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PTSD & Veterans: A Conversation with Dr. Frank Ochberg 
Dedicated to Veterans and their Supporters 
Dr. Frank Ochberg is a psychiatrist and former associate director of the National Institute of Mental Health. He is one of the team members who wrote the medical definition for posttraumatic stress disorder. Dr. Ochberg was the editor of the first treatment text in America for PTSD and is a recipient of the lifetime achievement award from the International Society for Traumatic Stress Studies. Dr. Ochberg is the founder of Gift from Within. Acclaimed anchor reporter, Mike Walter, knows of PTSD. After his brother returned from Vietnam, Mike saw firsthand the debilitating effects of PTSD on his brother and the family. And then on that clear autumn day,- 
LIVE BREAKING NEWS AMERICA UNDER ATTACK MIKE WALTER CNN 
Mike was an eyewitness to the 9/11 attacks on the Pentagon. In the days that followed, he found himself grappling with the same issues that affected his bother. Mike is a Dard Ochberg fellow where he studied PTSD and where he met Dr. Frank Ochberg. 
EMOTIONAL WOUNDS OF WAR 
MIKE WALTER  Frank, you watch the news just like I do and you see all of these stories about returning veterans, the emotional wounds of war, so I’m gonna start with an unusual question. Is this a hopeful situation? 
DR. FRANK OCHBERG Well, I think it’s hopeful as a therapist. I mean, we have tools of the trade, and we have now, ah, 28 years after inventing the diagnosis, PTSD. We have some concepts that we can work with. And PTSD is actually an encouraging diagnosis. When it’s PTSD alone, without a lot of other problems added in, it means were working with a relatively normal person, someone who has a capacity, for relationships, for insight, and for recovery. 
MIKE WALTER  They do present unique challenges though versus, let, let’s say, a civilian coming with PTSD versus, ah, ah, a person in uniform. Talk to me about that. 
DR. FRANK OCHBERG  Well, this is a new war and this is a new circumstance for young men and women going to war. You know, back in my day the, the Vietnam era, you served a tour. Hopefully you’ll live to came out whole. But even if you were wounded and even if you were badly damaged, the tour was over and done within 13 months. Now, people are being sent back again and again. And some are being sent back on psychoactive drugs. So, this isn’t necessarily the realm of the therapist, helping a person prepare for yet another tour. In a way that’s pre-traumatic stress. But we’re talking about advice for colleagues who are good clinicians. They’ve dealt with a range of issues, and, and they wanna think about how their skills apply to this particular group. 
EMOTIONAL WOUNDS OF WAR THIS IS A NEW WAR 
MIKE WALTER  As a senior therapist who’s done this ah, so much, are there simple, concrete coaching tips that you can give to help with this unique population? 
DR. FRANK OCHBERG Well, I, this unique population is unique for us in, in, in this part of, ah, 2008. I think it’ll be here 2009. That’s, ah, it’s our war. These are our veterans, and these are our young men and women. And for the most part, they are, uhm, they’re in their early 20s. They are different from previous combatants in that many of them are still facing a return call to duty, and that’s very unsettling. And I believe a lot of us are finding that if you do go to war long enough and you’re not really the professional soldier. Ah, you’re going because, you pretty much have to go even though there’s not a draft, you have to go. Ah, your, not risk, of, of mental condition goes up considerably. So, it’s not an unrealistic fear or dread. It’s a sense in the bones that if I keep being called back, ah, I’m gonna hurt. 
MIKE WALTER But turning that light switch on and off, transitioning in and out, ah, that presents unique difficulties too. 
DR. FRANK OCHBERG And, and, and it does in a, in a range of situations. There are many of us who are therapists have dealt with people who are going through profound transitions. I mean divorce is a profound transition. Escaping an abusive husband is a profound transition. Ah, not all of us are fortunate enough to have jobs that we love and jobs that are stable. And so, I don’t think that in itself is a new challenge for a therapist. 
