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Rethinking Our Approach to Mental Trauma

A conversation with psychologist Ken Falke, who uses the concept of post-traumatic growth—which emphasizes that there can be positive consequences to trauma and suffering—to help combat veteran suicide and post-traumatic stress disorder.
U.S. Army soldiers salute during the national anthem during the an anniversary ceremony of the terrorist attacks on September 11, 2001 on September 11, 2011 at Bagram Air Field, Afghanistan. Ten years after the 9/11 attacks in the United States and after almost a decade war in Afghanistan, American soldiers paid their respects in a solemn observence of the tragic day.

"If there is a meaning in life at all, then there must be a meaning in suffering. ... Without suffering and death, human life cannot be complete."

Viktor Frankl’s account of his experience at the Auschwitz death camp is just one example of a theme that cuts across all of human experience: Life necessarily entails struggle. The key insight from Frankl's Man’s Search for Meaning is that you can find meaning in suffering by responding to—even embracing—your own struggle.

In important ways, this lesson has been backed up in recent years by the advancement of the concept of post-traumatic growth (PTG). Developed by academic psychologists such as Richard Tedeschi, PTG emphasizes that there can be positive consequences to trauma and suffering, such as changes in self-perception, strengthened relationships, and a changed life philosophy.

Members of the military, in particular, are a group that illuminates the potential of PTG. On the one hand, service members show elevated levels of trauma—whether before, during, or after their service—and are widely known to have disproportionately high levels of suicide. But they also may demonstrate how trauma can be used as an opportunity for growth and development.

To be sure, PTG isn’t a strategy for everyone. As the journalist Jim Rendon wrote for the New York Times in 2012, "When it comes to treatment, however, there isn't a consensus on how, or whether, to integrate the concept of growth." As he points out, some studies suggest that pushing this sort of growth mindset might be harmful to, and even stigmatize, people who simply can't take up the narrative. In addition, there's the challenge of objectively measuring a phenomenon based so much on self-reporting.

To better understand how PTG might be applied to veterans care, New America spoke to Ken Falke, the chairman and founder of Boulder Crest Retreat, a Virginia-based non-profit that offers programs for free to veterans. Importantly, Boulder Crest is a training program, not a mental-health therapy program overseen by clinical psychologists. Falke and Josh Goldberg, the director of strategy at Boulder Crest, recently published a book called Struggle Well: Thriving in the Aftermath of Trauma. Below is a transcript of the conversation, lightly edited for length and clarity.


Your book highlights how the programs at Boulder Crest Retreat are the first to integrate the concept of post-traumatic growth (PTG) into veterans care. Can you explain a little more about what PTG is, and how it applies to the approach taken at Boulder Crest?

The short description of post-traumatic growth is the concept of "what doesn't kill us makes us stronger." When a traumatic event occurs in our lives, that time—if properly managed—gives you the opportunity to create some time and space to set a vision for how you can not necessarily put this out of your mind, but put this in the past and make a plan for learning how to live in the present—and set goals for a productive future. We learn from that trauma.

So what do you think separates Boulder Crest from existing approaches to helping veterans reintegrate and succeed?

The traditional mental health approach to trauma, whether it's for veterans or civilians, is to establish a diagnosis, determine if it needs to be treated through medication and/or talk therapy, and execute that pharmaceutical solution—pharmaceutical meaning medication or talk-therapy solutions. That's historically what's happened in the world of psychotherapy, and you don't have to pick up a paper to find out that what's happening today doesn't always work very well. You can see that in a couple statistics—one being that 20 veterans per day take their own lives. The second statistic that's interesting is that 123 Americans take their own lives every day, and in the United States, suicide is the only cause of death that's on the rise. It just seems to me like the current system isn't working very well. And the patients—not only the providers—have a problem, too, because a lot of people who take their own lives weren't even in treatment, and if you don't get any treatment, it's definitely not going to work.

So what [Goldberg and I] did was follow a RAND report, which said that the two biggest issues associated with veteran suicide are the stigma around mental health care in general, as well as what the report calls a "lack of cultural attunement," which means that the therapist and the patient [the veteran] aren't necessarily in tune. You can imagine a scenario in which you're a veteran sitting across from a therapist, and the therapist says something like, "I know how you feel," and he says something like: "How do you know how I feel? You didn't serve in Afghanistan, your friend wasn't killed," right? So the veteran gets up, leaves, and never goes back for treatment.

What we tried to do at Boulder Crest was tackle those two issues head-on. The first thing we did was really look at the stigma, so rather than having a therapy program, it's a training program—more in the life-coach model than the therapeutic model. The second thing we did was be a very peer-based [program], so although we're still supported by psychologists, social workers, and licensed therapists, our program is primarily delivered through peers. That got at that cultural attunement issue. We also do this very intense retreat setting—seven days of hardcore retreat and intense training—and that's followed by 18 months worth of follow-up training. It's a pretty robust program. And we understand that not every person or every veteran is going to be able to come through our program, so that's one of the reasons we wrote the book—so that we could get the framework of what we're doing in the retreat setting out into the general public.

