Long Road Home

Candace Baker woke up the morning of January 1, 2018, and said to herself: Something’s got to give.

Medically retired from the Army since 2011, Baker was spiraling downward. Chronic pain, post-surgery complications, and post-traumatic stress disorder (PTSD) had eroded her ability to navigate the daily demands of work and life. The more time passed, the worse her situation became. For a time, she was “houseless,” as she calls it. Her only major possession was her car, and even that wasn’t in her name.

Shortly thereafter, Baker joined the Emory Healthcare Veterans Program at Emory’s Brain Health Center. In the two weeks of intensive outpatient treatment that followed, she began to write a new chapter for her life. “Mental health and physical health are inseparable,” she says. “It’s like peeling back an onion.”

In January, the American Journal of Preventive Medicine published the results of a survey which found that for veterans, health remained the top concern both at three months and six months following their return home. Of survey respondents, 53% reported a chronic health condition, 33% reported a mental health condition, and approximately 40% reported a chronic pain condition. The report concluded that there is a need for “bolstered support” to prevent the development of “chronic readjustment challenges” in the veteran population.

Emory health care providers, researchers, and educators are helping to create a healthier long-term future for veterans. Across the Woodruff Health Sciences Center, faculty are pioneering holistic and increasingly personalized treatments. And they are strengthening alliances with the Atlanta VA Health Care System and other partners.

For Baker, asking for help after her medical discharge from the Army proved difficult. Not only did she face bureaucratic challenges to getting the care and social services she needed, she confronted an even more insidious obstacle: her own internal critic.

“In the military,” she says, “everyone tries not to be the weakest link. Being able to hold your own—that’s everything.” When her physical condition first began to affect her ability to perform her Army duties—she was an Avenger Systems Repairer at the time—Baker ignored the warning signs and pushed through the pain. Her physical health deteriorated. Her emotional health suffered, also.

Baker didn’t want to be perceived as the problem child—and still doesn’t, she says: “If a bone isn’t sticking out in the Army, they don’t think you’re hurt. I would have rather lost a whole limb than deal with all the other things I was dealing with back then.”

Too many veterans drop out of treatment for PTSD and other chronic conditions because accessing care over time can pose a logistical challenge. Sheila Rauch, the Mark and Barbara Klein Distinguished Professor in Psychiatry and the deputy director of the Emory Healthcare Veterans Program, is tackling the accessibility question at Emory and at the Atlanta VA Medical Center, where she is director of research and program evaluation for the VA’s mental health service line.

“The biggest barrier,” Rauch says, “is getting the treatments that work out to veterans where they are.” To that end, she’s developing and testing telemedicine and primary care treatment models for PTSD, so that veterans can receive the best evidence-based care without having to seek out a specialty mental health office.

In fact, during the COVID-19 pandemic, much of the program has switched to telemedicine and virtual contact. “We are continuing to serve veterans, just teleworking. We are still conducting intakes. We are seeing outpatients via telemedicine. And we just had our first fully telemedicine cohort for the intensive outpatient program,” says Rothbaum.

They quickly developed a remote intensive outpatient program “that delivers life-transforming care in the comfort and privacy of the warrior’s home,” she says. “This option is currently available for those warriors residing in Georgia but we hope to expand to other states.”

The social work and wellness team compiled a library of online resources to help warriors practice mindfulness, develop listening skills, manage family stress, strengthen resilience. And veteran outreach coordinators set up virtual meet-ups to help warriors connect with each other in real time. 

Rothbaum has long been a pioneer in virtual reality therapy for patients with phobias, anxiety, addictions, or PTSD, such as veterans.

Virtual reality exposure therapy involves having patients describe aloud their most traumatic memories while the therapist matches those descriptions using a computer-generated 3D environment. “The virtual reality exposure system provides an effective treatment and allows for controlled delivery of sensory stimulation by the therapist,” she says.

Follow-up care for veterans who do participate in intensive treatment programs remains key. Each Warrior Care Network site has a VA-based social worker on the team who helps veterans with continuity of care, even after they have returned to their regular health care provider.

“I wasn’t ready for college,” he says. “I didn’t know what I wanted to do, but I knew I wanted to test myself. So I picked the Marine Corps, and I picked the infantry.”

He started boot camp in 2006 and served in the Marines for four years, including two overseas deployments in combat zones. He was emotionally unprepared to handle what he saw when he arrived at his first post in Fallujah, in Iraq’s Anbar Province.

“My first sight was of a destroyed city,” he says. “After that, I just wanted to make it home alive.”

By his second deployment, Banik wasn’t sure he would make it to his next birthday. He’d faced combat firsthand. He’d watched a badly wounded friend being transported to emergency medical care on a Black Hawk helicopter. He’d seen the bloody aftermath of improvised explosive devices (IEDs). Those sights would haunt him. “Maybe I’ll make it to 21 so I can get home and have my first legal drink,” he remembers thinking.

Discharged in 2010, Banik did take that first legal drink. Then he took another. He wound up relying on alcohol to self-medicate his symptoms of depression and PTSD.

He suffered from suicidal thoughts. He sought help but says the medication prescribed made him feel even worse. “I called the suicide hotline at the VA countless times,” he says. Not until his wife learned about the Emory program and urged him to enroll did he begin to chart a way forward.

