PSYCHIATRY, COMBAT STRESS & PSYCHO- TRAUMATOLOGY CLINIC, A NEED OR RE- QUIREMENT?

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1 PUBLICATIONS Interview Col PhD RADOSŁAW TWORUS PSYCHIATRY, COMBAT STRESS & PSYCHO- TRAUMATOLOGY CLINIC, A NEED OR RE- QUIREMENT?

2 Wywiad z płk dr n. med. Radosławem Tworusem. Listopad Publikacja w ramach projektu Mars fundacji Stratpoints. Interview Col PhD RADOSŁAW TWORUS PSYCHIATRY, COMBAT STRESS & PSYCHOTRAUMA- TOLOGY CLINIC, A NEED OR REQUIREMENT? Poland s engagement in military operations abroad has got a long and rich history. The operations has started to change their character from typical peacekeeping under the United Nations auspices through training, stabilization training, to stabilization ones. At these operations which should be called combat, soldiers started to use weapons and different weapon systems were used against our troops as well. The Armed Forces have gained necessary combat experience but these activities caused death, wounds and soldiers psychical changes. The last ones have initially not been noticed however, they appeared so important that, finally, actions have had to be taken. Lt. Gen. Ret. PhD Mirosław Ròżański: When was the Psychiatry, Combat stress & Psychotraumatology Clinic created and what the reason was for that? MR: THE MINISTRY SHOULD BE INTERESTED IN SOLDIERS QUICK AND FULL RECOVERY TO CONTINUE THEIR SERVICE FOR THE COUNTRY. Col PhD Radosław Tworus: The Psychiatry, Combat stress & Psychotraumatology Clinic was established by the Ministry of Defense (MOD) Decision in That year Polish troops started their participation in the combat operation in Iraq. The MOD leaders, expecting psychic consequences of Polish soldiers involvement in combat actions, disseminated the decision and attached financial resources to create such a place like the Clinic. The construction of the facility took two years and in the middle of 2005 the first soldiers were sent to the Clinic. It was the first and only such a place in Poland. Nowadays, psychiatric wards which support veterans, the so called combat stress wards, are located in military hospitals in Bydgoszcz, Gdańsk, Krakòw and Wrocław, as well. MR: There are many psychiatric facilities in Poland so, what is the goal to have such the specific Clinic? RT: The essential goal is the special psychiatric psychological treatment for soldiers returning from military operations abroad. Active service soldiers as well

