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By Sarah Bruyn Jones | The Roanoke Times | 981-3264

IT'S KNOWN AS BUILDING 168.

It is a sterile, single-story brick government office building where bright fluorescent lights shine down on white tile floors.

But for Debbie Camicia and other veterans who visit the Veterans Affairs Medical Center in Salem, both the physical building and what goes on inside are noteworthy.

"It's a big improvement," said Camicia, who served in Iraq seven years ago. "My relaxation class is so much better because of the setting. ... And you're away from the general population. ... There are not eyeballs on you looking at you all funny."

Amid the lingering stigma that many still associate with post-traumatic stress disorder and the growing demand for services tied to 10 years of war, Building 168 stands as an answer.

The $1 million facility opened in December to house the Center for Traumatic Stress, the outpatient therapy arm for veterans who need treatment for PTSD and related anxiety and mental health disorders.

And as Camicia points out, it is tucked away from the tangle of cars, people and buildings aimed at serving more than 112,500 veterans in a 26-county area of Southwest Virginia.

About 8 percent of the general population has PTSD, first defined by the American Psychiatric Association as a clinical diagnosis in 1980. Cases are tied to rape, car crashes, fires, earthquakes and other traumatic events.

But among combat veterans, PTSD is far more common.

Studies show that 20 percent of veterans who return from the wars in Iraq and Afghanistan are diagnosed with PTSD. Half of Vietnam veterans who served in high combat zones are said to have it.

The Salem center illustrates the dramatic improvements made in access to treatment over the past 15 years.

"We have started treating more and more people," said Dr. Frank Ochberg, a professor at Michigan State University and one of the psychologists who wrote the definition of PTSD for the APA. "We're now trying to meet the needs, where before people didn't have a place to go."

That means more buildings like 168 in Salem and more people trained to lead group therapy sessions. There also have been strides in standardizing the treatment for PTSD to meet the needs of the masses.

But challenges remain.

Ochberg and others argue that more research and understanding are needed.

"I don't see any tremendous breakthrough in progress from those specific techniques that are being used," he said.

Plus, PTSD hardly ever exists by itself. Typically, veterans struggling with PTSD also have other related diagnoses — substance abuse, depression or even mild brain injury — that make treatment complicated.

And not everyone who needs treatment is willing to seek it.

"It is still one of the least respected wounds of war, and it is pervasive," Ochberg said, pointing to the fact that medals are given to troops who come home with a missing limb — but not to those who have PTSD. "It is a very honorable wound of war. It means you've been right there when your buddy died."

A dedicated team

The development of the Center for Traumatic Stress was the culmination of a series of small changes the Salem VA has made over the past decade.

First, the VA hired an expert in treating victims of rape and sexual assault. As that program grew, the needs of veterans facing any trauma, not just sexual ones, were crystallizing. Instead of lumping veterans needing outpatient PTSD treatment in with all other mental health diagnoses, the Salem VA sought to create a team of specialists who would focus on PTSD.

Additionally, as the wars in Afghanistan and Iraq continued, there was a growing recognition that more had to be done to help the nation's warriors address their mental health needs related to combat.

"At the time, we were facing the post-9/11 wars and were aware of the limited resources we had," said Dana Holohan, who was hired to create the military sexual assault program at the Salem VA and now is the director of the Center for Traumatic Stress. "And we were already anticipating a new generation of veterans who were likely to experience a significant amount of trauma."

Six years ago, the Salem VA received $432,000 to hire that first team of therapists dedicated to treating PTSD in an outpatient setting. The move set the Salem campus apart from its peers nationwide and is one reason it prides itself on being a leader in the treatment of veterans with this fairly new disorder.

As the center grew, and the number of veterans seeking care increased, the center sought its own space, which led to the opening of Building 168.

Today nine clinicians work with more than 700 new patient referrals a year and treat about 350 veterans a month.

"You can call any time to be seen," said James Lugamira, a Roanoke veteran who participates in weekly group treatment for PTSD. "Before, it could take you five months to get in. Now you can just walk into Building 168 and see a doctor if you need to."

In the year since the building opened, Holohan has focused on creating more therapy programs and building the research component that could lead to advancements in treatment. The center already has doubled its evening classes to accommodate schedules of working veterans, and it's setting up ways to make more use of video chatting so veterans can talk to a therapist, or a group, from a location closer to home.

The center is just one of the ways the Salem VA reaches veterans with mental illness. A total of 30 psychologists and 24 psychiatrists treat veterans at the Salem campus, which also has a newly renovated 13-bed inpatient unit dedicated to treating PTSD.