MIKE WALTER Should the approaches be different? 
DR. FRANK OCHBERG You know, we’re who we are. Ah, some of us are so comfortable doing family therapy and some don’t we even have an extra chair in the office. So, the approach should be leading to your strength. And if you do find you’re working with a returning veteran and the situation feels alien to you and you’re not comfortable. Ah, ah, you do have to refer out. Ah, I, I think you really have to be honest with yourself about your limits. But I think the general skills, generalized to this population, and if you’re mature and wise and resourceful, you can do so much that’s useful. 
MIKE WALTER You, you talked about, ah, playing to your strengths. And, ah, a lot of these returning, ah, veterans work with the VA where there’s, ah, these people are, are used to seeing this type of, ah, patient. And then, they return to their local hometown. Uhm, I’m the local therapist. Someone like this comes to me, ah, this may not be my strength. What would you like to tell them? 
DR. FRANK OCHBERG Well, first of all I think, things have improved in the, close to 30 years now that we have the PTSD diagnosis, I wanna say to you out here who were gonna be treating people who’ve been traumatized, please be sure you understand PTSD and that you’ve read some of the basic works and you’re comfortable hearing stories that can give you some, some nightmares yourself. I mean, many of us who, who’ve lived through this work have found times when we inherit the stories of our, of our clients, our patients. We not only have to be comfortable doing that. We, we have to project to the client that we are comfortable; we’ve been here before. You’re not gonna damage me ‘coz the returning soldiers and marines are, are really so honorable. They’ve suffered and, and I wanna be very, very careful that they don’t make others suffer. 
TREATING PTSD IS A PRIVILEGE 
MIKE WALTER  Frank, there’s a good chance that we’ve got a therapist in a rural state who, you know, all of a sudden there’s an influx of, this population. What advice would you give to them? 
DR. FRANK OCHBERG So, all of a sudden they have three, four, six patients? 
5MIKE WALTER Exactly. 
DR. FRANK OCHBERG And this could happen when a National Guard unit comes back. 
MIKE WALTER Exactly. 
DR. FRANK OCHBERG And, there in, ah, my state, upstate Michigan, yeah. Well, I guess we’ve, we’ve said before, treating this population is a privilege. And I’d say right of the bat and welcome to the group, that’s working with PTSD and related issues and that’s helping our returning vets, men and women. Ah, it’s, ah, it’s rewarding, it’s gratifying. Most of your clients are gonna do well. There gonna be some difficult situations. You’re gonna be able to draw on a lot of skills and experiences that you have from working with incest survivors, ah, bad accident victims, ah, ah, people who’ve had to deal with shocking news. If, if you have no familiarity whatsoever with PTSD, this, this is not your cup of tea. And, you, you probably need colleagues to do the work, ah, where you need to take some courses. But assuming, that you’re, ah, a mid-career therapist, you’ve seen a range of issues, ah, I, I would say welcome to working on our veterans. 
MIKE WALTER Don’t feel overwhelmed. 
DR. FRANK OCHBERG No, no, no, I, ah, common things are gonna be depression, avoidance, intimacy problems, drinking too much, and adjustment to all the demands of civilian life: new job, new kids, and these are young people who are facing the beginning of adulthood. And in a way they’ve grown up in a hurry, but in another way you have to remember what the age and stage of life is. 
THE BATTLEFIELDS AT HOME 
MIKE WALTER  Is there a marked difference between civilian PTSD and, and military PTSD? 
DR. FRANK OCHBERG No, no, PTSD is PTSD. And when it happens, it means that you can’t shake the traumatic memory that comes up at you from the past. Ah, and it means that you’ve lost something in your full range of human feelings and human capacities, and that means that you’re wired. Ah, you’re very, very easily distracted, upset, can’t sleep well, startle a lot, ah, and, and you can get this condition from exposure on the battlefield or you can get it from civilian life. And the therapist who could treat one should be able to treat the other. And the feelings that’s, are veterans now, civilians have, I don’t think are foreign to the experience of us therapists. We’ve been there, we’ve seen it, and we, we’ve, like we’ve, we’ve taken care of parents of murdered children. We’ve taken care of incest survivors who have been raped. Ah, we’ve taken care of people who have walked off the campus on the Virginia attack. We’re no strangers to the civilian trauma and tragedy, and the battlefields at home are as just as intense as the battlefields over there. 