3 as reserve and retired ones, who have psychic problems resulting from a participation in combat activities within the Polish Military Contingents, are directed to the Clinic. MR: That means that military authorities dedicated financial resources to build the Clinic and treat hospitalized soldiers who come back from an operation with mental disorders. RT: MOD assigned financial resources to build the Clinic however, the Ministry hasn t been financing the soldiers treatment because they cannot do it. The soldiers treatment is financed in a similar way like other Polish citizens. The National Health Fund (NFZ) pays for a soldier s stay in the Clinic, like for any other person s treatment. MR: Are there any special procedures to finance a combat stress treatment by the NFZ? RT: The NFZ, as a paying agency, has implemented financial criteria for an individual sickness. The criteria do not include specifics / circumstances of the illness cause. A posttraumatic stress disorder of a traffic accident victim and a soldier who took part in a combat are treated as the same medical problem and are financed on the same level. MR: It seems to be a fair financial system because it does not divide citizens on the better ones soldiers and worse civilians but it finance a particular health problem, doesn t it? RT: Obviously, ill cannot be divided on soldiers and civilians but, in the case of a disorder resulting from a soldier s combat actions the problem is highly complex. MR: What is the complexity? RT: In the period of almost fifteen years of the Clinic s activity it has become the well-known place in the country and seen by psychiatrists and psychologists and, especially, by soldiers, as a facility where veterans with psychic disorders should be sent. As a result soldiers from the whole country are directed to the Clinic and every year there are more and more of them. Nowadays, about 40 50% of all admissions are veterans hospitalized in the Clinic. Even though some time has passed since the end of operations in Iraq and Afghanistan the number of veterans applying to the Clinic is not smaller. In most cases we diagnose psychic disorders resulting from a participation in a combat operation. More and more seldom it is PTSD but, there are still patients with PTSD lasting and untreated for years. Many of them apply for help persuaded by a family or colleagues. The average hospitalization period of time in the Psychiatry and Combat stress Clinic is over 40 days and exceeds norms established by the NFZ. Veterans prolonged stay is caused by two reasons. Firstly, from the specifics of this group of patients, making diagnostic process more difficult. Secondly, because of a long-term psycho and medication therapy in the case of PTSD. Prolonged diagnostic process (by average two weeks longer than in the case of civilians) is caused by soldiers defense attitude that results in more examinations (interviews, questionnaires). The basic reasons for the defense mechanisms and their results are as follows: 1. Presenting themselves as people who can manage any problems, focused on actions and not on emotions; 2. Fear against weakness release connected with dread against consequences at work, a suspicion that information would be relied to commanders at units. Often, the initial therapy phase is to build a therapeutic alliance and check whether the therapist follows the rule of confidentiality; 3. Fear against a negative assessment of a stay and combat activities fulfilled at the operation in a public opinion context that prolong the process of making connection with a therapist. Problems in therapeutic work (after the diagnostic process) resulting in its high cost and long duration are caused by: 1. Work with trauma causes an increased emotional burden for a therapist. It may immensely influence a job burnout. It is connected with a bigger need for a supervision (it should be conducted four times per month what means four times more often than nowadays, what greatly increases costs with incomes already underestimated); 2. The Clinic is one of few facilities in the country where there is a work with combat trauma. It requires from a psychologist psychotherapist to elaborate an individual program because a training available on the market is dedicated to another type of a patient. Job improvements require periodical trainings and studies. To meet the combat trauma requirements it is necessary to individually connect deferent psychotherapeutic methods of influence. The imagination exposition method, implemented in the Military Medical Institute Psychiatric Clinic, consists of a connection of different therapeutic technics. The cost of only one technic s

4 Wywiad z płk dr n. med. Radosławem Tworusem. Listopad Publikacja w ramach projektu Mars fundacji Stratpoints. training is about 2000 PLN. 3. Work with trauma requires more intensity and frequency of psychotherapeutic influences two individual sessions per week at the minimum. As an effect much bigger experienced psychotherapeutic staff than a standard one is needed. I stress experienced because young and unexperienced psychologists and psychotherapists cannot stand the burden that result from the work with combat trauma. 4. Psychological tests questionnaires that assess psychotherapeutic work effects need adaptation because most of them come from American sources translation as well as adaptation costs of tools elaborated for the U.S. Armed Forces to Polish reality. 5. Work with soldiers with serious physical wounds requires from the psychological psychotherapeutic personnel broader medical knowledge. This is connected with additional time sacrifices for talks with medical personnel about the somatic status and its effects as well as knowledge development in this area. There are other factors, which can be described as disturbing, determining the prolongation of the diagnostic psychotherapeutic process. They reveal themselves after a few weeks of hospitalization. The most important of them are as follows: 1. A difficult family situation (home violence, adultery, divorce possibility) often requires a consultation with a whole family so a patient might be engaged in his / her own therapy. A family session usually lasts about hrs. 2. Legal, job (a threat of a lack of contract, new place of service) and alcohol problems (many times hidden by a patient what makes the diagnostic psychotherapy work more difficult) prolong the diagnostic process for three weeks at average. Their disclosure effects a scheme of work with a patient. It means a necessity to find an anti-addiction facility, release with preplanned time for a next admittance after legal, administrative or job issues are solved. Patients are asked to sort out their problems before they enter the Clinic. 3. The distance to the living place (patients from all over Poland), separation from the family, lack of family visits because of the distance, financial issues caused by a loss of an extra income when hospitalized, a problem of the only income provider in a family. 4. Intercultural differences in the context of different regions of Poland which influence an understanding of various social, living, professional and religious issues a necessity to adjust a diagnostic therapeutic work to the cultural specifics. The factors presented above cause that time of many hospitalizations exceeds 40 days and the longest has lasted 157 days and this soldier has returned to the service and is still there, he was promoted, set up a family and has children. MR: Don t all the mentioned problems and, as you may assume, the level of costs connected to such specialized treatments influence the quality of the delivered support? RT: The executive board of the Military Medical Institute assumes that the support for a physically or mentally disabled soldier is a priority and cost calculations should be on the second place in terms of importance. All soldiers, especially Polish Military Contingents veterans hospitalized in the Military Medical Institute may count on the specialized psychiatric psychological support offered by our team. The range of this support is adjusted to this group of patients needs. In an obvious way we cannot fulfil all dreams and expectations of our patients. That means that we adapt our support to diagnosed disabilities and not always it meets a patient s anticipations. In the therapeutic work we utilize genuine programs developed by the Clinic s team throughout multi-year researches and clinical experiments. There was no ready solutions to work with Polish soldiers and methods of psychiatric psychotherapeutic support used by our NATO allies could not be directly implemented. The programs are permanently updated and improved by the Clinic s personnel through participations in scientific conferences and professional trainings, both military and civilian, concerning broadly understood stress. To gain new clinical expertise that might be helpful for Polish soldiers with stress disorders symptoms the Clinic has extended its support for patients hospitalized in the Military Medical Institute Trauma Center for the Mazowieckie Voivodship. Thanks to that, supporting our patients, we possess knowledge in the area of both combat stress and civilian psychotraumatology. MR: How could you assess the quality of the support? RT: The quality of the psychiatric psychological support might be estimated by systematically increasing numbers of hospitalized veterans and soldiers who, after the treatment is concluded, come back to service and after some time they suggest our Clinic to a colleague who has problems but previously he didn t want to be treated. Such a situation, when a patient recovers, comes back to work, to family life and advises the facility to another patient, is the best token of the support quality.

