L Abbott
Dr Frank Ochberg is a pioneer in the study and treatment of post-traumatic stress disorder (PTSD), which he believes should be renamed post-traumatic stress injury (PTSI). As his research developed, he believed that PTSI was a more relevant term. Approaching combat trauma through the lens of an injury rather than a disorder was, to him, more beneficial. In 2012, he noted that traumatised people ‘tell us that they will feel less stigmatized. But they also explain how the concept of an injury, rather than a disorder, does justice to their experience. Once they were whole. Then they were shattered. When their counselors, employers, friends and loved ones behaved as though they were survivors of injuries, with lingering wounds, they could heal. When they felt like mental patients and were treated as persons with pre-existing weakness, they could not heal’.1
Dr Ochberg developed what he termed the Counting Method, a form of exposure therapy. After establishing a relationship based on trust, the therapist counts to 100 as the patient silently recounts their experience. Afterwards, the patient and therapist discuss what has occurred. Dr David Van Nuys notes that ‘it has been Dr Ochberg’s experience that through this sort of procedure, patients will recall forgotten aspects of their trauma experience that help maintain PTSD symptoms. Through the recall process, some of the intensity of the PTSD symptoms are reduced’.2
He received his BA from Harvard and his MD from Johns Hopkins. From 1969 to 1979 he held numerous positions in the National Institute of Mental Health, including serving as Associate Director. Following this, he became director of the Michigan Department of Mental Health for three years. At present, he is a clinical professor of psychiatry at Michigan State University. He was honoured with the Lifetime Achievement Award from the International Society for Traumatic Stress Studies, of which he was a founding board member. In addition to his work with veterans, Dr Ochberg founded the Dart Center for Journalism and Trauma in order to work with war- zone journalists who suffer from PTSI.
In 1993, he was instrumental in starting Gift from Within,3 an organisation which offers support to trauma survivors. The website provides information not just for war veterans but for anyone who has suffered from trauma. He is also medical advisor to Honor for All,4 a group that seeks recognition of the invisible wounds of war. He has co-edited three books on trauma and is the author of over 100 articles relating to various aspects of traumatic stress. Most recently he appeared in the documentary To Be of Service (directed by Josh Aronson, 2019), which chronicles the use of service dogs as a way of reducing PTSI symptoms.
Ochberg is not an art therapist, but sees that art can be a valuable strategy in understanding the inner world of the client. Art can be a method of reframing one’s experience and bringing the experience out in a concrete form. Overall, Ochberg’s philosophy is to ‘create a collaboration with the trauma survivor, traveling alongside one another, walking back to the scene together, re-experiencing it together, encouraging a sense of shared humanity during that walk… Post-traumatic therapy should be individualized, not routinized’.5 Art in various forms can be part of individualised therapy.
At 80 years young, Dr Ochberg’s over 50-year career continues with no loss of energy and enthusiasm and desire to help those with PTSI. He offers a unique perspective on the treatment of combat trauma. I spoke with him in September 2019, as part of a larger project on trauma and the arts.
Larry Abbott: You’ve noted that PTSD therapy was in contrast to other therapies in that it’s about making the all too conscious memories into tolerable, manageable memory that can be accepted, carried, shared, respected. Can you develop that thought?
Frank Ochberg: Yes. There are psychoanalysts whose theories and whose practice is derived from Freud and from others from that era. And what they’re accustomed to doing, and doing rather well, is help neurotic people who might be compulsive, might be depressed, might be anxious. These people have wounds from childhood that weren’t necessarily what we would call traumatic, but they’re stuck in those places. The analysts work by bringing dreams to light, by assuming that certain feelings end up getting projected onto the analyst. It’s a long process with free association, to get past the defences that suppress painful memory. Patients end up recovering repressed memories that happened decades and decades ago. But what we’re talking about are more recent and blatant traumas, major, obvious traumatic events and their impact is very different. As I visualise it, the brain is shocked. It goes into a very different mode, and it doesn’t come out of that mode for at least a month. And it could be much, much longer than that. My job, as the psychiatrist working with people who have PTSI injury symptoms, is not to go back to their childhood. That’s really irrelevant.
