Mending a Soldier’s

Heart

Written, Designed, and Photographed By Nate Becker

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DEDICATIONThe following book is dedicated to the millions

of veterans who have risked, damaged, and lost their lives fighting for the United States.

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ACKNOWLEDGEMENTSThank you to Tessa Fisher for taking time out of your busy schedule to discuss Post-Traumatic Stress Dis-order, to Ramon Ontiveros for sharing your trauma, and to Bob Kenyon for letting us into your home and

your history.

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TABLE OF CONTENTSForeword.................................................................10

Chapter 1: A Soldier’s Heart...................................13

Chapter 2: Trauma Triggers....................................15

Chapter 3: Caring, Not Curing................................16

Chapter 4: Complications and Complexities...........20

Chapter 5: The Need for Change............................23

Works Cited.............................................................29

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FOREWORDroutes as well as curbs, subcon-sciously worrying about roadside bombs, a very real threat she faced while overseas. I had always thought of the disorder as uncommon and something that was embellished in movies and stories. I had never considered the impact it may have on everyday tasks, such as driving. I decided to research PTSD, mainly interested in the daily lives of veterans afflicted with the disor-der. I began my search for possible interviewees and was able to in-terview Tessa Fisher, a psychiatric social worker at the Veterans Af-fairs Hospital in Palo Alto, CA. She had much to say and many thought-provoking vignettes to share. Fisher discussed how PTSD is often under diagnosed because there is a stigma against having it and many veterans refuse treat-ment. Because of the isolating na-ture of PTSD, I found it extremely difficult to get veterans to come for-ward and talk about their disorder. I realized that changes needed to be made regarding the gen-eral stigma and treatment ofPTSD. The first step in bring-ing change is spreading awareness

I have always been interested in psychology, the study of the mind. I come from a long line of doctors, many of whom are either psychia-trists or psychologists. My dad is a psychiatrist and I have always taken an interest in his work. I also took a psychology class my sophomore year of high school, which I found quite intriguing. From this class, I learned a significant amount about this field of research and medicine. Post-traumatic stress disorder (PTSD) is something that I have been aware of for quite some time; however, until recently, I did not know much about it. Several months ago I read an article in the New York Times called “Back From War, Fear and Danger Fill Driver’s Seat.” This ar-ticle focuses on a post-combat vet-eran named Susan Max who suf-fers from PTSD. Max, who used to love driving her maroon Mustang,now has trouble behind the wheel because of the trauma she enduredin Iraq. She avoids small parking garages without convenient escape

and that is the goal of this book. This book contains images from my research, including pho-tos of people I interviewed, places I visited while conducting these in-terviews, and memorabilia that are significant to the topic. The con-tent of this book will give readers background regarding PTSD, such as history, causes, symptoms, and treatments. It will also explore dif-ferent factors involved in deter-mining the severity and curabil-ity of the disorder. Finally, it will discuss how the macho culture of the military makes it difficult for veterans with PTSD to accept their diagnosis and seek treatment.

World War II belt buckle

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“I never knew what PTSD was until April 20, 2009. When they discharged me from the service, they

said, ‘Ramon, you’re just suffering depression, that’s all.’ I wanted to kill myself. That’s how bad it was.”

-RAMON ONTIVEROS

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“Patient says he was in Iraq 2004-2005. Patient says when he thinks about Iraq, he sees things in color like a movie. Patient says he feels apathetic and has ‘no interest in anything anymore.’ Patient says he does not like to see other people and does not trust them. He says he does not get along with bosses. Pa-tient says he almost killed his neph-ew when he got out of the military, when his nephew sneaked up be-hind him. Patient says he does not sleep, usually 2 to 3 hours a night, and has nightmares. Patient says he avoids war movies, loud noises, and crowds of more than 3 people. He says he starts sweating and gets agitated. He says ‘my short term memory is shot.’ He says he forgets everything. Patient says when he wakes up at night, he checks doors, is hypervigilant” (Fisher). This ex-cerpt was taken from a screening for Post-Traumatic Stress Disor-der (PTSD) at the Veterans Affairs (VA) Hospital in Palo Alto, CA.

