 Hello, and thank you for taking time to watch this program. The title of the show is drawn from Tibetan wisdom, which says we picked this marvelous and crazy planet to grow spiritually and to awaken. It's said that we have to be brave like warriors to face the uncertainty and challenges of human life. This takes courage to face the rather ubiquitous anxiety and fear of human existence altogether. Being courageous, we discover our nobility and our inherent compassion and wisdom which guides us to solve the challenges facing us. Today I have a frontline warrior who has devoted his life to helping our vets return from war. Dr. Kenneth Hirsch has spent 22 years in our armed services, his last deployment beginning immediately after 9-11. He retired if you call retiring to a 40-50 hour work week retiring to manage the outpatient and residential services for the treatment of post-traumatic stress disorders in the Department of Veteran Affairs Pacific Island Healthcare System. He has been treating post-traumatic stress disorders for 37 years. Thank you, Ken. So much for coming on. I know it was a big deal to get you sprung free from your work, and I appreciate the person that you didn't see, the patient that you didn't help, and thank you so much for coming along. My pleasure. Thank you for the invitation. Now, we met four years ago, or I think we said it was even longer. Yeah, 2009, I think we decided. One of those time flies when you're having fun situation. At that time I really didn't understand the extent and the wonderful protocol that you'd put in place at your clinic, not exactly clinic, but I wonder if you'd talk about the protocols that you're using for post-traumatic right now and also it's a residential program. Go into it a little bit for me. Both the residential and an outpatient treatment program. The outpatient treatment program is much larger in terms of the number of patients that it's able to accommodate, and it uses as much as possible evidence-based treatments, one treatment programs that have been demonstrated by extensive research to be effective, not just hand-holding, not just make someone feel better for a few hours or a couple of days, and then the symptoms are just there again. The residential program is much more intensive, and it's for individuals for whom outpatient care just wasn't sufficient to get a good handle on the symptomology. It's a eight to nine week program, 12 patients at a time. We use a cohort model so everyone starts together and finishes together, so that it functions almost like a squad, and we use that sense of unity, that bonding as a therapeutic tool. So they're helping each other in a sense. That's correct. That's part of it, is the bonding that they're used to as warriors. As warriors. They're at a wet branch of service. In addition, it provides an opportunity for them to provide ongoing support to each other after they leave. So they learn by teaching in some sense, learning, teaching to each other. That's right. Uplifting the whole situation. And even though they come from really all over the Pacific Basin, and sometimes from the mainland, with modern technology, they can stay in contact and support each other that way, whether it be by a closed Facebook page or something like Group Me, so that it helps while they're in treatment with us, it helps in aftercare. Wow, they're in community. That's correct. And that itself is a huge therapeutic goal, because that community is what keeps them going. Now, go through the actual protocols, because even whatever that is now, six years ago, seven years ago, you were using CAM, Complimentary Alternative Medicines. You were using kind of traditional cognitive therapy. That's correct. Now, we emphasize actually the empirically bound programs or treatment structures and programs that have been demonstrated to be very effective, but they don't do everything. They don't take care of everything themselves. So we use cognitive processing therapy. We use seeking safety. We use present-centered therapy. We've assembled a group protocol. Most of our therapy on the residential program is group-oriented to address moral injury. Then in vivo exposures to both group and individual challenges. I'm going to slow you down just a little bit there. In vivo, go into moral injury, because you meant in our conversation, and it's a stunning word, moral injury. One of the things that we find that is relatively unique to combat-related post-traumatic stress disorder, and to some extent, law enforcement-related PTSD. Yeah, you said this, where the police forces are showing up with exactly the same symptom-tology and having to wrestle with protocols as well. And what we find something that is relatively unique to those two causes of PTSD is the fact that the sufferers, the victims of the PTSD, feel that they have either done something which is a violation of their moral code, or by failing to do something have done something which is a violation of their moral code. In the Western world, one of the most obvious things like that is killing another person. And if you think about the Ten Commandments, one of them people think is they'll shout not kill. Actually, it's they'll shout not murder. That distinction has a huge psychological impact. But no matter which definition you use, say you shoot someone in self-defense to save someone else's life. You still shot someone. That takes a toll because in our cultures, and I say cultures plural because it's pretty ubiquitous, taking another person's life carries with it a very strong moral price. And how do you recover from that? That's part of what we talk about when we describe it as moral injury. We spoke about this. It seems like out of the species we've been causing harm to one another and killing for our livelihood on some level, our whole existence on the planet. And yet I'm stunned by the fact that it seems that somewhere inherent in our makeup, we know that we do not, when we see something very violent, it's almost imprinted to