The American Indian Veteran and Posttraumatic Stress Disorder: A Telehealth Assessment and Formulation

V. is a 52-year-old American Indian male, divorced father of two daughters and one son, ages 15–29. He lives by himself in an isolated part of a large rural reservation in the Dakotas. V. currently works in the maintenance department of the Tribal Housing Authority, a job he has held for the past eight years. He served in the Marine Corps from 1967 to 1970, and did two combat tours in Vietnam from 1968 to 1970 with Marine Reconnaissance. V. was recently evaluated and assessed through a Veterans Administration (VA) telehealth clinic that provides outpatient services to his community. This VA telehealth clinic uses live interactive videoconferencing technology to link the Regional Veterans Administration Medical Center (VAMC) to a reservation-based clinic to provide weekly mental health assessments and treatment.

V. was referred to the clinic from his work, after several recent incidents during which he lost his temper and had angry outbursts at his coworkers. In the past several weeks V. had felt extremely irritable at work, and found it difficult to be patient with his coworkers. He stated that there were times when he lost his temper with different coworkers for what he perceived to be their poor performance. During these incidents he yelled at them, but within a short period of time his anger dissipated and he experienced remorse and regret for these behaviors. Afterward V. wanted to apologize to his coworkers, but was unsure how to do so. V.’s nephew was killed in a car wreck one and-a-half months previously, and V. identified this as the cause of his recent irritability at work. He complained of feeling “down in the dumps” since his nephew’s death and could not understand why he just “can’t snap out of it.” In the two weeks prior to presentation he also had increasing thoughts and memories of his experiences in Vietnam that were quite bothersome for him.

V. spent his two tours in Vietnam serving in six-man Marine Reconnaissance teams that conducted multiple-day patrols in enemy territory, engaging in reconnaissance and ambushes. During his time in Vietnam V. had several combat experiences, and is able to relate numerous incidents that meet Criterion A for posttraumatic stress disorder (PTSD). The most troubling experience for V. was during his second tour of duty when he was on recreational leave and his entire recon team was wiped out in an enemy ambush. V. felt that if he had been on this patrol he would have been able to prevent the tragedy from occurring.

V. described a history of heavy alcohol use beginning in Vietnam, but reported that he quit drinking five years before with the help of a local Alcoholics Anonymous (AA) group. Three weeks prior to assessment he went on a two-day drinking binge, which V. attributed to a reaction to his nephew’s death. He denied having used alcohol since that time.

V.’s recent symptoms related to his Vietnam experiences, including trouble with intrusive thoughts, Vietnam-related nightmares two to three times a week, occasional flashbacks, numbing, isolation, avoidance, exaggerated startle response, irritability, and trouble with sleep. In addition he complained of depressed mood and trouble with concentration, but reported no appetite or energy problems. V. denied current suicide ideation, although he described having suicidal thoughts in the past when drinking heavily. He has never attempted suicide. V. has a history of fights when drinking, but denied recent altercations. He also denied homicidal thoughts or intent.

V. stated that he recently heard his deceased nephew’s voice calling his name at times, and also reported seeing his ghost sitting on a bridge two weeks previously as V. drove by. For the past several years when going to bed V. reported hearing the voices of his dead Vietnam comrades calling his name.

V. had not received previous treatment for PTSD, although during a stay in alcohol rehabilitation in the 1980s he recalled treatment providers mentioning that he might have PTSD. His first drink at age 16 was with an older cousin. V. drank several times in high school, but did not report drinking regularly until enlistment in the military. V. began drinking more frequently during his initial military service, and reported heavy drinking binges in Vietnam when off duty. This drinking pattern continued after he returned from Vietnam. He remained sober during the week and drank heavily on weekends, consuming at times up to two to three cases of beer or a liter of hard liquor. On several occasions V. drank to the point of passing out and experienced blackouts. He has a history of DUIs, as well as several arrests for being drunk and disorderly.

In the mid-1980s V. participated in two inpatient alcohol treatment programs at separate Veterans Affairs Medical Centers (VAMCs). After both treatments he was able to maintain his sobriety for several months but eventually returned to previous drinking patterns. In 1996 V. again quit drinking, and joined a local AA group. He has been fairly successful at maintaining his sobriety since 1996, but has experienced two to three short relapses lasting a couple of days each. Prior to the binge three weeks ago, V. had not had a drink for the past two years.