My job is to help them come to terms with what happened and with the lingering effect of what happened and have them develop an ability to have normal memory, rather than trauma memory; to turn off their alarm system, and to recover a certain ability to have positive emotions, which they’ve lost. And when they begin to recover from one part of PTSI, the other parts start coming back and they are free to have friendships. They can come to their daughter’s christening, or their son’s bar mitzvah, or a family holiday and not feel as though they are bringing a black cloud onto everybody else.
So it’s really is a different theory. It’s a different approach. As you know, I’ve written about the way I do treatment for this condition. It’s not that of a formula, but it does mean paying attention to all the dimensions.
LA: Let me ask you this. Are there biological and physiological aspects to combat trauma?
FO: Absolutely. When we first created a diagnosis back in the late 70s and published it in 1980, we had no idea how the science would illustrate what we were finding. But since then, we’ve learned some things about brain anatomy and brain physiology. For example, there is the part of the brain, the amygdala, that is like a power station that sends out signals to get the whole body into alarm mode.
It helps change the blood flow and the effectiveness of the large muscles and the ways your eyes work to focus on what’s right in front of you and let the background blur. You are moved into a situation where you can fight for your life, or you can flee for your life. We know that when you are stuck with this condition for months and months, you have an erroneously hot amygdala. It’s placing you in a state of lethal alarm, and it doesn’t do you any good to be in that state.
By the way, the Special Forces, the people who are very good at handling lethal threats, their bodies bring them back to normal very quickly. It’s been shown in scientific experiments that the people who are highly adapted to handling high stress have a capacity to have these brain changes and body changes that equip them for lethal encounters. But then they come back to normal very, very rapidly.
LA: Are you saying that the biological or physiological effects can be reversed?
FO: Well, I’m saying that as the condition improves, these anatomical and physical components are restored to normalcy. In a way, it’s the chicken and the egg. It’s a circular thing.
A person going through recovery from their circumstance has their brain normalise as a sense of their self normalises. It goes together. There’s another very significant part here, and that is that the frontal part of the brain, which is where our reflexes for being socially appropriate lie. That part seems to detach from the central parts of the brain that are placing us into a fight or flight mode.
There’s another part of the brain called the hippocampus. It’s a small structure near the amygdala, and that part seems to actually get smaller in most cases of this condition. If it’s somewhat smaller to begin with, you have a greater chance of developing PTSI.
There’s more and more data that gets discovered as this highly scientific research goes on. What I keep pointing out is that PTSI is real. This is not just in somebody’s head. It’s as real as having diabetes or having atrial fibrillation. There is an organic change. We’re learning more and more about it. It helps to have medical doctors appreciate the condition and treat it.
LA: You’re not in favour of the term PTSD. You are for renaming that PTSI. Can you explain that a little?
FO: Yes. I did write an essay for one of the military journals about this.6
Several Vietnam Veterans convinced me. I joined their campaign. I’m the medical advisor of Honor For All. We’ve been successful in getting a majority of the states of the United States to raise the flag and have a ceremony on what these states are now calling PTSI Awareness Day instead of PTSD Awareness Day.
The term ‘disorder’—maybe it shouldn’t be—but the term ‘disorder’ is stigmatising. Who wants to say ‘I am disordered’, when you can say, ‘I’m injured. I have an injury, and it’s an honourable injury’? In Canada, you can get a medal, a Sacrifice Medal, for this very same combat stress injury that we call PTSD. So they’ve gone a little bit further to get it considered an honour rather than an insult by calling it an OSI, operational stress injury. Of course, I’m for that.
LA: Are you connecting this, or is this related to, moral injury that Nancy Sherman writes about, for example?
FO: I know Nancy, and she’s written a good book explaining moral injury. But we really ought to credit Jonathan Shay, because Nancy did pick it up from Jonathan Shay. According to Shay, moral injury goes back to the Peloponnesian Wars. It’s something that Achilles experienced when he was betrayed by his king. You need a sense of support and honour to risk your life for something you believe in. And when what you believe in has been dirtied and damaged and insulted, the result isn’t PTSI. It’s something else that’s even more profound. It’s a loss of a sense of meaning. It’s beyond a physical or a psychological wound. It’s worse than that because it destroys what you’re all about and what you’re going to risk your life for.
There’s a different definition of moral injury, developed by Brett Litz, and this is when you, yourself, do something that conflicts with your deepest beliefs. So the sergeant orders you to drive like hell from one place to another. And there’s a civilian in the road, and you have no choice. You run that person over not because the sergeant was being unethical, there was just a higher value on doing what the military unit had to do. But in doing it, you violated your own sense of what is right. It’s a different kind of a moral injury.
