War Trauma
Keith Armstrong wants to make sure today’s vets get better care and services than veterans of the Vietnam war.

BY JILL KRAMER

Keith Armstrong was already counseling Vietnam vets 20 years ago when his life’s work became clear to him. Back then, the concept of “posttraumatic stress” was new and unfamiliar, and he and the other social workers at the San Francisco Veterans Affairs Department Medical Center often mistook severe stress symptoms for psychosis. But when his best friend was struck by a car on his bicycle and killed, he got it. His grief sent him into an emotional tailspin that he recognized as similar to what he was seeing in vets. He decided then to dedicate himself to helping war veterans recover from emotional trauma. Shortly afterward, the San Francisco VA opened a posttraumatic stress disorder (PTSD) program, and Armstrong has been working there ever since.

Now he’s come out with a book, Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families, co-authored with colleagues Suzanne Best and Paula Domenici, two psychologists who also specialize in the treatment of traumatized vets. Published in February by Ulysses Press, it’s a realistic approach to combating aftereffects of war such as depression, grief, anger and substance abuse. It offers step-by-step guidance for recognizing and coping with trauma, all the while taking into account the tendency of many vets to deny that they need help at all.

Armstrong, now 47, was still in high school when the Vietnam war ended. He grew up in Buffalo, New York, a blue-collar town where boys just a few years older than he were expected to join the military. He comes from a long line of ministers and social workers. His Scots-Irish heritage shows in his blue eyes, ruddy complexion and the thick auburn hair that he wears long on top. He’s tall and youthful-looking, with a crooked grin that gives him the air of a mischievous choir boy.

He and his best friend played on a Frisbee team, competing together in tournaments while attending Boston University. They came out to California together the summer after graduating, while waiting to hear where they’d be accepted for graduate school. Armstrong got in to the social work program at the University of California at Berkeley and his friend went back to New Jersey to attend Princeton. He was killed while working on his doctorate.

There was still more grief in store for Armstrong. In the space of two years, he lost his entire nuclear family. His father and sister died of cancer, his mother succumbed to a stroke. At the same time, however, he was starting a family of his own. He and his wife had met on the Berkeley campus during an anti-apartheid demonstration and got arrested together. Two photos of her being dragged away by the police in handcuffs hang on the wall of her study. She’s a short story writer and full-time mom. They live in Fairfax with their two children, a boy and a girl, ages 8 and 3-1/2.

Armstrong says he actively resists the tendency to be a workaholic like his own father was so that he can spend time with his kids. But he loves his work and wears many hats. In addition to his job with the PTSD program, he has two other roles with the San Francisco VA—director of couples and family therapy and director of mental health social work. Though he’s licensed as a social worker, he’s also a clinical professor in the psychiatry department at UCSF, teaching couples and family therapy to psychiatry residents and psychology interns. On top of all that, he took on the book project last year, taking his laptop to cafés and cranking out the first draft in six months.

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When did you know you wanted to do this kind of work?
Forever. I have a lineage in my family of ministers and social workers that goes back a number of generations.

You look like a minister!
That’s a scary thing to say to somebody [grinning]. My dad was a minister and my mom’s dad was a minister and his dad was a minister. My father was also a social worker and my great-aunt was a fairly well-known social worker as well. She did a lot of work in India. I’ve got cousins who are ministers.

What church were you brought up in?
My dad was a minister in United Church of Christ and in the Presbyterian Church. They’re generally in the liberal end of the Protestant church. My mother was Methodist and my grandfather was more of a fire-and-brimstone New England minister. No alcohol. Good guy. He taught me how to swim and how to fly-fish.

Pretty strict in some of his thinking, though. I’d love to have a conversation with him now, since my uncle came out.

As gay?
Yeah. It was an issue in the family [laughs].

Did you ever consider going into the church?
No, I had a bit of a rebellious streak in my youth. You know, hitchhiking out to California when I was 17. Part of it was the times, the mid-’70s. The Vietnam war was winding down. Because of my age, I had missed that experience. Men my age didn’t have to register for the draft. But I had always wanted to be involved in helping others. What shape it would take, I wasn’t quite sure.