Born in an Indian Health Service (IHS) hospital on his reservation, V. had an uncomplicated delivery. He grew up in a small rural reservation community with an older brother, an older sister, and a younger brother who is also a Vietnam combat veteran. Both parents were migrant laborers. V. was partially raised by his paternal grandparents, who were fairly traditional and spoke V.’s native language at home. In addition to his native language, V.’s parents spoke English. He did not become fluent in English until attending boarding school when he was six years old. His mother was Catholic and the children attended church with her. V. also participated in traditional activities while growing up, mainly powwows and sweat lodges. V. does not have a history of childhood abuse.

Beginning in first grade V. was educated at a Catholic boarding school, and spent his summers at home. The boarding school was a relatively strict, structured environment. V. remembers being physically disciplined on occasion at school and his teachers discouraging him from speaking his native language. Upon graduating from high school he joined the Marines and volunteered for Vietnam.

In 1970 V. returned to the reservation from Vietnam and married his high school girlfriend. They had one daughter, currently 29, who lives with her children several hours away. His first wife left him in 1975 and V. remarried in 1982. The second marriage lasted 12 years, producing two children, and ended in divorce in 1994. The son from the second marriage is 20 years old and in the Air Force; the 15-year-old daughter lives with her mother and stepfather on the reservation. V. blamed his drinking and temper for causing the break-up of both marriages. He is on good terms with his ex-wives, and reported that he is close to his children, although he is unable to see them as often as he would like.

Upon returning from Vietnam V. attended a local community college, obtained a degree, and worked as a tribal police officer for ten years. It is unclear whether he quit or was fired from this job, but V. reported that working in law enforcement was extremely stressful for him, and contributed to increased alcohol consumption. During this period V. witnessed several traumatic events, primarily motor vehicle accidents, in the course of his work. After leaving the police force V. engaged in odd jobs, including farm and ranch work, until undertaking his current job, which he has held for the past eight years.

V. lives by himself in a rural area several miles from his nearest neighbors. He likes the feeling of isolation and safety that this provides. V. does not interact with others outside of work, and avoids big gatherings. He is not active in the Catholic Church, and although V. would like to participate in more traditional ceremonies such as sweats and sundances, he avoids them due to the crowds and claustrophobic conditions.

V.’s father struggled with alcohol problems for several years during V.’s early childhood but has maintained his sobriety since the mid-1960s. V.’s younger brother, also a Vietnam combat veteran, is a heavy user of alcohol, and by V.’s reports also seems to be struggling with the aftermath of his Vietnam experiences.

After receiving an initial assessment and diagnosis, V. began participating in outpatient treatment through the VA telehealth clinic. He is receiving medication management for his PTSD, individual therapy, and is a member of a weekly PTSD support group, all through telehealth. He is currently taking sertraline (100 milligrams a day) and trazodone (25–50 milligrams as needed for sleep).

The treatment received through telehealth has allowed V. to gain better mastery of his anger and irritability. Since beginning this treatment he has not had any further incidents or angry outbursts at work. This treatment has also helped to reduce the level and severity of V.’s PTSD symptoms, and he has been able to maintain his sobriety. Through therapy and the support group V. has learned coping mechanisms to help him better tolerate and deal with his multiple PTSD symptoms. His medications seemed to help eliminate the voices that he had heard when drifting off to sleep. V. still struggles with daily intrusive thoughts and memories about his Vietnam experiences and the accompanying arousal that goes with them.

The telehealth clinic through which V. receives his care is located in a tribal veterans program located on the reservation. The clinic has a designated telehealth room with live interactive video-conferencing capacity connecting with the regional VA. This clinic operates one day each week providing assessments, medication management, and therapy for tribal veterans with mental health issues. An on-site designated staff member coordinates and administers the clinic. The clinicians are located at the regional VA.

On V.’s first visit to the clinic he expressed doubts about the effectiveness of telehealth assessment. He had no exposure to live interactive videoconferencing and very little experience with computer technology. Before assessment V. was given a brief ten-minute orientation to the use of the telehealth technology. During the first 10–15 minutes of the assessment V. remained extremely guarded and reserved. As the assessment continued V., seemed to become progressively more relaxed and comfortable with the technology and the assessment process. He was able to talk at length about his Vietnam experiences and his current problems. At the end of the interview V. stated that he had shared things during the assessment that he had never been able to discuss with anyone else previously.