Last year, 169 veterans were treated in the six-week inpatient program, and the waiting list can be months long, said Jerry Gilmore, associate chief of clinical services for mental health at the Salem VA.

"I think we're getting stronger, and over time patients have more choices so we can reach more people," Holohan said.

Managing anger, overcoming fear

Camicia has learned to take deep breaths.

It's one of the relaxation techniques she's learned during therapy at the VA to help her relax and manage her PTSD.

"You get upset or something ticks you off," she said. "Instead of going ballistic, you sit back and … " She inhales and slowly exhales, eyes closed, shoulders sinking.

She relies on the relaxation techniques daily. But sometimes she forgets.

"Someone will open up their pie holes, especially teenagers, and say something stupid that offends me," she said.

This summer, an altercation with a restaurant owner left her realizing she hadn't managed her anger. She had just finished exercising and was hungry. She went to a restaurant within walking distance of her southwest Roanoke home. When she realized she didn't have any money, she asked the owner if she could eat and then return with cash.

He said no.

She cussed him out.

"I need to forget it and move on," she said a few weeks after the incident. "I think it is because of my pride. I think it was partly my fault, so I take responsibility for that."

Part of the treatment for PTSD is teaching veterans anger management and relaxation, Holohan said.

The center also holds classes for an array of other coexisting issues — sleep disorders, stress, depression, social phobia — and it reaches out to family members with classes, including one that runs over 15 weeks to help couples communicate.

Sometimes veterans are referred to services outside the center.

"We want to treat the trauma first, if appropriate, but there are cases, safety issues, where we have to address those other things first," Holohan said. Veterans who are suicidal or homicidal or have psychotic disorders have to deal with those serious threats before they can begin to tackle the root of their PTSD, she said.

Treatments at the center can range from retelling the story of the traumatic memory to specific homework assignments that deal with overcoming a fear.

For a veteran who has trouble stopping at stop signs — because in war if you stop you die, an easy target for the enemy — the assignment could be as simple as getting in a car, driving to the nearest stop sign, and sitting there, stopped, until the fear passes.

Sometimes therapies are first about recognizing the things that trigger the intense memories, and later confronting those situations when doing so can be done gradually and safely.

Many veterans avoid crowds and fireworks.

Camicia avoids Covington.

She used to drive through the city on her way to West Virginia to see family. But after she returned from Iraq, she swore she smelled dead bodies every time she passed through. The odor would send her back to 2004, when her Army Reserve military police unit was stationed at Abu Ghraib and she had to pick up body parts of detainees killed in an attack.

Logically, she said, she realizes the smell was likely from the paper mill, but for her it was the intense smell of death.

Options for treatment

As VA campuses across the nation have sought to meet the growing demands for PTSD treatment, processes have become standardized.

Two therapy approaches have emerged as the most popular: cognitive processing therapy and prolonged exposure.

While both revolve around the traumatic event, cognitive processing requires the person to talk about the impact of the trauma, and prolonged exposure involves describing the event repeatedly and in detail.

Cognitive therapy aims to retrain a person's way of thinking about the traumatic memory. For instance, Holohan said veterans often will blame themselves for things that were out of their control, like the death of a friend.

"By reteaching them how to think about an event, the guilt goes away and the self-hatred goes away," she said.

The stop sign exercise is an example of prolonged exposure, which teaches veterans to confront situations that are safe but that may have some connection to an earlier trauma.

But there is ongoing debate over whether mass-produced therapies are the best methods.

"The research has focused on techniques that can be taught. It's useful, but it is not the same as meeting one on one with someone older and wiser who has seen many cases," Ochberg said.

Holohan said the center provides individual treatment plans for each veteran, and one-on-one therapy sessions are still available when a group setting isn't appropriate.

"We want what is best for addressing the problems they are having," she said. "We are also respecting the veteran's time. … If there is a more efficient way for a veteran to have treatment, then we do that."

Ochberg said the danger in looking for efficient ways to reach many veterans is that each patient's struggles are unique.

"There has been considerable improvement in education, training and finding a tool kit to help, but you can't have any quick course here that says this is exactly how you do it," he said.

Ochberg said more professionals need to be trained in this specialized field.

Holohan is well aware of the training needs. Medical residents in psychiatry, and psychology interns and fellows come through the center's doors regularly, learning skills and working with patients.

For patients looking for a steady relationship with a therapist, that turnover can be difficult.

Sarah Bonner, 31, is an Air Force veteran of the Iraq war who has struggled to find a therapy program that works for her.

Her first therapist argued with her, she said, telling her she wasn't depressed and didn't need help.