THE LOSS OF EMOTIONAL TONE TAPPING INTO THE EMOTION 
MIKE WALTER  I remember af, ah, the first anniversary of September 11th, ah, an interview with a gentleman in New York who just went through this horrific, ah, series of events. And he told the story, but he told them with, ah, without any emotion flat… (crosstalk) 
DR. FRANK OCHBERG Hmm. 
MIKE WALTER …delivery, and there are, there are returning vets who tell their stories without tapping into the emotion. How do you get them there, and how important is it to get them there? 
DR. FRANK OCHBERG Oh, you wanna get there, Mike, and that is paragraph C of the definition of PTSD. You know, PTSD, the first part is, something happened and it was real. The second part is you have a set of symptoms in which you’re haunted by what happened. The third part, the C part is you, you, you’re blunted. You, you feel like a shadow of your former self. You, you could be restored to life with people you love, and, and you describe, ah, “I know I love; I, I just don’t feel it.” And, you sometimes see this in a, in a person’s face, ah, a constricted affect. The, there’s no direct remedy for that, and there is no pill to restore the range of emotion. If depression is a part of the loss of emotional tone, anti-depressants can help, and it’s very common to diagnose PTSD and major depression or dysthymia at the same time. And in that case you treat the depression. But, but to treat the avoidance and the detachment and the loss of, of, of zest, that is part of PTSD, I, I, I think you really treat the whole person, and you watch for that to start coming back. 
THE LOSS OF EMOTIONAL TONE PTSD IS NOT A DOWNWARD SPIRAL 
MIKE WALTER  Uhm, a, a patient comes to you who’ve got a permanent disability for PTSD, and so as a result, they think, ah, “I’m, I’m permanently messed up. You can’t help me. Treatment… (crosstalk) 
DR. FRANK OCHBERG Uh hmm. 
MIKE WALTER …isn’t gonna help.” How do you work with that? 
DR. FRANK OCHBERG Ah, let me explain to you. PTSD is not a steady downhill course. It’s not a death sentence. This is not something that’s going to progress. In fact, episodes of problems are gonna be further and further apart, and you’re gonna learn how to tolerate what you had to live through. Ah, dealing with it as a therapist amounts to explaining and interpreting and instructing. Ah, if, if somebody feels that because of PTSD, they are diminished, lessened, hopeless, I also send them to the website, “Gift from Within.” 
Welcome to Gift From Within An International Nonprofit Organization for Survivors of Trauma and Victimization – Anything that has real and lasting value is always a gift from within. Franz Kafka A Call For True Personal Stories PTSD Etiquette: finding the right words Site Map Dear Friends, We started Gift From Within in 1993 with the intention of giving trauma survivors, their loved ones and supporters a credible online website that was friendly and supportive. PTSD is real and we wanted to explain the condition without being too technical or too superficial. Gift From Within believes that persons with PTSD and related traumatic stress syndromes deserve the same respect and support that individuals and families suffering the impact of cancer, heart disease and stroke receive. At least 10,000,000 Americans have experienced some form of PTSD. Gift From Within was founded to help provide this support. Proceeds from the sale of the materials will be dedicated to accomplishing this mission. You can help with your purchase or donation. Thank you! 
DR. FRANK OCHBERG  There are, ah, many ways of recovering the poetry of life and the meaning in, in life of, not every therapist and neither I with all my patients have had a chance to get to the later stages where e, enough improvement has occurred and there are enough new stages of life to face together, a person who hasn’t had children, who does, a person who hasn’t had a civilian child, who does, a person who hasn’t been married, and, and is married. So, our patients may not be in a position to look down the road and to savor the next steps of life that are there. 