Since his initial assessment V. has been very active in receiving care through the telehealth clinic. He has engaged in individual as well as group sessions by real time interactive videoconferencing. V. has expressed great enthusiasm for this treatment modality and has been able to work well with his telehealth providers.

One expressed benefit of telehealth for V. revolves around issues of privacy and confidentiality. The clinicians working with V. are hundreds of miles distant, are not active members of the community, and do not work or live in the local area. This has helped address V.’s concerns about accessing local mental health resources as a member of a small rural community. V. does not have the same fears that the clinicians he sees via telehealth may interact or share information with his friends or relatives.

Another important aspect of the telehealth component of the clinician–patient relationship is that of space and comfort for the patient. Although some may argue that live interactive videoconferencing introduces additional distance between the clinician and patient, this distance seemed to contribute to V’s ability to open up in a meaningful way and feel safe sharing his struggles. Having a clinician in the same room as V., especially during the initial assessment, appears to have created a feeling of intrusiveness that may have made it difficult to share traumatic experiences. Telehealth, by providing space and distance for V., helped to create an environment wherein he felt safe to explore traumatic issues.

The videoconferencing technology has not been a problem for V. He has become very adept at the use of the cameras and volume controls at his teleconference site. Although V. continues periodically to express some distrust and suspicion of the federal government, he has been able to build enough rapport with his VA providers through telehealth to engage in treatment and to seek care.

This American Indian Vietnam combat veteran is dealing with multifaceted mental health issues, including chronic posttraumatic stress disorder, acute bereavement, and long-standing alcohol dependence. There are also several complex cultural issues and interactions pertinent to his assessment and treatment, which are the focus of this cultural formulation. Although almost all of V.’s current problems can be linked to his Vietnam experience, until very recently V. had not sought or received treatment for PTSD. V’s drinking, his contradictory views about PTSD, its associated stigma, and limited access to resources presented significant impediments to adequate treatment. When his drinking became better controlled in the 1990s, V.’s contradictory views about his distress still prevented him from seeking appropriate care. On the one hand, he felt these could be pathological sequelae to his traumatic exposures. On the other, he associated these difficulties with personal weakness, which conflicted with his warrior persona. Even aside from these barriers, his comfort level with the local services and distance from specialized care significantly hindered his seeking help to address his PTSD. The telehealth clinic proved important to facilitating V.’s treatment.

V.’s grief over his nephew’s death was complicated by his previous losses from Vietnam. The loss of his nephew amplified his symptoms of PTSD, and reminded V. of the loss of his military team. The traditional notions and practices around death that limit grieving in V.’s culture make it more difficult for him to process this loss and the additional losses that this reminded him of. Yet these concepts also serve as a powerful framework for V.’s understanding and engagement in mourning. The stress of these difficult emotions led V. to briefly return to nonadaptive coping mechanisms, i.e., binge drinking. Luckily V. quickly realized the danger in this behavior and turned to his AA group for support. His current PTSD treatment encourages and supports continued sobriety while enabling V. to deal with his multiple losses.

V. is caught in a dilemma with respect to his desire to increase his involvement in traditional activities. Going to ceremonies and participating in powwows could be a significant benefit in treating his PTSD, by aiding in his spiritual healing and increasing V.’s social support. Unfortunately V.’s PTSD symptoms currently prevent him from taking advantage of these opportunities. Hopefully by engaging in active PTSD treatment V. can increase his coping and find ways to increase his involvement in traditional activities. Through the telehealth clinic V. is exploring ways in which he can become more involved in these activities. The clinic is considering ways to facilitate this, such as by talking with traditional spiritual leaders in the community about V.’s specific concerns and needs.

One of V’s most challenging tasks in treatment is integrating the multiple traditional, community, and biomedical models available to him for understanding and addressing his illness. Each model presents its own strengths and weaknesses. V. seeks an understanding for himself that helps to account for his experiences and individual perspective while facilitating his ability to utilize available resources in the healing process.

The telehealth clinic has provided an ideal medium for assessment and engagement in treatment. It has provided V. with feelings of safety and comfort that he was unable to obtain from the local health services. It has also been able to provide access to the VA system, which offers specialized mental health care for veterans suffering from PTSD. Without access to telehealth, VA services would be time-consuming, difficult, and costly. V. would not be able to receive care at the same level of intensity, including weekly support group and individual therapy sessions. V.’s case demonstrates that high-quality cross-cultural assessment and care can be provided through live interactive videoconferencing, and that this modality can be critical in delivering such care to isolated, under-served communities.