"I kept saying, 'I know I'm not right; I need help,'?" Bonner, who served from 2004 to 2006, recalled. "I was crying a lot. Sleeping too much or not sleeping at all. I was overwhelmed and she was telling me I'm fine, I'm not depressed."

She found someone else at the center to talk to. They clicked.

But three months later, the therapist left.

Retired National Guardsman Ken Asbury has considered participating in the VA's prolonged exposure therapy, but, like many veterans, he prefers hashing out his issues with fellow soldiers rather than someone with a Ph.D. who's never been in combat.

So Asbury, 52, attends weekly group sessions at the Roanoke Vet Center in Old Southwest, where he participates in behavior therapy called Seeking Safety. He learns coping skills — such as not blowing up in the Lexington Walmart, as he did recently when he couldn't find a particular brand of frozen pretzels. He also meets quarterly with a VA psychiatrist who re-evaluates his antidepressant and anti-anxiety medications.

"The therapy and medication work pretty good," he said. "But when I get mad, I still get really mad, where I don't know what I'm saying or doing."

The no-show phenomenon

A small note hangs in the waiting room of the VA's Center for Traumatic Stress:

"No shows hurt all veterans," the sign begins — underlined, boldfaced and in all capital letters.

"There is no reason for a no show," it ends. "Thank you for helping us help you."

But the sign isn't always effective.

"Some are quite hesitant," Holohan said. "They come in once and then go away. We don't see them again, and we don't always know why."

The overall no-show rate for PTSD therapy appointments nationally is about 10 percent, and Holohan said she has no reason to believe the Salem VA's rate is any different.

No-shows tend to improve as a veteran becomes more engaged, so it is more likely that a new patient will skip an appointment, Holohan said.

The no-show rate for a post-deployment clinic for veterans returning from Afghanistan and Iraq is about 40 percent, said Shelby Assad, the program manager for those veterans.

"Part is they think they're well and some probably are well, and some may not be doing so well but aren't ready to acknowledge it," Assad said. "That's who we worry about."

The Salem center is studying the no-show phenomenon, including looking at whether there are differences between veterans of Iraq and Afghanistan and veterans of Vietnam.

The reasons for skipping appointments vary, but veterans and VA officials say the rural geography of Southwest Virginia is often a factor.

Asbury knows the hourlong drive between Lexington and Salem.

For Bonner, the distance between Lynchburg and Salem ultimately led her to stop going to appointments because she couldn't miss any more work.

Holohan said she has patients who travel three hours each direction to see her.

Addressing the challenge of distance is a priority for the VA and veteran advocates, such as the Virginia Wounded Warrior Program, a state-run organization that helps veterans with PTSD and brain injuries.

The VA reimburses some veterans for travel, and Wounded Warrior is testing a program in the eastern part of the state that uses volunteers to drive patients to appointments.

The VA has emphasized its rural community centers in places such as Danville, Wytheville and Staunton. Those sites, which offer primary care and mental health services, also connect patients to the Salem offices through video chatting.

Wounded Warrior recently hired more caseworkers — going from two to 10 — to connect veterans in remote areas of Southwest Virginia to services.

"We needed the people on the ground ready to help," said Lisa Yost, who coordinates programs for Wounded Warrior in Southwest Virginia. "And we needed them in the rural communities where veterans often felt isolated."

Money to hire the new resource specialists, whose job is to connect veterans to community resources, came from a federal grant aimed at rural health ­outreach. Yost said a 2010 study that pointed to gaps in services in Southwest Virginia was a major factor in securing the $900,000, three-year grant.

The 2010 study found that veterans in this part of the state, when compared with those in other regions of the commonwealth, had the highest percentage of PTSD, the highest level of substance abuse and the highest rates for mental health treatment.

And, according to the report, which was conducted by Virginia Tech's Institute for Policy and Governance for the Wounded Warriors program, veterans in Southwest Virginia were the most frequent users of VA medical care.

'We still have stigma'

But advocates and veterans say that stigma remains the biggest challenge facing PTSD treatment — both in society at large and within the military.

Jamie Thurman, who served with Asbury in Afghanistan in 2004 and 2005, doesn't have a PTSD diagnosis. And he doesn't entirely understand why others who saw less combat than he did received the diagnosis.

He questions whether some veterans are taking advantage of a system that pays out monthly disability checks for something that is unseen.

"I have it — hell, I think everybody has it," he said of PTSD. "It is just a varying degree of how you function with it. Everyone has the stain of war. You don't do what we did and not change. That's just part of war. War changes a man."

