Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, January 24, 2015

Gene Kelly At The Waldorf

This is the main lobby at The Waldorf. The clock is taller than it seems in the photo. That's probably why I never noticed the little lady liberty at the top.

I want to write about one of the discussion groups I attended, the Service Members and Veterans Initiative that I mentioned in my previous post, Waldorf 2015. As preparation, I watched "Combat Fatigue Irritability",  a short film directed by and starring Gene Kelly, which was made for the Navy, to make people aware of symptoms of PTSD. The film was only referenced, not shown, during the group discussion, but it was interesting to hear from his daughter, Kerry Kelly Novick, who led the group. I kept wanting to ask her the completely irrelevant question of, "What is it like to see your father on the big screen?"

She did mention that her father was quite steadfast in his insistence on an accurate portrayal of the main character, Seaman Lucas', symptoms and behavior. He even had himself admitted to a psychiatric hospital to prepare for his role.

In the film, Lucas had worked on a ship that was blown up. His job was to monitor the pressure valves. He never went topside as part of his work. He never knew what was going on. He was not a gunner, so he had no active outlet. All he did was monitor the valves, and feel increasingly frightened and helpless. When his ship was destroyed, and he found himself in the water, he felt relieved, but also horrified at watching his buddies die around him.
After he is rescued and recovered, he has a 30 day furlough, and he returns home. At first things go well with his family, but he feels increasingly isolated and not understood, has trouble reuniting with his girlfriend, startles and gets angry when her little brother throws a paper airplane at him, gets into a fight with a bartender, and starts to shake uncontrollably when he goes hunting with his father, after which, he is hospitalized.
The film shows his coming to terms with some of his feelings in group therapy. The psychiatrist is portrayed as kind but somewhat patronizing and paternalistic, and places an emphasis on "fear that wasn't handled properly" as the origin of Lucas' symptoms. He is also shown sedating him, immediately following Lucas' breakthrough in understanding.

There were a number of interesting points made by various people, most of whom work with soldiers or veterans regularly. One idea that I hadn't considered is that the characters portrayed in the film, like most men in the military during World War II, were just regular guys who were drafted. Whereas today, we have an all-volunteer military, so those who have chosen to serve have done so with the intention of making it their career. They want to remain in the service, which makes them that much more reluctant to acknowledge when they are having emotional difficulties.

There was discussion about Lucas acting as "bad" as he felt he was, for his wish to escape from the boiler room, and then watching his comrades die. And of guilt as a defense against helplessness. Someone noted Freud's comment about the soldier's conflict between the wish to live and the wish to be a good soldier.

Isolation was another topic that came up in the discussion group, as illustrated by the sense Lucas has of not being understood by anyone who hadn't had similar experiences. The idea was that it's important for the clinician and for family members to recognize that this is so, but that those suffering from PTSD symptoms can use this isolation to defend against acknowledging feelings of guilt at their reactions to traumatic events, and feelings of loss-that to truly return to their former lives, they need to recognize that they have lost the versions of themselves that existed before the trauma.

One analyst has been working on petitioning the AMA to include military history as part of the social history for the E/M CPT code. Her group wanted the wording to be, "Have you or a loved one been in the military?" So far, they've gotten "you", but no "loved one".

An unfunded (by the military) area that someone brought up was pets. He said that the military has put together some research to show that pets are not that helpful in recovery for veterans, despite having evidence to the contrary. Basically, the military just doesn't want to pay for it. I don't think I came across this document when I wrote, The Comfort of Dogs.

The question of funding is an interesting one, especially in light of the opinion piece published in the NY Times a couple days later, After PTSD, More Trauma, written by a veteran, David Morris, who sought therapy for PTSD, and was placed in Prolonged Exposure Therapy, heavily promoted by the VA for its effectiveness. In this type of treatment, the patient repeatedly reviews his traumatic experience, over the course of a number of sessions. This turned out to be a bad choice of therapy for him, and he got worse, until he dropped out. He later underwent the VA's other PTSD therapy, Cognitive Processing Therapy, which he found helpful.

Morris notes the VA's contention that 85% of PTSD patients are helped by Prolonged Exposure Therapy. He cites a 2013 JAMA Psychiatry paper, Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care, that demonstrates evidence supporting the use of this treatment. It's open source, so you can read the whole thing, if you like. As usual, I'm skeptical about research that involves nothing but before and after checklists to establish efficacy, and a treatment for which the clinicians received 4 days of training, and then provided 8-15 sessions of therapy including, "(1) imaginal exposure or systematic and repeated exposure to the traumatic memory; (2) in vivo exposure or systematic and repeated engagement with nondangerous activities and situations that have been avoided because of trauma-related distress; (3) psychoeducation about treatment and common reactions to trauma; and (4) breathing retraining," to treat something so complicated.

Morris then goes on to state:

After my experience with prolonged exposure, I did some research and found that some red flags had been raised about it. In 1991, for example, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, conducted a study of exposure therapy on Vietnam veterans and observed some troubling complications: One subject developed suicidal thoughts, and others became severely depressed or suffered panic attacks. A similar study, published in the Journal of Traumatic Stress in 1992, found that Israeli army veterans experienced an increase in the “extent and severity of their psychiatric symptomology.”

My concern is that the military has strong motivation for funding the most cost-effective, and not necessarily the most effective, treatments. No doubt it feels compelled to conserve its financial resources for use in war-related technological advances that will create more soldiers with PTSD.

It's also interesting to think about the contrast between what the military thought was useful treatment for PTSD back in 1945, and what it thinks now.

It was quite moving to hear people speak about their work with soldiers and veterans. Here's a link to the Service Members and Veterans Initiative page, if you want to learn more about the program.

1 comment:

  1. It sounds like a great meeting. I would really like to see that Gene Kelley film. Even though they were "before my time" I recall watching both him and Fred Astair at campus film societies in those days. They were both so athletic and light on their feet it was amazing. That Singing in The Rain Scene with Gene Kelley is still one of my all times favorite dance scenes. I meditate on it when I want to feel better. I wish you had been able to ask that question.

    I share your concerns with the one size fits all approach to the problem and checklist documentation. There has to be more than that. There has to be a stable clinic of clinicians helping people solve their problems. That is how I remember excellent care at VA facilities. You attract and keep a good staff or professionals who are all interested in providing excellent care and they discover it. You don't train people to provide some brief intervention with a checklist before and after and have them repeat that for 25 years until they retire. I am also quite sure that some of the experts in exposure therapy would not see it that way either.

    I have worked in clinics where the manualized therapies resulted in complications that had to be dealt with by clinicians providing supportive psychotherapy.

    Life is not a manual or a checklist.