THE LOSS OF EMOTIONAL TONE A SMALL SPECK OF SHRAPNEL 
MIKE WALTER  You had a story the other day where you used shrapnel as a metaphor. It’s a small speck of shrapnel and having to understand the anatomy and that, that the PTSD, go back over that again. 
DR. FRANK OCHBERG Oh, yeah, we were thinking about what a PTSD therapist does and has to know about. It isn’t that you can’t treat PTSD in the abstract as though there’s one symptom, and that’s like the piece of shrapnel that’s in the body and you’re gonna get that out and it’s all over. And because that piece of shrapnel goes through the lungs and the liver and the kidney and you have to know about each organ now metaphorically, what are those organs? They’re your work life. They’re your sense of self. Ah, they are your important relationships. Ah, they are your, your faith, ah, your reason for living. So, a trauma therapist, when the therapy goes well, has a chance to help with all of these elements, ah, ah, of life. I, I, I remember the charming story of this old man who goes to the doctor, and says, “Doctor, my bowels aren’t moving. My head hurts. I have this itch that I just can’t scratch away, and, Doctor, I myself don’t feel so good.” (laughs) And, and, and every once in a while, there you are, you’re working on that sense of self. 
PTSD AND DEPRESSION REMITTENT DEPRESSION 
MIKE WALTER  Talk to me about that another piece that you, you talked about earlier, major depression and… (crosstalk) 
DR. FRANK OCHBERG Oh, yeah. 
MIKE WALTER …PTSD. 
DR. FRANK OCHBERG Yeah. I, I often see that two together, Mike, and, and I give both diagnoses. And, uhm, when, when I was a resident, which was at Stanford in the ’60s, that’s a long time ago now, we thought there were two very, very different forms of depression. Well, one was situational. You were in a very tough situation that was hard to cope and felt lousy and you’d rather be in bed. Now, we, we call that exogenous depression. And the other was an inherited, remittent disease, ah, like, ah, ah, psoriasis or, ah, diabetes, something that had flare-ups. And, by the time you became an adolescent or a late adolescent, this disease would show up. You had a strong family history for it. It wasn’t necessarily related to bad times and you would spend, ah, the winter with a bad depression. Spring would come and you’d get better. Well, now it turns out that these two conditions overlap very much. If you go through a period of high stress and sadness and, ah, grief and loss, you can come out of it with a remittent depression and major depression, and it’s very much alike to the kind that we used to think only happened as a, as a matter of your genotype. So, look for depression, and when PTSD, which is causing a lot of return to scenes of trauma and tragedy and depression co-exist, it means that in addition to the flashback and in addition to the avoidance and the anxiety, you feel helpless, hopeless, worthless. You have, you have very clear suicidal, ah, I wouldn’t say wishes, but sometimes the suicidal thought as a form of relief, and, and that’s dangerous. That’s something we therapists have to be so vigilant about, and particularly with the, with the group that se, seen a lot of death, and ins, instruments of quick death available. So, consider depression. Now, ah, any therapist knows about treating depression, and it’s no different in this population and in the other population. You know, you mobilize all that you can and in ways of reframing thinking. You use cognitive behavioral treatment and help someone learn that they have thoughts that come along with bad feelings. And instead of being down on themselves, they learn to recognize a downer thought and figure out where it’s coming from and change that thought and the feelings eventually change with it. And medication, and now, now some people, like, have a philosophical aversion to medication, and they don’t understand the medication that helps with depression, that, uh, the, there’s no black market for Prozac. It doesn’t make a normal person feel better. It works when, like diabetes, you don’t have enough insulin, ah, your, your brain isn’t producing enough neurotransmitter. The Prozac helps your brain use the neurotransmitter that it has more effectively. And if Prozac doesn’t work, and there are sometimes some problem for the, one drug, there is another that works well. Ah, the psychiatrist and, well, the internist who has more and more experience with these medications sometimes has to fiddle with the dose and add extra drugs, uhm, but there’s no reason for a person to suffer with these week and month long black moods. 