LA: You’ve worked with Vietnam Veterans and the veterans of today. Do you see a difference between the Vietnam Veteran and the current Iraq/Afghanistan Veteran?
FO: Not really. I mean, they’re a different generation, but what I’m tuned into are the similarities. I try to help that person explain his or her situation to me and articulate it in a way that they believe has gotten across to me, and I just have a conversation with them about it. I am helping them find their way back from feeling diminished, violated, having violated their own principles. And I don’t do it in some glib way like saying, ‘Oh, it’s not that bad’. I never do that. But I do give them a chance to figure out why they are punishing themselves, and a chance to work on very straightforward things like insomnia. You know, solving that problem is terribly important. People in my field learn various ways to do that. Some do involve medication.
Sometimes, it’s just as important to keep a little journal when you’re falling asleep. And rather than stay awake ruminating about what’s going to keep you awake, you’re going to deal with it in the morning. You’ve written it down before you fall asleep. You get into the habit of handling your obsessive thoughts or your anxious thoughts in the morning, rather than in the evening. It helps. There are a lot of tricks of the trade, and they’re important, too. But I really want to get into what brings us together now. It’s the ghost, the idea that something haunts you. There may be a way of dealing with what haunts you that has far more to do with poetry and art than with psychiatry.
LA: You mention in your essay that you want to reframe the traumatic memory and minimise or eliminate the discomfort from those memories. Do you see that art and writing are methodologies or ways to reframe or transform traumatic memory?
FO: To reframe it, but also to explain it and to bring it to somebody else. I’ve written a few poems, and I do want to share them with you. Maybe not right during this conversation. One of them has been put to music recently by a colleague who is a singer/ songwriter and a therapist. It was premiered at a dedication at a veterans’ park a few weeks ago. I feel like I’m in this with you where we really have to use every tool in the box. The historic tools involve art and poetry much more than psychiatry.
The artists put into some form an experience so that others can see it and resonate with it. They do not do this in a dry, academic way. Sometimes the experience that’s being transmitted from the veteran to the civilian who needs to know is shocking. And it’s meant to shock. The soldier who has been so deeply aggrieved by the death of his friend in arms, that soldier needs to find a way of having somebody else appreciate and understand it.
Let me tell you about the Marine Veteran who I’ve worked with just last month. His high school friend and he were in the unit together. The friend died and he happened to have the same first name as I do. Ben was calling for air evacuation as he’s holding Frank, and Frank is screaming. And Ben’s last words to Frank are, ‘Shut the fuck up, Frank’. We can chuckle at it now, but imagine dreaming, night after night, of yourself saying, ‘Shut the fuck up’, to someone whose life you’re trying to save. However, it all happened between Ben and me, I know that he got his feelings across to me and that mattered a lot to Ben, and it helped his nightmare to stop.
LA: It seems to me that art is a way to objectify the experience, take it out of the mind where it might be tormenting the person. I thought of TS Eliot’s idea of the objective correlative, bringing thoughts and feelings out into ‘the public’, like with trauma masks. Melissa Walker works with veterans to create masks which express their experience that they could not express in words. The masks are like a doorway into further discussion. The veteran can then talk about the mask as an objective item, and then explore how the mask came about, what the masks represent. The mask reveals those mental states.
FO: Sometimes, those masks can be horrifying. What is it about a mask? It’s an altered face that you can put on your own face. I’m not sure that objectifying is the right word, but it might be. The mask is an object, but what’s going through your brain is not an object. It’s a lot of horrifying distortions.
LA: The distortions can be transformed into the artwork, whether it be a mask or a painting or a poem. Regina Vasquez takes old uniforms and turns them inside out and writes her story on the uniforms and hangs them up in a gallery. She calls them ‘Fatigues Clothesline’. The viewer walks through the exhibit, reading her story on the old fatigues. There are different formats that veterans are using to deal with their experiences.
FO: I’m thinking as we’re talking. Is it a distortion if what it really is something from inside the machine of the mind? We create and recreate reality out of our neurons and our brain biochemistry. What is a thought? It’s so complicated. Ten billion neurons and so many different connections. That’s our brain, and the brain can do strange things.
LA: The neurons have been disturbed by the trauma?