Banik completed the intensive outpatient program in February 2018. The program taught him that what he had experienced in war did not have to control or define him. He found the psychotherapy component of the program transformative.

“I had to believe that I deserved a better life,” he says. “That was hard at first.”

Today, at 32, Banik is a secondary market analyst at a bank. He and his wife recently bought a home. They have a dog, and they’re thinking about starting a family. Banik has started sharing his story with other veterans, connecting with General Garrett and volunteering with him to lead a recent hike up Kennesaw Mountain. Afterward, they took everyone out to breakfast and shared their stories.

Listening to veterans also means acknowledging that wounds of war do not come from combat alone, says Ursula Kelly, a nurse scientist at the Atlanta VA Health Care System.

“There are differences between PTSD caused by combat and PTSD caused by sexual trauma,” she says. “Both are life-altering, but military sexual trauma often involves a deeply personal betrayal. These are the people—fellow service members and superiors—who were supposed to have your back. With PTSD related to military sexual trauma, not only are veterans dealing with the stigma of having PTSD, but there is the added stigma and victim-blaming associated with women’s sexual assault.”

The VA defines military sexual trauma as sexual assault or ongoing threatening sexual harassment while serving in the military. It is now so common that the VA routinely asks all veterans if they have experienced it. Between 20% and 40% of female service members report having experienced military sexual trauma, depending on what study is being cited, according to Kelly. Male service members also experience military sexual trauma, but their reporting rates are much lower—3% to 4%—though experts believe their actual rates are actually similar to women’s.

In research funded by the VA, Kelly and her colleagues are comparing the effectiveness of trauma-sensitive yoga to evidence-based psychotherapy for PTSD. She believes yoga, as an embodied treatment, offers an important tool for healing over the long term.

How does yoga help? The answer might seem counterintuitive, she says. Yoga works precisely because it does not require the patient to retell their story, at least not right away. Kelly’s theory is that yoga has the opposite effect of PTSD on the nervous and immune systems—and provides a non-cognitive pathway to healing.

“For some survivors,” she says, “exposure therapy just isn’t possible right away. They’ve usually experienced multiple traumas throughout their lives. The complexity is just too great. ‘Telling your story’ is exceedingly difficult for these women.”

The results of her research to date are promising. Trauma-sensitive yoga is proving to be as effective as evidence-based psychotherapy (specifically, cognitive processing therapy) for treating PTSD and co-occurring depression in women with PTSD and military sexual trauma. Kelly isn’t looking to replace psychotherapy. But she thinks yoga could provide an alternative or serve as an additional treatment. Yoga helps people learn to regulate their emotions through their bodies, rather than through their thoughts and memories.

At the Emory Healthcare Veterans Program, yoga is offered to participants as a valuable general practice, though not as a specific treatment for PTSD.

Virtual reality therapy also is among the treatments offered to veterans in the program with military sexual trauma-related PTSD. According to research conducted by Rothbaum’s team, virtual reality therapy holds promise for providing relief for veterans grappling with this particularly difficult set of experiences.

Kelly’s work at the VA serves as a reminder of how important skilled nurses and nurse scientists are for veterans’ healthcare nationwide.

Emory is one of 18 U.S. nursing schools competitively chosen by the Department of Veterans Affairs to participate in the VA Nursing Academic Partnership for undergraduate nursing students and graduate nurse practitioner students.

The program trains nurses to understand the unique and often chronic issues within the veteran population. Lisa Muirhead, associate professor of nursing at the Nell Hodgson Woodruff School of Nursing, serves as principal investigator for both programs. “I’ve been most inspired by the willingness that veterans have shown to share their stories with our nursing students,” she says. “I’m also inspired by the growing interest in caring for veterans that our students express as they are immersed in the provision of veteran-centered care.”

Since its launch in 2013, the VA Nursing Academic Partnership program has graduated more than 100 nursing students. More than 20 graduate nurse practitioner students have graduated since 2015, the start of the graduate arm of the program.

Muirhead says training programs like these are making meaningful change, helping build a robust nursing workforce capable of addressing the complex needs of veterans. “It’s essential that schools of nursing integrate veteran-centered concepts within their curriculum,” she says. “Our nation’s heroes deserve no less.”

Georgia State Representative Josh Bonner also toured the Emory Healthcare Veterans Program as part of a legislative visit and has a personal perspective on the importance of its work.

“It is clear that Emory is all-in for our warrior community,” he says. “As a 23-year Army veteran, I encourage all of my brothers and sisters in arms to consider reaching out in your time of need.”

There’s a lot that being in the military can and does prepare you for, says Banik, the Marine veteran:

“But they can’t teach you how to deal with the outcomes of war or what you might see in wartime situations. I want my fellow veterans to know that help is possible. Mental health is possible.

For her part, Army veteran Baker credits the Emory team with introducing her to additional veteran service organizations after she graduated from the program. She now volunteers with The Mission Continues in her Virginia hometown. When asked how she feels about the military today, she fights back tears.

“It’s a double-edged sword,” she says. “I will never love anything like I loved the idea of the military. Some days I think I will never love anything that much again. But I can’t go back. I have to move on.”

By Stacia Pelletier