PTSD AND DEPRESSION WHO IS ON YOUR BOARD OF DIRECTORS? 
DR. FRANK OCHBERG  Ah, ah, let me go on to something I was, that I find awfully useful with my PTSD and depressed patients. Most of them do say negative things about themselves to themselves. “Oh, I screwed this up,” or “Ah, this is just isn’t working out,” or, and, and, and I’ll ask them, consider where that statement comes from. Is, is it like you have a board of directors in your head? And somebody from the past is sitting in that directors chair, and, and, and the people will say, “Yeah, yeah. I, it’s my grandmother,” or “Ah, it’s my father.” And he, he always said that you’re not gonna amount too much. And, and I ask them, “Well, who else do you have in the room? Who else in your life gives you messages about yourself?” And they’ll remember a teacher or the whole, I, I remember (laughs) ah, Maya, who had been badly raped, said, “Arlo(ph), my gay brother. He likes me. I’m gonna put him in the chair and kick my father or mother,” I can’t remember, “Out.” And, and, and he actually have this image of whose in the director’s suite. Well, that director’s suite is also known as the Super Ego. It’s the part of us that judges us. So I, I just had, I, I’ve had enormous succ, success in helping my patients figure out whose on their board of directors and shoving someone to the back of the board. Unfortunately, you can’t kick ’em out forever. And, and, and, you know, all the studies are showing cognitive behavioral treatment and medication together do the job for depression. Depression is a prevalent disease. We have to be on the lookout for depression. Untreated depression can be lethal and it leads to drinking… (crosstalk) 
MIKE WALTER Uh hmm. 
DR. FRANK OCHBERG …and it certainly, ah, messes up interpersonal relations. 
RESISTANCE MOVING DOWN THE PATH TOGETHER 
MIKE WALTER  Let’s say I have a returning vet and I’m working with them and yet they don’t wanna go there. They don’t wanna go and talk about, when’s the proper time to move in that direction? Ah, ah, do you probe them? How do you, how do you when’s the right time to make the move? 
DR. FRANK OCHBERG Well, I, I do probe and I’m very cautious about getting there too fast. And in fact, I often say with a traumatized person, ah, “There will come a time when we’ll go there. And, and it can feel like and be like elective surgery. I’m not gonna go there before you are ready.” Ah, and, and it’s not “tell me when you’re ready,” it’s, it’s in the conversation lets you know. 
MIKE WALTER It, it’s just an innate sense, you know, when it’s time? 
DR. FRANK OCHBERG  Let me say two things. First, it’s that, early on, I think it’s important to let a, a traumatized person know that you’re not gonna zero in and try to hear the worst of it to soon, that you’ve been there before. You, you will have the sense of when it’s right, and, and, and both of us will have a sense of when it feels right to go for the issues that hurt. And then as far as knowing when you’re there, that’s a hard thing to describe in the abstract. I, I guess now after doing this for over thirty years, I, I do have a sense. I sometimes encourage a person by saying, “Well, ah, are we ready to do the counting method?” And then I’ll say more about that in a little while. Ah, often I’ve explained in advance that there will come a time when that flashback that you have, that nightmare that you have, that image that haunts you, ah, you’re gonna want to share with me, and, and we’ll be there together and here’s how I go about helping you have your worst experience with me present. So, just explaining that there will come a time when we’ll go for that, help set the stage. 
MIKE WALTER It, it, it’s really important for them to know that it, it’s a partnership, that they’re moving down the path with you. Is it important that, ah, ah, as you’re outlining this, and, and we’ll get to the… (crosstalk) 
DR. FRANK OCHBERG Uh hmm. 