FO: Yes. Yes, absolutely. Now, it’s a different, very literal kind of injury when you have a bullet fragment in the brain. If it doesn’t kill you, it’s a shock and your brain is shaken and damaged, that’s a TBI. That’s a traumatic brain injury. That’s not a PTSI. They overlap, and we are talking about injuries, and then recovery from that injury, sometimes not full recovery, but you can have a wonderful adaptation to an injured brain, just like Max Cleland had a wonderful adaptation to being a triple amputee.
He becomes the Secretary of the VA and a fantastic senator. I’m privileged to have met that man. Maybe it’s also that the gifted veteran poet and the gifted veteran artist can make something out of what is inside them, and they pass it on for our benefit. We appreciate their service, their suffering, their resilience, and the fact that they’re still part of us collectively. I had a phrase in one of the essays that I wrote, I didn’t realise that it would have an impact, but it’s that some of us keep horror alive for the rest of us. That’s important. And if you can put it into a poem, as Sassoon and Owen and Brooke did for World War I, that’s alive for the rest of us.
LA: I think of some of the artists from that time, like Claggett Wilson and George Bellows, and a hundred years later, writers and artists are doing the same thing.
Ron Whitehead is a Desert Storm Veteran who’s an art teacher in New York State. He told me ‘I put into my photographs what I cannot say in words’.
Art and literature, maybe more the visual arts, are ways that the veteran is trying to explain or show his or her ‘condition’, let’s say.
FO: Well, yes. And in addition, what it can do is it can evoke something in the receiver. We’re not all going to look at a piece of art the same way. I don’t think we’re going to respond to a poem in exactly the same way. That’s the beauty of it. If it’s good enough to be curated and in a major museum, or it’s good enough to find its way into an anthology, that means it is reaching thousands if not millions of people. It’s causing us to have a profound experience. It’s encouraging to think about combat vets who become artists and teachers and honest purveyors of difficult truths. It is one thing to tell a personal experience. It is another and more difficult task to evoke accurate understanding when words are not enough. That’s the irony of PTSI. It fills a person with experience that begs to be given to others at the same time that it freezes feelings and silences speech. It’s not the same as a dictionary definition of ‘trauma’ by a longshot.
I like to think of myself as having a slightly different non-traditional academic place in this field. I’ve written my share of academic articles, but that’s not what I’m invested in doing anymore in my life. I love that I have a chance to interact with journalists, with women veterans, with artists, with you. Look at what we’re talking about. We’re going to reach people in a different way. Our goal is to increase public understanding. Even more than that, an appreciation for the impact of these events on people who’ve suffered through them.
LA: In an interview with Jon Stephenson, you talked about the idea of alienation.7 I think that art and literature can reduce that sense of self-alienation.
FO: Absolutely. That’s so important. But let’s think a little bit about why that alienation happens. There’s often been that moral injury. It’s so profound when a piece of you that has been hurt… it’s hard to put into words. It’s your core sense and beliefs. Those can get shaken. It’s a loss of self.
I worked with Terry, a Vietnam Vet, for a long time. Terry was very, very religious. I am not religious in a traditional sense. I’m poetic and spiritual perhaps, but Terry and I were going through his loss of ability to have positive feelings. We’re talking about feeling God’s love, and he wasn’t feeling that. And then all of a sudden, he realises it’s not that God isn’t loving him, it’s that he has PTSI, so he can’t feel the sensation of love. And he leaps up, and he gives me a big hug, and he said ‘Frank, you restored my faith and you don’t even believe in my faith’.
It wasn’t that I restored it, but we got into it together. I’m just beaming thinking about this. He’s dead now, but in his world, he’s in a happy place. He learned how to love, and he learned how to feel loved. That was part of what we were working on. I helped him have a colour wheel of positive emotion. It wasn’t artwork, but it was related in a way. It was giving colours and symbols for all the different ways of feeling good, from a very bright joy to a very mellow, blue tranquillity to red for love and purple for spiritual love.
LA: So you would say, just to wrap up, that you see hopeful signs in the treatment of PTSI?
FO: Absolutely. Oh, very hopeful signs. And it’s from all different parts of our human community. It’s not that only the doctors are doing it. We don’t do it alone because, my goodness, trauma, shattering trauma, humiliating trauma, devastating trauma, individual trauma, group trauma, you don’t get through life without some of that. And you don’t get restored to your own humanity by pills alone.