such a profound extent that we cannot release it. I mean I have to ask, as a human, what is it that you think that has this program on the one hand where we have seen violence or we seem to be fairly, we have to kill the eat on some level, even if it's a tomato on the way down? There's some sense of that, but there's also this almost universal experience that when it goes too far, it deeply sets into your psyche. And what's interesting in support of that? What is the moral fiber there that's a part of us? We don't know, but it's interesting that you make that point because historically, even if you look at very violent cultures, they have difficulties with the same issues. Shakespeare wrote about PTSD without realizing it in his play, Henry IV. Homer in his two most famous works, The Odyssey and the Eliot, the stories of the tragic downfall of Odysseus and Achilles, well, Dr. John Shea, who used to work for the VA until he retired a few years ago, happens to be a Greek literary scholar, a white guy. And he wrote a book about each of those two works demonstrating how the downfall of Odysseus and the downfall of Achilles would be attributed to what we now call PTSD. And these are violent cultures. Right, right. It's just so amazing. The price is the same. Yeah, it's just so amazing. Our brains, although they have seen this, when they see violence of a certain nature, know that it is inherently not something, it breaks some sort of inherent moral code. Again, you're talking great figures in literature pointing this out. And then you also, I'm sorry, I'm going to have you go back in vivo. Desensitization in vivo. Right. One of the characteristics... So we're back down to protocols now. That's correct. So we're shifting back to symptoms and how to deal with them. Yeah, protocols. One of the characteristics of PTSD, no matter what the type of trauma that gives rise to it, is a tendency to avoid situations that remind one of the trauma. Or the feelings associated with the trauma. Right. Well, if you have someone who's avoiding reminders, they tend to stay in their homes. They avoid situations. Right. If it's combat, well, there's not much combat going on here in Honolulu. But there are things that remind you of it. If you're a veteran of Iraq or Afghanistan, a pile of trash by the side of the road is spelled IED. I have a friend just talk about a patient. They saw trash in the middle of the road. They swerved radically to the right, ran into another car, and they said, fortunately, the other car was a vet. And he just... He saw IUD. He saw a pile of trash. He saw IUD. So there are many reminders just in day-to-day living. And we want to get our veterans, not just our veterans, because two-thirds of the population we treat in the residential program is still active duty. We want to try to get them to the point where they don't avoid so much. So we send them out. We have group activities that are graduated in terms of level of anxiety-provoking stimuli. And we have individual challenges that are more individually tailored to each one, where they go out and challenge themselves, and they have to sit with the anxiety. And that reduces not just what they feel at the moment, but it reduces the amount of anxiety that they feel when they first go out there. So it's preventative as well as treatment. Right. And then you have classic talk therapy. And... You have the group situation going on, the group enforcement. But even those classic ones, we use programs and treatment paradigms that are tailored specifically to PTSD. It's not just general talk therapy. So that if I were working with someone who had a single traumatic event that seemed to be really impacting their life, I might use prolonged exposure therapy, because that has a tremendous wealth of research supporting it in that setting. If I had someone who had multiple exposures to trauma, but no one or two that really was salient, then I might tend to use something like cognitive processing therapy, which is also very useful for group format, as opposed to individual, and in fact can be more powerful in the group. Let me also go into a few other things that even when we interviewed or chatted a few years ago, you were already doing acupuncture, auricular acupuncture, you were already doing mindfulness meditation. I think EMDR, I move into sentiation, but it has become much more research and somewhat prevalent in the use of the field. It's one of three primary evidence-based protocols for the treatment of PTSD, those are still lacking somewhat behind cognitive processing therapy and prolonged exposure therapy. The other techniques that are used, whether it be acupuncture or mindfulness meditation or a variety of others, are considered to be adjunctive or ancillary that is used in support of those three. You say evidence-based, you have a lot of experience. What is your view on that person? How do you see them being integrated and used? What if it's the placebo effect of these other modalities? First off, I don't have any problems using a placebo effect, but I want to make sure that I use those other tools in addition to the evidence-based procedures, not in lieu of. Some of them are very powerful, whether it be something as simple as one of the things that we've started using just the past six months or so. We use adult coloring books. Oh, beautiful. Wonderful, wonderful. And what we find is that a lot of the guys, not all of them, but actually the majority of them find that it calms them. In fact, we even call that segment of the program Color Me Calm, and they love it. Some don't, but the ones who do, it's another tool. Stress and Mindfulness Meditation, yoga, nidra, any number of different things. Movement. What are you doing in terms of movement, yoga? We have some yoga, but we also have a range for surf lessons. Oh, yes, you said that last time, marvelous. We do have, we really stress emphasize, stress exercise. We have a pretty good gym on tripler's grounds. We encourage our folks to use it. We