While your work has focused on combat veterans and their families, this books seems to have a much wider audience in mind. What was the reasoning behind that approach? Could your framework apply equally to civilians?

That's a great question, because we think the short answer is yes, and we think that for a couple of reasons. One, we've had some civilians come through our program—not what I would call true civilians, but we've had a couple of first responders who weren't military personnel. We had a former NFL player, and we've had a lot of military spouses. But, we're 17 months into an 18-month longitudinal study, and what we're seeing is some pretty significant success. In terms of symptom reduction alone, our system is three times as effective as traditional mental health care. People see those results and ask if this could work in the civilian world and the answer is absolutely, but we know that our two small retreats in Virginia and Arizona are probably unrealistic, that we probably wouldn't be able to deliver this program on a much larger scale, although we're looking at doing that. What we want to do is get this message out, and lay out the framework. If we can give people these techniques to help themselves, we feel as though we're making a small contribution.

How does the civil-military divide—broadly defined as 1 percent of the country serving in the military, a general lack of understanding of what it means to serve, and a "thank you for your service" culture—affect veterans as they transition out of the military?

It's about 0.6 percent that actually serves in today's active-duty military, and in the country there's about 22 million veterans, which is around 7 percent of the country. But then you start to add in dependents and friends, so the percentage starts to become a little more substantial than just 1 percent.

I tell everyone that communication is a two-way street. I think that, on September 11th, 2001, there wasn't a single American who didn't want to go take care of the bad guys. But this is now the longest war in our nation's history—17 years this September—and people are tired of it. They're tired of how much money is being spent, of the losses, of what appears to be a lack of an endgame or goals in Afghanistan and Iraq. And what happens is that people don't want to have the harder conversation and get into it, and so it's pretty easy to say "thank you for your service." I don't think anybody means disrespect by it, and that's what I tell veterans. Maybe that's all they understand—they see you in uniform and think that that's the right thing to say, so the answer should be: "Thank you for saying that. Is there anything you'd like to learn about military service?" We need to create these good conversations, rather than just have veterans angry because they feel like civilians don't understand, and of course they're not going to understand if veterans don't educate them.

And, vice versa, civilians need to have an interest in learning about military service. My guess is that if they're willing to say, "Thank you for your service," they're willing to have a little bit of a deeper conversation. As all good communications are, it's two-way, and I don't think there’s anything wrong with saying, "Thank you for your service." I just think that there's a deeper conversation to be had.

I'm curious about an exercise you write "seems to be the turning point for almost everybody"—the My Old Story exercise. Can you briefly explain that exercise, and why you think it's so effective?

The My Old Story exercise is really about unpacking all the trauma that comes with us. For example, I'm 56 years old, so I've got 56 years worth of history that in some form needs to be talked about—not every single thing I've ever done, but things that might hamstring me from moving on. So what we do is give everyone in the room a family tree, and we fill out the boxes, leaving you and your spouse and/or kids at the bottom. Then, after we've built this family tree, we give everybody a red marker and they identify areas where there was trauma, based on something called adverse childhood experiences, things like poverty, neglect, abuse, trauma. Then we give them a blue pen, and we ask them if there were any gifts they received from their family. In my case, I had an alcoholic grandfather, and I had a grandfather who had a great work ethic, and I feel like my strong work ethic comes from him, and one of the reasons I'm not an alcoholic is because I witnessed him. Those kinds of things can happen—we can get gifts and trauma from the same people.

Then, right at the bottom, we ask them to draw a thick green line between their immediate family and the rest of their family tree, and then we look every person in the eyes and tell them, "You've got to stop it," referring to what's known as multi-generational trauma. If you continue to proliferate this trauma through your family, your children and grandchildren will be drawing red circles around you at some point down the line, and that's not what you want.

How would you like Struggle Well and Boulder Crest's work to shape or change future discussions of veterans and post-traumatic stress disorder?

I think that the real motivation for us is for therapists in this profession to look a lot harder at prescription medication delivery system. Most people in this business don't go straight to medication, but a lot do for, in many cases, the wrong reasons. What we want to have happen is an understanding that growth is an opportunity after trauma, that we can't create a zombie nation in which we're over-medicating, talking to people in therapy sessions like they're children, and teaching people how to live like a diminished version of themselves. That's what we hope to do, to normalize this concept of struggle, that all of us have it. It doesn't matter how successful you've been, everybody is fighting a battle.

This story originally appeared in New America's digital magazine, New America Weekly, a Pacific Standard partner site. Sign up to get New America Weekly delivered to your inbox, and follow @NewAmerica on Twitter.