This patient exhibits many signs of PTSD, a relatively common anxi-ety disorder that can be caused by a traumatic, life-threatening event. Ramon Ontiveros served in the United States Navy and was stationed in Da Nang, Vietnam from 1967 to 1970. Ontiveros said, “I never knew what PTSD was un-til April 20, 2009. When they dis-charged me from the service, they said, ‘Ramon, you’re just suffering depression, that’s all.’ I wanted to kill myself. That’s how bad it was” (Ontiveros). His symptoms were initially misdiagnosed and he did not seek treatment until roughly forty years after he was released. The American Psychiatric As-sociation (APA) did not recognize PTSD as a mental disorder until 1980, when PTSD was added to its Diagnostic and Statistical Manual of Mental Disorders (DSM) (Fried-man). However, people have been aware of this disorder for centuries. Before the APA recognized PTSD as a valid disorder, leaders and doc-tors simply viewed its symptoms as cowardice or weakness. During the civil war, PTSD was referred to as “soldier’s heart,” during World War

I it was called “combat fatigue” or “shell shock,” during World War II it was known as “battle fatigue” or “gross stress reaction,” and as re-cently as the Vietnam War, PTSD was diagnosed as “post-Viet-nam syndrome” (The History of Post-Traumatic Stress Disorder). The symptoms of PTSD can be divided into four main cat-egories. The first entails reliving an event through flashbacks, which can often be triggered by sounds or sights. The second category involves the avoidance of anything that may trigger memories of the event. The third entails emotional numbness and difficulty expressing feelings, of-ten to avoid memories of the event. The fourth category involves hyper arousal, always being on the prowl for potential danger (What is PTSD?). It is often difficult for veterans to adjust to civilian life after the war. Tessa Fisher, a psychiatric social worker at the First Step Substance Abuse Program at the Palo Alto VA, said, “It’s very hard to adjust to the monotony and boredom of ordinary life, as well as feel like you can never

Chapter 1:A Soldier’s Heart

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be a part of humanity again based on what you’ve seen and done” (Fisher). Having PTSD makes this adjustment even more complicated. It is an isolating disorder and can make relationships difficult. People with this disorder often get little sleep due to nightmares recalling the traumatic event. The work environ-ment can be quite difficult for peo-ple suffering from PTSD because it contains many stimuli. Driving can also be particularly problematic be

cause there is a lot of trauma asso-ciated with driving during the war. While at war, much of the driving involves the transportation of explo-sives, constant vigilance about road-side bombs, and continual worry about the possibility of death. PTSD can make daily life quite difficult for those suffering from the disorder. There is currently research being done on potential treatment meth-ods and medications that can help with the various symptoms.

There are many factors that can shape a single case of PTSD, but this disorder makes daily life a grueling task regardless of its symptoms and severity. Due to its isolating nature and the stigma surrounding it, PTSD tends to be under diagnosed and under treated. Changes need to be made regard-ing care and the general shame that is associated with it in the Army.

Ramon watches performances at the Menlo Park VA14

In order to properly investi-gate treatment methods for PTSD, it is important to understand its causes. This disorder is often associated with veterans and combat, but it can stem from causes that are not associated with war as well. Any situation that is potentially life threatening can trigger PTSD. Some of these events include: combat or military expo-sure, child sexual or physical abuse, terrorist attacks, sexual or physi-cal assault, serious accidents, and natural disasters (What is PTSD?). Several known factors can determine the severity of each case of PTSD. Some of these variables include: the intensity and length of the trauma, loss of someone close, injury, proximity to the event, strength of reaction, control over the event, and help and support after the event (What is PTSD?).

Chapter 2:Trauma Triggers

Ramon drinking a beer in Santa Claus costume

Pistol from World War II

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This disorder, like many men-tal disorders, tends to be under di-agnosed and under treated. This is likely due to the isolating nature of PTSD and the fact that many peo-ple who have it do not want to ad-mit that they have symptoms and do not seek treatment. Tessa Fish-er described this common denial: “There’s a guy in the program now who’s in the Army and I think he did two or three tours and he hasn’t got any diagnosis even though he clearly is suffering from it. He came back I think in October of 2010, couldn’t find work, started drink-ing, and started drinking more to the point where he lost everything. He’s like a nice, regular, ordinary kid from an ordinary family but he was to the point of living in his car and he just said, ‘You know, especially in the Army, you’re the guys who go with the guns and kick down the

doors and shoot people. You can’t admit to having PTSD. You’re con-sidered a complete failure’” (Fisher). Those with PTSD have trou-ble discussing their feelings and often repress the traumas of their past. Ramon Ontiveros said, “Never wanted to talk about it. First time I’ve talked about my Vietnam trau-ma was 3 years ago, April 29, 2009. Didn’t want to talk to anybody. I never talked to my mother, my fa-ther, my six, seven brothers, one sis-ter, I never wanted to speak about it to nobody. That’s deep, deep, buried, didn’t want to talk about

it, didn’t want to think about it. It changed me that much” (Ontiveros). Although PTSD cannot be completely cured, treatment can help to diminish its symptoms. There are a number of effective treatments for this disorder. Cognitive behav-ioral therapy (CBT) has been found to be the most successful treatment. There are different treatment meth-ods within CBT, such as cogni-tive therapy and exposure therapy. Cognitive therapy assists patients in overcoming problems by iden-tifying and altering unproductive thinking, behavior, and emotional