have one person who's reasonably skilled and he can supervise and help them with setting up an exercise. A protocol etiquette. That's correct. That's just marvelous, all the things you're bringing together. Now, I know the other piece that you wrote a paper on this, I hope we have a moment to finish it, is on a stellate ganglion block. It's a kind of a new... Well, it's new for PTSD, but it's not new. It's a nerve block that you use for pain. It's been used for certain types of pain syndromes for over 90 years. And a doctor, Lipov in Chicago, noted that it seemed to help with some of his patients who had anxiety disorders. He brought it to the attention of the folks at Walter Reed. They did a five-patient series there. One of those docs came here, he and I hooked up, and we've done a much larger patient series, and now there's ongoing research in it. It seems that the stellate ganglion, stellate just means star-shaped ganglions, collection of nerve cells, we each have two stellate ganglions, one here, one here, but the one on the right, it's actually more towards the back, but the one on the right is the major pathway for the sympathetic nervous system, fight, flight, or freeze. So it gets to amygdala, or it gets to the deep limbic system kind of information? It ties in with that. But fight, flight, or freeze, which is hyperarousal, think adrenaline. The saber-toothed tiger is chasing you, you need the extra energy and strength. That's mediated by the sympathetic nervous system. PTSD, hyperarousal, hypervigilance, not being able to relax, always being on guard, exaggerated startle response, all of that is a result of the over-activation of the sympathetic nervous system. The leg ganglion block seems to tamp that down. So that's that whole hypothalamus, pituitary, adrenal axis that you're starting to be directly going to and say, let's chill out here, in fact the saber-toothed tiger is not in our midst right this moment. No, but we have equivalents. Aloha Kako, I'm Marcia Joyner, inviting you to navigate the journey with us. We are here every Wednesday morning at 11 a.m. and we really want you to be with us where we look at the options and choices of end-of-life care. Aloha. Hello, I'm Michael North, inviting you to join us on The Art of Thinking Smart, every second Thursday at 12 noon here at the beautiful ThinkTech studios in downtown Honolulu. I'm guest hosting for David Chang of Wealthbridge. Now we're talking to Hawaii's most intelligent, accomplished leaders about what makes them successful in their professional lives. By absorbing their practical wisdom, all of us can think ahead, think deeper, and become more successful ourselves. We look forward to seeing you on The Art of Thinking Smart. Again, I'm really excited to speak with you and have this information get out. You know, we've talked about protocols now. We've talked about the residence program. I want to talk about resiliency and I want to talk about what can be done to make the warrior feel more welcome when he or she gets home. You know, one of the things I researched on this was how different cultures have accepted their warriors back into their culture. We talked about the fact that the armed services are quite unwieldly situation of millions, literally. And that there's a little inner service rivalry that distinguishes brown shoes from black shoes, etc., etc., I mean army, navy, etc. But in general, have you explored and also the military not only known for its acronyms, but also for its rituals, for its rites of passages that are sometimes close to hazing, striping. Is there any rituals that you think are... Now, I realize the armed services probably can't get a head around this because you're also bordering into the quote-unquote spiritual or the quote-unquote. But is there any rituals that you have seen or that you would advocate that's coming home to you? Well, the problem is rituals are culture-based. So I couldn't recommend any specific or even set of rituals for widespread usage because we are a multicultural society. The military itself has many cultures within it. There are specific cultures that have rituals and ceremonies to welcome and cleanse a warrior upon his or her return. And they are effective within those cultures. Right. The American Indians and Navajos have a beautiful... A variety of different... ...may you come home completely, may you walk in beauty. Correct. Really that welcoming home of a psyche and a spirit. And there are a number of such rituals and ceremonies, but they're all based on specific, relatively homogeneous and unique cultures. Right. To generalize that to a much broader Western United States culture. I don't know how we would do that. Even if you tried to do it just military-wise or just army-wise or just ranger-wide, I think it'd be extraordinarily challenging and I don't know how to do that. I'm thinking more of the actual commitment of civilians to welcome within the cultural milieu or within the religious milieu. For instance, I think his name is John Schlager is doing a beautiful work with a welcoming warrior circle home. These kind of ritualistic things that different churches and spiritual traditions are starting to reinvigorate. Even in my own Tibetan Buddhist tradition, the Shambhal, we have rituals for these rites of passage to try to make sense or still hold this person that might have that moral injury that you spoke of to know that they're being held in love and compassion and care. What do you see the place for that work? I think it has a very significant role because one of the things that we find commented upon by many of our patients is no one seems to remember that we're over there fighting. In the Vietnam era, our warriors were desecrated. Now they're ignored. I'm not sure which is worse. Wow, what a thought. It's just like on the tube over there, we go about our shopping at Costco and everything's good to go. That's correct. And you come back from war and ask most of our folks who come back, not just our