Ochberg emphasized that every veteran does not have PTSD, but he said combat veterans without the disorder can still be deeply affected by war.

"I think there is a general vulnerability in some people, and I think it depends on the level of exposure a person has to traumatic events," he said of PTSD. "It is an injury to a fairly delicate function of the brain."

And Thurman acknowledges that some people do struggle more with PTSD and depression than others. He has seen it in Asbury.

"You never know what's going to happen to a person once he sees war," Thurman said. "You can't predict it."

Some veterans go out of their way not to be diagnosed with PTSD. When asked about symptoms, they give answers that they know will avoid a diagnosis.

That's what Andrew Smith initially did.

"You know which boxes to check," he said. "Before I came back from Iraq, I had to fill out paperwork and I was afraid to be honest on any question. I didn't want to restrict my options, so I answered them all generically."

But ultimately Smith, who earned a purple heart for his service in Iraq, said he realized that it was his duty to acknowledge he needed help.

"I get it. You see the downside of not getting treatment. My generation owes it to society because it's available to us," said Smith, 29. "I look at the Vietnam generation and see the toll PTSD took, and they didn't have what I have access to. ... I feel a responsibility to seek out treatment."

Yost said one way they've tried to fight stigma — and to better connect generally to veterans in the region — has been to embrace the military culture.

Wounded Warrior employees all have some connection to the military. Yost's brother and father are veterans.

There is a need for that military connection, Yost said, because there are no nearby military bases, and many of the area's veterans are retired from the National Guard or Army Reserve.

Plus, she said, the stigma against seeking help is best understood by those who know the military.

"Veterans do not ask for help," she said. "It's not part of who they are. They are used to doing things for others, serving their country."

Some veterans say they've seen improvements in putting aside the stigma.

"It used to be you wouldn't find a veteran complaining about not having a psych doctor," Lugamira said. "Now they're available, and with all the emphasis on getting them help, the stigma has really lessened in the last year."

He specifically credits the opening of Building 168.

"It's a normal thing now to say you're going to 168, or to say, 'I'm going to see my psych doctor.' I used to feel bad about it before, but now I'm more comfortable, too."

But when it comes to the general public's understanding of PTSD, more needs to happen, Ochberg said.

"We still have stigma," he said. "We need to do a major national campaign to de-stigmatize PTSD similar to what has happened for breast cancer."

Ochberg said he has had discussions about a purple bat day for major league baseball, replicating the pink bat day on Mother's Day in May.

"All it takes is one person saying, 'Oh, get over it,'" he said.

'Tools to treat themselves'

Getting over PTSD is not the goal.

The goal, Holohan said, is to get veterans to a point that they don't need ongoing treatment.

"Our clinic embraces the idea of time-limited treatment," she said. "Our goal is to treat the veterans by giving them the tools to treat themselves."

About a third of people with PTSD continue to have some symptoms, according to the National Center for PTSD run by the U.S. Department of Veterans Affairs. For them, the goal is to cope with the symptoms so they no longer interfere with everyday activities, work and relationships.

Some treatments last a few sessions; others, a year.

Holohan said that after a veteran completes a treatment program, he or she can take refresher courses. Stress associated with life changes — such as divorce, job loss or news events — can conjure up familiar symptoms in those who had been doing well, Holohan said.

In many ways, Smith represents the outcome that Holohan and others would like to achieve with the veterans they treat for PTSD.

He continues to deal not only with his PTSD but also with the other consequences of a 2003 roadside bomb. The blast sent shrapnel ripping through his left knee and has left him with migraines, short-term memory retention problems and vertigo, all from a mild traumatic brain injury.

He still has nightmares related to his PTSD where he ends up pulling his sleeping wife from their bed to the center of the room and throwing himself on top of her. But he has learned to control many of the symptoms that he couldn't when he was first diagnosed.

"I was angry a whole lot," he said. "I lost my filter not to run my mouth."

Smith, who now lives in Pilot with his wife and two kids, sought help early and soon was diagnosed with PTSD.

He has built a community support system for himself that relies heavily on his wife as a buffer and on helping others through his church and other nonprofits aimed at assisting veterans.

But he still has to remind himself on occasion to check his anger.

For Smith, one-on-one therapy helped more than group classes did.

"It was the same person all the time, and I stuck with that long enough to make a difference," he said.

But he said group therapy taught him he wasn't alone.

"When you're in war, everything is life and death. The smallest thing can kill you," Smith said. "I guess over time I've realized that everything isn't life and death in the civilian world. I've learned to see that."

Staff writer Beth Macy contributed to this report.

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