When did you start working at the VA?
I did an internship there in 1982, then got a job there in July 1985. That was my first experience working with Vietnam vets. I worked for four years in an unlocked inpatient unit. So the patients were less acute. At that point they were able to stay for fairly long periods of time. You could work with somebody for a couple of months while they were there. Now, everything is done outpatient. It’s all cost-containment and “call me in six weeks.” But the government as well as the civilian population didn’t do very well with Vietnam vets, you know. Vets were spat at and called “baby killers.” It really did happen. People really mistreated these folks—badly! And we at the VA didn’t do a great job with them, initially. We misdiagnosed them.

How so?
We mislabeled people as personality disordered or schizophrenic. Or we ignored them. We didn’t really want to talk about the war. It’s amazing how little people talked about it.

You’re saying the VA counselors didn’t talk about the war?!
Yeah! People didn’t deal with the war. I got there at the tail end of some of the worst of it. These guys were in their 30s. They’re blowing through jobs. Nothing’s going right. But nobody knew anything about PTSD. It didn’t come into existence as an actual diagnosis until 1980. There were other terms that had been used—shell shock, battle fatigue, soldier’s heart—to describe something that was happening to soldiers. But I think in each war, up until Vietnam, we would forget what the human cost of war is. And, as a country, we did an incredible disservice to Vietnam vets. One of the things that happened around 1980 was that Vietnam vets decided that they were not going to put up with this anymore. And they lobbied Congress for storefront centers where vets could go to get therapy services, and Congress approved veterans’ readjustment counseling centers as a kind of parallel organization next to the VA. So vets could come and talk about their experiences with other vets and finally feel understood. And that exists today. And in 1988 or ’89, the VA started funding PTSD programs across the country. I think Congress and the VA got it at that point—that we have got to treat war vets, and we’ve got to put some money into it. At our VA, we got funding to have one of those counseling centers. But right before that, in 1986, my best friend, the guy that I moved to California with—he had moved back to Princeton and was working on his doctorate—he got killed in a bicycle accident.

Oh, God.
That affected me tremendously. And... [He stops, turning his head away, unable to speak for a full 30 seconds. When he speaks again, his voice breaks with emotion.] So I knew what it was like to lose somebody. And I think that really changed my focus on what I wanted to do.

After all these years, you still feel that so deeply.
Well, I think the idea of getting over things is really not the way to understand it. It’s really a question of, how do you live with life-changing experiences? And, for me, that was a life-changing experience. The positive twist is that it helped shape my career. Obviously, I’d prefer if my friend were here, but that experience gave me a personal knowledge of what it’s like to lose somebody close to you and it allowed me to move into an area of working in trauma. So as soon as there was a position at this counseling center, I applied for it and was lucky enough to get hired on.

It must have been tough, though, trying to counsel war veterans when you’d never been to war.
I ran one group with a co-therapist who had been in Vietnam for three tours—a really talented, wonderful guy. And I remember once making the comment to the group, “You know, I wasn’t in Vietnam, but... ” and one of the guys in the group said, “Keith. Listen, man. We know you weren’t in Vietnam and we don’t care. Are you able to help us?” So the real question was, “Is this a safe place, and am I going to be understood, and are you going to be useful to me?” And vets would come in and test my mettle. Was I going to be able to hear their horrible stories and be present when they talked about their trauma?

So how did you convince them that you could begin to fathom what they had gone through?
Well, I probably didn’t convince all of them. But the majority of folks are convinced by my perseverance. Just by being able to listen to their story and help sort it out and figure out how it’s affecting them now. One of the concerns is, “If I tell you, what will you think of me?” Second is, “If I tell you, will you be as impacted as I am?” When I first started, they were all older than me and had these experiences I hadn’t had. But there is a different dynamic as I’ve gotten older. I’m seen now as more of an authority figure. Whereas when I was younger, my role was more collaborative—how should we handle this? So one of the good things about getting older is that people have this idea that you’re wise [laughs].

I’ve heard vets say that getting counseling for PTSD is implicitly—or sometimes explicitly—discouraged. They’re told they should just suck it up. And people on active duty are concerned that going for counseling can hurt their military career.
Well, I’ve never worked with people on active duty, but my sense is that it really depends on who your commanding officer is. There are some units where the CO encourages people to get help and really believes in counseling for stress. But there was an interesting study that recently came out, looking at 202,000 Marines and soldiers who had spent time in Iraq from 2003-2004. And they found that between 31 percent and 35 percent of Marines and soldiers had sought mental health treatment. And that 31 percent or so doesn’t count going to see a clergyman or anyone outside the system, so the number seeking help was probably even higher. But I think that speaks to a change in the military culture, if you’ve got one-third of folks willing to go for help. I mean, these are Marines and Army soldiers. These are people that are in a pretty macho culture. So things may be shifting around what they think about mental health. But one of the hallmark symptoms of PTSD is avoidance—not wanting to deal with it, pushing it away. So people who are highly symptomatic may stay away from any kind of help until things get so bad that they have to get help.