patients, and they get angry because someone gets upset about the coffees too cold. You're upset about that. That's unimportant. What about our brothers and sisters who are still fighting and dying? Yeah, they want to go back whether they have arms, legs, or any. And they found some sort of profound, this is the other kind of contradiction, although our psyche seems to absolutely abhor violence at a certain point. There's also some sort of profound love and bonding that goes on in the war arena. It's a shared, horrific experience. Shared, horrific experience. It's like the hurt lock, remember that movie? Very much so. The guy just comes apart looking at 20 different kinds of cereal choices he's supposed to make and his mind is over there. And again, one of the characteristic feelings that's expressed is the battle zone is the only place I fit in. You've mentioned that, that they come back in that mind. So it must help also that you have this residence program and that they can actually speak. I mean, every time I looked up the spiritual or holistic approach to this, one of the things came up was listening. They need to speak and they need to be listened to. And not just in the residential program, but in the outpatient programs that the VA has across the country. And we've got 22 residential programs, so it's not like ours is the only one. The group therapies are very powerful because they can listen to each other. They have someone who they know has gone through something similar and they can be understood. This is a big question. I know you a little bit as a human, as a man. I want to, what really motivates you? You've 37 years with this very profound, painful disorder. What motivates you? Actually, it was a Hawaiian term that put a name to it. Ho'oponopono. So it brings, I just spoke of this yesterday. So yeah, to heal, to make right. To make right. Yeah. So for 37 years you've been... It's, we owe it to these people. And not just our warriors. We owe it to each other. And that's why I do what I do. Ow it to each other, expand more. Ow it to each other to listen. As people. Ow it to each other to heal one another. Ow it to each other to uplift one another. To help each other live, to help each other be what we can. To enjoy ourselves as much as we can. To grow as much as we can. To love as much as we can. All of the above and lots more. Yes, I'm a romantic. Planted of the courageous. I mean, it's beautifully said. The other aspect I wanted to speak about was you mentioned that so much of our police force now is also demonstrating our symptoms of this trauma. It's a lower incidence, but the symptoms are strikingly similar. Because the causes are so similar. Right. You're going out, you're putting your life at risk again and again and again. You are underappreciated by the people whom you are serving. You can't be understood by the people whom you are serving. So there's a very small select group with whom you feel you can share your experiences and your feelings. Very strong analogy to what we find in the military. So the symptoms are very similar. And I'm taking, I saw a study of the University of Chicago and then another one done in LA that's fully two-thirds of people living in inner cities right now have seen some sort of violent act. That in fact, again, breaks their moral injury. And a third of those in this study will have some symptoms of post-traumatic stress disorder. So another question I would have for you is, how is your work and your kind of vanguard type of work bleeding into the civilian population, helping it? What are the communications? All of the treatment techniques that we use can also be used and are being used in the general civilian sector. I mean, you can treat PTSD due to a flood or a tsunami or an auto accident or a mugging. Use the same treatment techniques as you do for someone who's been to war and come back. It's only the type of traumatic event that initiates the PTSD that's different. The symptoms are in many cases the same. Brain's the brain. So the treatments are almost identical. And this is setting you up, but I hope it's a fun question for you. If you had a magic wand, change one design feature in the world or one... Or one disease? Yeah, one disease. That's actually how I framed it. Actually, it would be depression. Depression. It's more widespread and takes a greater toll than PTSD. It's just so interesting. The World Health Organization called the 20th century the century of anxiety. And they're actually framing the 21st century as the era of depression. In other words, you can't keep up anxiety long before you get depressed. So once again, we're back to that kind of ubiquitous, pure anxiety that seems to be part of being human, but seems to be also getting faster with the speed of things and maybe with the loss of the cultural milieu. We don't have as much of a supportive culture. We've gotten around away from the communities where you could draw upon each other for support. We still have some of that, but it's nowhere near as strong as it used to be. It used to be the norm. You grew up in a town. You stayed in the town. You died in the town. You knew everyone in the town, and they knew you, and you would watch out for each other. We're much more mobile. We don't stay in the same places, and the places in which we do stay are so large you don't know everyone anymore. Right. So this profound sense of isolation. Mother Teresa just said, one thing I see in your world is you're all isolated. You're all in this fear and pain alone. And that engenders individuality to the extent of ignoring the needs of the other. Ignoring the needs of others. So beautifully said this. I think somewhat of a wonderful note to leave this on is I want to thank you so much. Is there anything that you would like to add, Norm? No, I think we've covered it. Have we covered it? We've covered it in a half hour. In a half hour. There's more to cover. Now if you want to talk for another five or six hours, I'm sure we could do that.