The truth is that most
returning vets are probably not going to get treated
in a military sense. The majority of these people
will get treated in the general publics, and trying
to increase awareness and expertise among docs
outside of military settings is one of our goals.
And then research. We have good treatments for
PTSD and TBÌ, but they are far from perfect, and
a lot of people still are symptomatic after receiving
standard treatments. So we are looking to learn
more about the disorders and to develop the next
generation of treatments to try and get more people
better. We do outreach, to go out there, fnding
that a number of vets, not surprisingly, want to
deal with other veterans. For some people, having
that ongoing vet-to-vet contact is critical.
MATLACK: So my understanding is that there’s
drug treatment and therapeutic treatment.
POLLACK: Psychosocial treatment too. Both
psychosocial treatments or psychological
treatments are effective, and pharmacotherapies
as well. Among the psychological treatments,
the two most commonly used and documented
effective are cognitive behavioral therapy and
cognitive processing therapies, which basically
involve having patients expose themselves to the
memories of what happened, and giving them
cognitive and behavioral tools to deal with the
affective symptoms that come up. And by repeatedly
exposing themselves to those situations, and
managing the feelings that come up over time,
they gain some control over the feelings. Those
are the cognitive behavioral therapies, or cognitive
processing therapies. The other are medication
treatments and also can be effective. Drugs like
antidepressants are commonly used, and then
there are other medications as well.
MATLACK: Ì was hearing about, in terms of
exposing patients to the actual trauma, that
technology’s being used in that regard.
POLLACK: That’s something that’s been an
active area of research, and we’re starting up a
program here with the idea that, for some people,
remembering what happened to them, or bringing
it back up in their mind and talking about it, and
writing it down, kind of exposing themselves to
the memory, can be inordinately painful, to the
point that it’s very hard for them to do it. For those
people, using a virtual reality, where in some ways
they’re kind of surrounded, prevents them from
avoiding thinking about it, and can be very
evocative. The idea is to expose the person to what
they’re afraid of repeatedly, and again, give them
some tools for sort of managing the arousal and
the anxiety as they go through it. With repeated
exposure over time, their fear tends to extinguish.
The virtual reality stuff is a way of getting people
to expose themselves to these memories and
situations that they’re afraid of.
MATLACK: So this is actually a good use of video
POLLACK: Well, the main thing is that the
technology useful. Ìnterestingly, it looks like
there's a balance between making it very real÷Ì
mean, crystal clear÷and leaving it a little more
general÷driving down a road, and then suddenly
an explosion goes off in the car. And they'll talk
about that, and they’ll sort of go through it, and
they'll say, when÷Ì'm making one up÷that fgure
in the black burqa went across the road, and made
me remember÷and, you know, turns out there
was no person in the black burqa. Ìt was triggering
their own experiences.
MATLACK: So they impose their memory on it.
POLLACK: Yeah, that’s sort of what you would
hope would happen. Ìf you made it too exactly real
to life, that it might inhibit somebody from putting
in their own kind of experience. But certainly with
the second generation, they're imposing flm into
certain parts of it, so there’s going to be a balance
between making it so real that maybe it’ll lose some
of its generalizability, and making it real enough.
Click the link to “See Virtual Iraq”.
MATLACK: So when a veteran is hooked up to
this virtual reality, what are the techniques that
you’re using to allow them to manage their fear?
POLLACK: Well, in some ways you would do it the
same ways as you do regular behavior therapy,
where they’re exposing themselves to their own
memories, and helping them talk in great detail
about what happened, feel those feelings and
realize the anxiety and the arousal will rise, peak,
but it will end. The more they go that experience
of seeing it arouse, and increase, and then peak,
and then start to come down, the more confdence
they have that it’s not going to last forever.There’s
a sense of constantly reminding them that, while
you’re feeling this, while you’re experiencing these
memories, in fact, you are in a safe place, and
the fact that you’re feeling your heart racing, and
you’re feeling that sense of anticipation, doesn’t
mean you’re actually in danger. Trying to teach
them to distinguish what happened in the past
from the present safety.
MATLACK: So at its core, post-traumatic stress
really is, in some ways, about the unconscious or
conscious belief that you’re still in that situation.
POLLACK: Ìt's about the impact of memory, and
dysregulations in memory, and at the moment,
feeling like you’re back in the traumatic situation.
The distress that you get triggered in certain
situations makes it hard to distinguish what was
then from what was now.
MATLACK: Ìs there any distinction in treatment
between personal danger and something that
might have happened to someone else?
POLLACK: Ìt can often have the same sort of
impact. People developed PTSD after September
11. Ìf you're driving down the road and you see a
horrifc accident, bloody bodies lying by the side of
the road, or somebody really injured, those kinds
of things can trigger it in an individual. The
fashbacks and nightmares don't have
to be happening directly to you.
MATLACK: On a personal basis, how did you get
interested in this kind of work?
POLLACK: Well, Ì was doing this to some extent
already in civilian populations. My brother is career
military, was over in Ìraq in 2004 and 2005, even
before this started. Ì'd be listening to the stories
he would tell, where every day kids would line up,
and every day, four or fve of them wouldn't come
back. And everybody knew it, and they still went
out. Ì have to say, it feels like very meaningful,
important work trying to help some of these people
who÷you know, it's a bandied-about cliché, but
these people really have sacrifced their lives,
their health in some cases, given up years to do
this for us to some extent, and it feels important.
And it does feel sort of like an honor to be able to
do some of it, to help give something back, and
Ì think a lot of people are feeling that way too.
The owners of the Red Sox felt that they wanted
to give something back. Think about what it was
like in the '60s and '70s, where you saw people
in uniform, and for many people they tended to
abuse the soldiers and veterans. Now you go from
the airport and the veteran walks by in uniform,
people will spontaneously go up and thank them,
buy them a beer. The airlines will upgrade them
when there's opportunities to. Ì think there's a
sense, Ì think, people have of trying to do better
this time than last time. Ìt feels important to me
and gratifying to be part of that, Ì think.
MATLACK: Ì think the other thing that's happened
is that the politics of war, and the individuals that
carry out war, have been separated÷which is
good. So whether you support a war or not, as an
American citizen, you still have to respect what
POLLACK: You meet some of these soldiers, and
they are just extraordinary people. Ì don't know
that they were all extraordinary when they started.
Ì mean, these were probably regular guys who felt
some calling to do this. But there’s something about
their experience that really, Ì think, has elevated
them, and made many of them do extraordinary
MATLACK: So do you talk to your brother about
this at all, and what does he say?
POLLACK: Well, Ì think he's happy that the
general public is kind of paying attention to this.
Ìf you talk to the people in charge of any military,
the generals, they’ll say that to really be helpful,
it really does need to be a partnership between
the private sector and the military. There are
hundreds of thousands of people, and it really is
going to require an effort on the part of the whole
country, not just the military, to help take care of
MATLACK: Ìt's great stuff you're doing. Ì really
POLLACK: Well, thank you.
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