Chapter 3:Caring, Not Curing

Ramon talks with friend at the Menlo Park VA

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“Never wanted to talk about it. First time I’ve talked about my Vietnam trauma was 3 years ago, April 29, 2009. Didn’t want to talk to anybody. I never talked to my mother, my father, my six, seven brothers, one sis-ter, I never wanted to speak about it to nobody. That’s deep, deep, buried, didn’t want to talk about it, didn’t

want to think about it. It changed me that much.”

-RAMON ONTIVEROS

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responses. Exposure therapy is often used in dealing with anxiety disor-ders and exposes the patient to the feared object or context in a safe en-vironment until they are acclimat-ed to the stimuli (What is PTSD?). Medications have been prov-en to work in addition to CBT. Se-lective serotonin reuptake inhibi-tors (SSRIs), which are a class of anti-depressants, are often used in treating depression, anxiety disorders, and personality disor-

ders. SSRIs have been found to effectively treat patients suffer-ing from PTSD (What is PTSD?). There is currently research be ing done on further treatment meth-ods that can be applied to patients suffering from PTSD, some more controversial than others. The Unit-ed States Food and Drug Adminis-tration (FDA) authorized the first study regarding MDMA, common-ly known as “Ecstasy,” as a potential prescription treatment for PTSD

in November 2001. The feelings of openness associated with Ecstasy will help patients overcome their emotional instability and recover by diminishing fear, depression, and anxiety (Morgan). Obtaining conclusive results from such stud-ies can be a lengthy process. This is because psychology research is only an approximate science and there are an infinite number of variables.

The entrance to the Palo Alto VA 19

There are many variables from one case of PTSD to the next. Because this disorder is caused by something as general as a trau-matic event, the possible origin of PTSD can differ greatly. There are also other factors that may alter the effects and likelihood of this disorder. These elements include personal characteristics, spiri-tuality, and timing of treatment. Everyone copes with trauma differently, in part because personal characteristics vary from one indi-vidual to the next. Most studies con-cerning personality traits are carried out following the traumatic event. Therefore, it is not easy to make any definitive conclusions about the cor-relation between personal character-istics and the development of PTSD.

Chapter 4:Complications and

Complexities

Photos of Ramon in costume

Photo of Ramon with three of his brothers20

However, a study regarding the ef-fect of pre-deployment personality traits on the development of PTSD was published in The American Journal of Psychiatry. Five hundred seventy-two male veterans com-pleted a survey prior to the United Nations Protection Force mission in the former Yugoslavia from 1993 to 1995. The personality traits of negativism and psychopathology were found to have an impact on the symptom severity (Bramsen). Spirituality can take many

forms and has many definitions. For some, spirituality takes the form of religion or religious beliefs, but more generally it refers to deeply held feel-ings and beliefs that are considered sacred. Spirituality can affect how people view a traumatic experience and, therefore, how they cope with the trauma. Spiritual beliefs may govern the way in which survivors make meaning out of the traumatic experience. Research has indicated that negative interpretations of God can be connected with poor clini-

cal results (Spirituality and Trauma: Professionals Working Together).Symptoms of PTSD usually develop shortly after the traumatic experi-ence, but they may not occur until months or years later. One might assume that the timing of treat-ment for PTSD would play a role in its severity or curability. How-ever, a major study carried out by Israeli researchers indicates that beginning therapy shortly after the event versus waiting a few months produce similar results (Levin).

Plaque outside the Palo Alto VA 21

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Recent findings from the Na-tional Comorbidity Survey show 5% of men and 10% of women in the United States have PTSD. These findings demonstrate the astonish-ing prevalence of this disorder. PTSD is much more common in post-con-flict settings such as Algeria (37%), Cambodia (28%), Ethiopia (16%), and Gaza (18%) (Friedman). This data demonstrates the significant correlation between violence and the development of PTSD symptoms. PTSD, like many mental dis-orders, varies greatly from one pa-tient to the next. “Trauma can come in many different forms for people and I think there’s the traumatic event and then there’s how some-one handles the trauma. And one person may be subjected to a trau-matic event and while they may be initially traumatized, they don’t go on to develop PTSD. But someone else, because of certain character-istics they may have, does develop

