Extended Interview: Alfonso Batres
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SUSAN DENTZER: Let’s start out by talking about the vet centers. What are they?
ALFONSO BATRES: Vet centers are community-based counseling centers that are conveniently located in communities at 206 sites around this country. They are out of the hospital, convenient to access from the veterans’ perspective. They offer a variety of services in a very friendly, nonbureaucratic atmosphere…
Most of my staff are veterans themselves. Over 60 percent of them have served in a combat zone. Over 80 are veterans themselves. So what they get when they walk into a vet center is a group of folks who care about them, understand the sacrifices of military service, and they will be treated with dignity and respect in a very efficient manner. We provide a variety of transition services and readjustment services to include things like employment services, information about benefits, family services, counseling regarding any psychological response they might have had to exposure to combat and/or sexual trauma, and we offer a variety of different modalities and types of approaches at these centers.
SUSAN DENTZER: Let’s talk about the range of reactions, acute responses and longer term responses that veterans can have, or that soldiers, those in combat, can have both on the battlefield, in the war zone — immediate sets of responses all the way through to PTSD [post-traumatic stress disorder]. What is the range of things that people can experience?
ALFONSO BATRES: Well, we’ve learned a lot about these processes — most of it based on the dialogue actually opened up by the Vietnam War, which would begin to look very seriously at causality or effects.
Combat, by normal definitions, is out of the realm of everybody’s life. I mean, the types of experiences that soldiers go through is not normal. In many cases they’re life threatening, and in many cases they’re overwhelming. The issue becomes how does a soldier adjust to such situations. And the answer is that some soldiers appear to do quite well with the adjustment phase. They can handle great amounts of stress, they can handle all of these types of experiences and come out basically intact.
One of the key things in the battlefield is that the veteran may be just overwhelmed by the visual acuity or the environment. The military lately has really progressed in that they have field psychologists, psychiatrists, and mental health folks who now go with the teams that allows them the opportunity to sit down and process some of these things close to where the action takes place. I believe they call it PI, which is basically a model in which folks sit down and briefly discuss what their thoughts are and reactions are.
It does two things. One is it makes you kind of come to the realization that this is normal, that this response that one encounters in fact is what normal people would do, and by seeing other folks who are in the same situation and being able to discuss that and to process some of that, assist the veteran to go on with their duty.
In Vietnam, the veteran was exposed to the situation for at least a year at one time, which is an awfully long time, and I think the ability — as the Israelis have learned — to be able to process some of this, to know that other people are going through these experiences, and actually to have someone to talk to actually helps the individual to be a better soldier. And I think since Vietnam the military has come a long way in assisting veterans in the acute phase for these types of situations.
SUSAN DENTZER: …What particular sets of issues could arise for those now in Iraq?
ALFONSO BATRES: Well, it’s similar to the experience in Somalia in which our troops went in initially to assist the community, to bring food to the hungry, and to bring order and assist a country into a more democratic phase, if you will, and help them out, very quickly turned into the people that you were assisting either shooting at you or becoming aggressive toward you.
So in Somalia, it went from a humanitarian effort to more of a combat effort with the people that you were there to assist all of a sudden became the individuals who were shooting and causing problems for you.
I think that when a soldier witnesses kids that are starving … or civilians or others who may have been killed or run over, I think it impacts on the troops, on their psyche, and I think just witnessing these types of events I think impacts on our soldiers.
It’s interesting, a lot of World War II veterans and Korean veterans report the same phenomena. Their nightmares are not necessarily about combat, but about what they observed and what they witnessed in terms of the random effects sometimes of bombings or other types of activities.
SUSAN DENTZER: The Vietnam era having been the first generation of veterans who were systematically assessed, what did the study show about the degree to which they had experienced PTSD?
ALFONSO BATRES: The National Vietnam Veterans Readjustment Study, which was conducted by the VA — by the way, externally by a group, a consortium of universities external to the VA — found that over a lifetime, over 30 percent of Vietnam veterans were going to be diagnosed with PTSD. But that’s over a lifetime, which was surprising to many that it would be that high. The highest predictor, of course, is exposure to combat. So those veterans that had more combat exposure were more likely.