MIKE WALTER …counting method in just a minute, is it important early on to kinda set the agenda, say, “Hey, look. At some point we’re gonna do this or, or is that a gradual process too? 
DR. FRANK OCHBERG I, I think there’s a halfway point between having a format and then having your patient or client feel that you’re working on a schedule, and maybe not tailoring this to the individual. 
MIKE WALTER Uhm, it, you, you’re kind of outlining that it, and it’s a journey that both are making, ah, a partnership in a sense that both are going down this pathway and, ah, they can feel strength that someone is going there with them. How early on should you outline that to the patient? 
DR. FRANK OCHBERG  Well, I think by every gesture, by, by the way you greet people, by the, by the way you interact, it’s clear that we’re going there together. Ah, early on, Mike, I like to teach a little bit about PTSD and I’ll sometimes take out the book, you know, with, with the returning group of veterans, then I’m more about PTSD than the early cases that people my age dealt with. Sometimes, I would show the diagnostic manual and a person would say, “I can’t believe that’s there. This is all about me.” Now, with VA and benefits and, and arguing for your benefits, most people know a lot more. Uhm, and, but I, you know, I believe this is a partnership we model and that we’re together searching for painful pieces of the past. 
RESISTANCE CHINK IN THE ARMOR 
MIKE WALTER  There’s been this stigma attached over time, ah, and, and when you ah, have the sense, these are people that are prepared to go off to war, in, if, in a physical, ah, way and a mental way, and they, they think they got this physical toughness, this mental toughness. And then they come, and this is acknowledging that maybe there’s ah, ah, ah, they see it almost as a chink in the armor. How do you get them past that? 
DR. FRANK OCHBERG  Well, it depends on how deep that chink in the armor is. I mean there are some people that I see who can’t go to the job that they’ve had, whether it’s a military job or a train engineer or an airplane pilot, and ah, they usually know. Sometimes their employer isn’t that sure and my job is to help affirm the lack of ability to return to a job. Ah, at other times though, it’s, it’s on the fence or there clearly is capacity. I see capacity, and my, my patient may be very, very reluctant, may feel they’ll go back to something important and fail. Now, with ah, military, you can’t take risks and were putting people in harms way. Ah, I, I have written “not fit for duty” letters, which means that ah, the job isn’t there. 
RESISTANCE LIVING IN THE HERE AND NOW 
MIKE WALTER  Sometimes a patient will come and that’s all they want to talk about is the here and now. I’ve got a drinking problem… (crosstalk) 
DR. FRANK OCHBERG Right. 
MIKE WALTER …that I’ve got, failed relationships. They don’t want to go to PTSD, and, and ah, they wanna concentrate on, “How do I fix the relationship?” And yet you know that it’s all intertwined. How do you get them to really address that the PTSD may be driving a lot of this? 
DR. FRANK OCHBERG Ah, I do talk with people who are taking care of returning vets and I know their feelings are ah, this group doesn’t really wanna talk about PTSD, and it can be hard to keep somebody in therapy. There’s a lot of pressure on a veteran to get help and there’s resistance to that kind of pressure. So sometimes, it’s a reluctant, “Oh, I have to see, I have to see you to get benefits. I have to see you ‘coz my wife says I have to see you. I don’t really wanna be here.” Ah, and then, there is interest in talking about trivial things. Ah, Mike, we have to show extra interest in where we wanna help this person get to without being too aggressive about it. 
MILITARY SEXUAL TRAUMA A BREACH OF TRUST 
MIKE WALTER  Let me talk to you about female veterans ‘coz we’re seeing more and more of them coming back with PTSD, and there are gender differences. How do you approach that differently as a therapist? 
DR. FRANK OCHBERG  Well, we should be aware that many female veterans of this war have had abusive situations before volunteering. And unfortunately, there is a very high rate of abuse, harassment, and even rape ah, to our female soldiers. Ah, the experts in the field ah, know about this. There are all kinds of prevention programs …