What are the symptoms you’re seeing most often among the people returning from Iraq and Afghanistan?
In order to be diagnosed with PTSD, you need to have problems with nightmares, flashbacks, powerful memories, arousal symptoms and avoidance symptoms—feeling numb, detached from others, feeling like you don’t have much of a future. What I see most often are heightened arousal symptoms. Irritability. Jumpiness. Problems with concentration. Suspiciousness. Poor sleep. Those are the more overt problems.

What about anger?
Well, that’s what I was calling irritability. Being pissed off. It’s hard to make a transition even when your life hasn’t been threatened. When people come back from serving in the Peace Corps for a year, it is hard to make that transition. Things just aren’t the way you remember them. Roles in your family may have changed—somebody else is doing what you used to do—and where do you fit in? Well, add exposure to trauma, where people are trying to kill you and you’re trying to kill them—it’s a tremendously difficult adjustment. But, at least in civilian studies, which do include combat, 70 percent of people diagnosed with PTSD recover.

The symptoms are gone?
Or they’re not present enough to meet the criteria. So only 30 percent of people exposed to trauma and diagnosed with PTSD end up having more chronic symptoms that wax and wane throughout their entire lives.

Thirty percent is a big chunk of people.
It’s how you look at it, I guess. But yes, it is a big chunk of people. And what we’re looking at is, who are the people more likely to be vulnerable, long-range? And who are the ones that are resilient? They’ve found that women are twice as likely to develop PTSD as men. Early childhood abuse or other trauma also makes people more likely to develop PTSD. Intelligence is another factor. People with lower IQ are more vulnerable to PTSD.

I wonder why that is.
Maybe they have less ability to actively cope, to think about choices they’re making during traumatic events. Negative life events in the year prior to the trauma also have an effect. And one of the most powerful effects is stressful events in the year post-trauma. So, you come back from war and your wife divorces you, say. Or you deal with the death of a friend. That’s going to have a strong effect. And to me, that’s good news, because some of those events we can actually control. For example, how we welcome home troops, how we take care of them, can make a significant difference. As a culture, as a country, we can do something about this.

Good! Talk about the kinds of societal changes you’d like to see, and what the VA might do differently, too.
Well, as a country, we tend to forget about the things that aren’t getting attention in the media. So my major wish is that we keep the needs of these men and women on the front burner for the next 15 years. That we don’t just throw money at services for the next couple of years and then forget about them. Or have a welcome home parade and pat ourselves on the back. To me, that stuff doesn’t cut it. It’s nice, and it can be a good start, but a portion of these people are going to need our support for a very long time, potentially for the rest of our lives. There are some who will integrate into the community and be OK and that’s wonderful. But others are going to have a hard time and it’s important that we don’t forget about them.

So, specifically, what should we be doing?
People may need low-cost loans to help them deal with the financial stress they incurred while they were at war. Can you imagine—you’ve risked your life, you come back to an extra $20,000 in credit card debt because your partner was home taking care of the kids? People will need family therapy. They’ll need employment. They may come back with no specific skills, but damn if some of them don’t have some leadership potential. Let’s take advantage of that. They may need money or scholarships to go back to school. Going to war can turn your whole view of what you want to do on its head. So we could be providing vocational counseling, job coaches. And this doesn’t have to cost a ton of money. I get calls sometimes at the VA from therapists who would like to volunteer a couple hours a week to help returning vets. What a sweet offer! But I don’t think we’ve figured out a way to take advantage of that yet. Maybe we could create some sort of broker who could coordinate a clearing house where people could volunteer their expertise. No matter what you think about the war, these folks put their lives on the line and I think we owe them a tremendous amount of support. This was a huge mistake we made with our Vietnam vets. And by taking care of these men and women, we can pay tribute to Vietnam veterans that we didn’t take care of. It tells them, “You guys made a big sacrifice, but it wasn’t in vain. We get it now. We know now what we need to do.”

Keith Armstrong will speak at the Oakland VA mental health and substance abuse clinic on May 24 from 1-2:30pm. For information, call 510/587-3400.
For more on Armstrong’s book, go to www.courageafterfire.com.

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