What was interesting, though, was that that’s a lifetime problem. So they took those that currently had PTSD, estimated those that might have had it in the past, and then those that were going to have it in the future. It is the gold standard in epidemiology for PTSD, but it was at 30 percent for a lifetime.
SUSAN DENTZER: Based on that, what, if anything, might we assume about the experience of those who will be returning from Iraq?
ALFONSO BATRES: Well, we can assume that they’re going to need some services down the road. For sure they’re going to need transitional assistance, for example, at our vet center, getting them the information about what benefits the VA will have, the community may have, assisting them to get jobs when they separate, assisting them to readjust back to their communities, screening them for things like post-traumatic stress disorder, and also learning that by definition our services need to be conceptualized and structured in long term types of services, not just short term.
Yes, there’s the need for services for acute responses, but by definition, post-traumatic stress disorder can occur years later. So keeping these services up and running to assist those veterans over time is very important, as well as preventive type programs where we can educate the veteran and assist them initially, hopefully inoculate them a bit about what to expect, where their resources are, and the lesson we’ll learn from Vietnam, encourage them to talk about it, and also realize that it’s going to impact on their families and their children.
From what we’ve learned over the years, the family is very important in the process, and making services available, education available to the spouses and family members of these returning veterans.
So what the VA is preparing for is to provide these services. The secretary has gone a long way by encouraging, and in fact, requiring us to be very proactive, especially with soldiers that have been wounded, who would be a high-risk group, those that have been exposed to combat, and he’s allowed us to have access to them earlier on. He’s encouraging us to coordinate with DOD. We’re exchanging information like we have never changed before. We’re getting to them earlier. We’re able to get to the families, and I think the secretary is making a big difference with the Iraqi veterans by allowing us to be more proactive and encouraging us to do the right thing.
SUSAN DENTZER: Would we have any reason to expect, and I know this is unknowable, but would we have any reason to expect that 30 percent of those who served in Iraq will experience PTSD, lifetime risk?
ALFONSO BATRES: We don’t know. Of course, we will find out, and of course, we will be studying this. We’ve had over 2,000 veterans already access our vet centers from both Afghanistan and Iraq, and what we’re going to be doing is baselining their issues that they bring, and what’s going on with them, and I’m sure at some point we’re going to be surveying the type of problems that they’re having and establishing that baseline about how they present, and what symptoms they may bring.
That’s the population that’s presenting. In order to do good studies, we’re going to have to do the type of study that we did with the national Vietnam veterans readjustment study, which is to construct a more scientifically based survey to get a more accurate picture.
The military, though, is also very active in collecting data and asking questions relating to post-traumatic stress disorder and readjustment of every returning soldier.
So we’re going to have more data and more information for these veterans than we have had for any other era veteran from the get-go. So I believe we’re moving in the right direction.
SUSAN DENTZER: Is talk therapy more effective than drug therapy?
ALFONSO BATRES: They’re both important, depending on the veteran. See, not all veterans need the drugs, but all veterans need to talk, and that’s the way I conceptualize it. It’s therapeutic to talk about it.
My dad came back from World War II and he never talked about his experiences. He never said anything. And that was the way all my uncles and my dad were. They just never processed. They never talked, not even with their family members. So we encourage people to talk, not just to their counselors, but talk to their families. Talking communities externalize the process. Share it. The message is you’re not alone, you’re not sick. This is a normal response, and we encourage them to go.
If it turns out that they have severe — a different type of post-traumatic stress disorder, then we get into the medications, but a lot of our job a lot of times is to do the prevention stuff, the easy stuff, and to get these folks stabilized so they don’t have to move into the medical part of it. But some veterans need the medication in order to function. The majority don’t.
SUSAN DENTZER: Is there a cure for PTSD or is it merely a condition that can be treated and managed at best?