5 Wywiad z płk dr n. med. Radosławem Tworusem. Listopad Publikacja w ramach projektu Mars fundacji Stratpoints. MR: Are there any non-medical factors which might influence the recovery of patients hospitalized in the Clinic? RT: A family which understands the problem, supports, cooperates with doctors and therapists, patiently awaits mental status improvements and joins the therapy when necessary. That s the key. But it is important to have a superior s support as well, either a military or civilian one. The meetings with veterans conducted by: the President Bronislaw Komorowski, Prime Ministers Beata Szydlo and Donald Tusk, Chief of the National Security Bureau Stanislaw Koziej, Ministers of National Defense Wojciech Falkowski and Tomasz Siemoniak, Commanders of the General Command Lt Gen Lech Majewski and you Sir, Ops Commander Lt Gen Marek Tomaszycki have all been important events for a soldier and words of appreciation for military service are motivation factors for recovery, for a fight for himself / herself. treatment in the Clinic from the MOD funds. It is hard to imagine a situation when, because of any reason, there is no funds in NFZ to treat a soldier. The Ministry should be interested in soldiers quick and full recovery to continue their service for the country. Once again thank you and I wish you successes in realization of this honorable mission. MR: What is the focus of the Clinic led by you besides the medical treatment? RT: Researches over PTSD, mtbi (mild Traumatic Brain Injury) which means brain s injuries which occurred under a shock wave, methods to treat these problem e.g. with oxygen hyperbaric therapy, VR (virtual reality). Moreover, we make efforts to develop so called telemedicine it means remote specialized consultation system via videoconferences for soldiers who serve e.g. in Afghanistan. Such an idea appeared at meetings with Lt Gen Marek Tomaszycki and the current Ops Commander Maj Gen Slawomir Wojciechowski continues and develops this way of support for soldiers serving abroad. There is an active telephone counselling for veterans as well as their families in the Clinic, too. From Mondays to Fridays, from 5 pm to 8 pm, calling it is possible to get a specialized support without divulging a name, and this is what veterans are often afraid of. MR: Thank you for sharing information concerning the facility led by you. When I visited the Clinic I figured out how difficult the decisions to start a treatment are. Soldiers are anxious that they would be stigmatized in their environment and here there is a great role for commanders to support soldiers who have problems. As a soldier I ve got to share a reflection in my judgement it would be justified to finance soldiers

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