PTSD as a result of that trauma” (Becker). Each survivor experiences distinct traumatic events of differ-ing magnitudes. Everyone has dif-ferent personal characteristics that may either help or hurt him or her in the face of trauma. Some are spir-itual, and depending on the ways in which they interpret the trauma, it may be advantageous or disadvan-tageous. Survivors also undergo differing treatment methods and receive different kinds of support. All of these factors can affect the-severity and the curability of PTSD. The nature of the military

makes it difficult for veterans to come forward and seek treatment when suffering from PTSD. Soldiers are expected to be fearless and feel no pain. The emotional disconnect soldiers are often forced to undergo when in the war zone makes it all the more difficult to express their feelings and get treated. There have been instances of veterans with PTSD lashing out in recent news. These outbursts have negatively impacted our society and foreign relations. On March 14, 2012, Abel

Chapter 5:The Need for Change

Photo of Ramon and some of his family members

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Gutierrez, a twenty-seven-year-old Iraq War veteran suffering from PTSD, shot and killed his eleven-year-old sister in Gilroy, California. Gutierrez then took his own life. He is also suspected of shooting his mother whose body was discov-ered near a highway in San Beni- to County a week later (Newman). On March 10, 2012, Army Staff Sgt.

Robert Bales killed 16 Afghan civil-ians in their homes. Bales is likely suffering from PTSD and claims to have no recollection of the inci-dent. He is currently being detained at the Midwest Joint Regional Cor-rectional Facility at Fort Leaven-worth, Kansas (Dao). Both of these incidents occurred within a week of each other. There is no telling how

many more episodes there will be in the near future if changes are not made. The government needs to test post-combat veterans more thor-oughly and treat them more vigor-ously. The military must also inform enlisted soldiers of the symptoms of PTSD and urge soldiers to come forward and seek treatment.

Bob Kenyon shows off his helmet from World War II24

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“I have you to thank for the opportunity to talk to you and to listen to me. But remember the best gift you

can give any veteran is empathy and support and to say you’re proud of what they did.”

-RAMON ONTIVEROS

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Ramon Ontiveros looking at paintings at the Menlo Park VA Ramon Ontiveros dressed as Santa Claus

Ramon Ontiveros posing with his brother Ramon Ontiveros showing off his vest and patch

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WORKS CITEDBecker, Thomas. Personal interview. 27 Feb. 2012.Bramsen, Inge, Anja J.E. Dirkzwager, and Henk M. Van Der Ploeg. “Predeployment Personality Traits and Exposure to Trauma as Predictors of Posttraumatic Stress Symptoms: A Prospective Study of Former Peacekeepers.” Psychiatry Online. The American Journal of Psychiatry. Web. 18 Mar. 2012.Dao, James. “U.S. Identifies Army Sergeant in Killing of 16 in Afghanistan.” The New York Times. The New York Times Company, 16 Mar. 2012. Web. 19 Mar. 2012.Fisher, Tessa. Personal interview. 1 Mar. 2012.Friedman, Matthew J. “PTSD History and Overview.” U.S. Department of Veterans Affairs. U.S. Department of Veterans Affairs. Web. 18 Mar. 2012.Levin, Aaron. “Timing of Certain PTSD Treatments Doesn’t Appear to Be Crucial.” Psychiatry Online. American Psychiatric Association. Web. 18 Mar. 2012.Morgan, David. “Ecstasy Helps Treat PTSD Patients, Trial Finds.” CBS News. CBS Interactive Inc., 19 July 2010. Web. 18 Mar. 2012.Newman, Bruce. “Body of Martha Gutierrez Found Near Pacheco Pass Highway.” Mercury News. San Jose Mercury News, 22 Mar. 2012. Web. 29 Mar. 2012.Ontiveros, Ramon. Personal interview. 13 Mar. 2012.“Spirituality and Trauma: Professionals Working Together.” National Center for PTSD. U.S. Department of Veterans Affairs. Web. 18 Mar. 2012.Sulek, Julia Prodis, and Lisa Fernandez. “Gilroy Police: Iraq War Veteran Killed Sister, 11, Then Himself.” Mercury News. San Jose Mercury News, 16 Mar. 2012. Web. 19 Mar. 2012.“The History of Post-Traumatic Stress Disorder (PTSD).” Psychiatric Disorders. Psychiatric Disorders. Web. 18 Mar. 2012.“What Is PTSD?” National Center for PTSD. U.S. Department of Veterans Affairs. Web. 18 Mar. 2012.

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