ALFONSO BATRES: We don’t have a cure for PTSD currently. There is no secret medication, there’s nothing where we can bring someone in and just say hey, you are now cured. That’s a medical model term. And if you have an infection, you get an antibiotic and the infection is gone.
Post-traumatic stress disorder is a little bit more complex than that. So we have no sure way of getting rid of PTSD and I’d be very happy if we did, because that sure would save a lot of veterans from a lot of misery and nightmares and difficulty. And our scientists and our folks are searching for that. They’re looking for the right type of medication, or for that intervention.
Clinically, through counseling, I think we can really help the veteran’s quality of life and improve on it. If we can reduce the number and severity of nightmares, if we can get a veteran back on their feet to go to work, to relate to their children, to relate to their spouse, to be good citizens, then we’ve done, in my opinion, a good job of helping normalize that veteran’s life.
And the long-term prognosis seems to be that we need to keep that type of support up to assist those veterans periodically when they may encounter difficulties and may need to come back and get some more help at a vet center to continue their road. And it’s amazing how resilient our veterans are in terms of how well they can bounce back from some of these things in some cases. But also it’s amazing how powerful the grip of post-traumatic stress disorder can be with some of our clients. It seems to be chronic, it seems to be very severe at times, and these folks will need assistance over the years to help them to improve and maintain their quality of life.
SUSAN DENTZER: What is the worst case scenario? Can you describe for me a case or a constellation of cases that represent the most extreme episodes of PTSD, chronic conditions of PTSD.
ALFONSO BATRES: Well, we have clients — we have soldiers, as we do have non-soldiers — who have been extremely traumatized, and in those cases their life functioning is very much impaired. They could be fearful, they’re overwhelmed. They’re not as productive as one would like for the individual to be, and they seem to be enshrouded in a chronic symptom, you know, effect over a long period of time. And it affects their employability, it affects their ability to relate to the world in a meaningful way.
So it can be quite debilitating and quite chronic in some cases. Again, it would be a combination of the type of stressor, and what the individual went through, some measure of their social support system, and perhaps something having to do with their vulnerability to these types of situations. We’re not sure. But that’s part of what the research is focused on, is to look at why PTSD may affect individuals differentially, which we don’t quite understand well enough at the point where we have developed the type of strategies where we can get folks back to being where they were before they experienced the combat.
SUSAN DENTZER: Does the VA have enough in the way of resources to offer this treatment to all the vets who will need it in coming years?
ALFONSO BATRES: We have been working very diligently with our planning and our outreach efforts to try to get an idea of what the demand is going to be like. You know, you were asking a question earlier about epidemiology. That’s so important in terms of resources, in terms of what we plan and allocate for the future. It’s very important that we have the resources to treat the psychological end of combat as well as the physical end of combat. And I think that over time as we know how these soldiers may be impacted and more of what their needs are, we will be gearing up those services to address those needs. But it’s very important, from my perspective, that we anticipate and try to gauge what the need may be in the future.
The other thing is factoring in the type of soldiers that may be coming back. We’re quite concerned about National Guard and Reserve soldiers, the different proportion in this war. That has to be equated in, and we have to plan for those types of services because they will be eligible now for services down the road.
SUSAN DENTZER: And why are you especially concerned about the National Guard and Reservists?
ALFONSO BATRES: Well, traditionally, National Guard and Reserve soldiers do not go into combat for a year at a time. Their role and duty has been for a couple of weeks, activation for a while, and then return. We seem to have a higher proportion of National Guard and Reserve units now serving in Afghanistan and Iraq. We want to be prepared for that population because they’re going to be exposed and put into harm’s way in a higher number than they ever have before. And they may be differentially impacted.
If you join the Reserve, you will join the Reserve to be gone for two weeks a year. To be activated for a full year represents a change in the way in which the family and the soldiers prepare and adjust for these types of duties. We need to be prepared to service those families and those soldiers when they come back just like we would our normal active military personnel.