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Ignoring PTSD Crisis at Home: Americans Shot and Stabbed In Their Own Neighborhoods

| February 9, 2014

But will the fuller diagnosis detect PTSD? (Airman Magazine)

But will the fuller diagnosis detect PTSD? (Airman Magazine)

Chicago’s Cook County Hospital has one of the busiest trauma centers in the nation, treating about 2,000 patients a year for gunshots, stabbings and other violent injuries.

So when researchers started screening patients there for post-traumatic stress disorder in 2011, they assumed they would find cases.

They just didn’t know how many: Fully 43 percent of the patients they examined – and more than half of gunshot-wound victims – had signs of PTSD.

“We knew these people were going to have PTSD symptoms,” said Kimberly Joseph, a trauma surgeon at the hospital. “We didn’t know it was going to be as extensive.”

What the work showed, Joseph said, is, “This is a much more urgent problem than you think.”

Joseph proposed spending about $200,000 a year to add staffers to screen all at-risk patients for PTSD and connect them with treatment. The taxpayer-subsidized hospital has an annual budget of roughly $450 million. But Joseph said hospital administrators turned her down and suggested she look for outside funding.

“Right now, we don’t have institutional support,” said Joseph, who is now applying for outside grants.

A hospital spokeswoman would not comment on why the hospital decided not to pay for regular screening. The hospital is part of a pilot program with other area hospitals to help “pediatrics patients identified with PTSD,” said the spokeswoman, Marisa Kollias.“The Cook County Health and Hospitals System is committed to treating all patients with high quality care.”

Right now, social workers try to identify patients with the most severe PTSD symptoms, said Carol Reese, the trauma center’s violence prevention coordinator and an Episcopal priest.

“I’m not going to tell you we have everything we need in place right now, because we don’t,” Reese said. “We have a chaplain and a social worker and a couple of social work interns trying to see 5,000 people. We’re not staffed to do it.”

A growing body of research shows that Americans with traumatic injuries develop PTSD at rates comparable to veterans of war. Just like veterans, civilians can suffer flashbacks, nightmares, paranoia, and social withdrawal. While the United States has been slow to provide adequate treatment to troops affected by post-traumatic stress, the military has made substantial progress in recent years. It now regularly screens for PTSD, works to fight the stigma associated with mental health treatment and educates military families about potential symptoms.

Few similar efforts exist for civilian trauma victims. Americans wounded in their own neighborhoods are not getting treatment for PTSD. They’re not even getting diagnosed.

Studies show that, overall, about 8 percent of Americans suffer from PTSD at some point in their lives. But the rates appear to be much higher in communities – such as poor, largely African-American pockets of Detroit, Atlanta, Chicago and Philadelphia – wherehigh rates of violent crime have persisted despite a national decline.

Researchers in Atlanta interviewed more than 8,000 inner-city residents and found that about two-thirds said they had been violently attacked and that half knew someone who had been murdered. At least 1 in 3 of those interviewed experienced symptoms consistent with PTSD at some point in their lives – and that’s a “conservative estimate,” said Dr. Kerry Ressler, the lead investigator on the project.

“The rates of PTSD we see are as high or higher than Iraq, Afghanistan or Vietnam veterans,” Ressler said. “We have a whole population who is traumatized.”


“The rates of PTSD we see are as high or higher than Iraq, Afghanistan, or Vietnam veterans.”

Post-traumatic stress can be a serious burden: It can take a toll on relationships and parenting, lead to family conflict and interfere with jobs. A national study of patients with traumatic injuries found that those who developed post-traumatic stress were less likely to have returned to work a year after their injuries.

It may also have a broader social cost.  “Neglect of civilian PTSD as a public health concern may be compromising public safety,” Ressler and his co-authors concluded in a 2012 paper.

For most people, untreated PTSD will not lead to violence. But   “there’s a subgroup of people who are at risk, in the wrong place, at the wrong time, of reacting in a violent way or an aggressive way, that they might not have if they had had their PTSD treated,” Ressler said.

Research on military veterans has found that the symptom of “chronic hyperarousal” – the distorted sense of always being under extreme threat – can lead to increased aggression and violent behavior.

“Very minor threats can be experienced, by what the signals in your body tell you, as, ‘You’re in acute danger,’ ” said Sandra Bloom, a psychiatrist and former president of the International Society for Traumatic Stress Studies.

Another issue, wrote researchers at Drexel University, is that people with symptoms of PTSD may be more likely to carry a weapon in order to “restore feelings of safety.”

Hospital trauma centers, which work on the front lines of neighborhood violence, could help address the lack of treatment. Indeed, the American College of Surgeons, which sets standards for the care of patients with traumatic injuries, is set to recommend that trauma centers“evaluate, support and treat” patients for post-traumatic stress.

But it’s not a requirement, and few hospitals appear to be doing it.


ProPublica surveyed a top-level trauma center in each of the 22 cities with the nation’s highest homicide rates. Just one, the Spirit of Charity Trauma Center in New Orleans, currently screens all seriously injured patients for PTSD. At another, Detroit Receiving Hospital, psychologists talk with injured crime victims about PTSD.

Other hospitals have a patchwork of resources or none at all. At two hospitals, in Birmingham, Alabama and St. Louis, Missouri, trauma center staff said they hope to institute routine PTSD screening by the end of the year.

Doctors in Baltimore, Newark, Memphis, and Jackson, Miss., said they wanted to do more to address PTSD, but they do not have the money.

They said adding even small amounts to hospital budgets is a hard sell in a tough economic climate. That’s especially true at often-cash-strapped public hospitals.

In order to add a staff member to screen and follow up on PTSD, “Do I lay someone else off in another area?” asked Carnell Cooper, a trauma surgeon at Maryland Shock Trauma in Baltimore.

Many public hospitals rely on state Medicaid programs to cover treatment of low-income patients. But several surgeons across the country said they did not know of any way they could bill Medicaid for screenings.

The federal government often provides guidance to state Medicaid programs on best practices for patient care and how to fund them. But a spokeswoman for the Centers for Medicare and Medicaid Services said the agency has given states no guidance on whether or how hospitals could be reimbursed for PTSD screenings.

Hospitals are often unwilling to foot the bill themselves.

Trauma surgeons and their staffs expressed frustration that they know PTSD is having a serious impact on their patients, but they can’t find a way to pay for the help they need.

“We don’t recognize that people have PTSD. We don’t recognize that they’re not doing their job as well, that they’re not doing as well in school, that they’re getting irritable at home with their families,” said John Porter, a trauma surgeon in Jackson, Miss., which has a per-capita homicide rate higher than Chicago’s.

“When you think about it, if someone gets shot, and I save their life, and they can’t go out and function, did I technically save their life? Probably not.”

When RAND Corp. researchers began interviewing violently injured young men in Los Angeles in the late 1990s, they faced some skepticism that the men, often connected to gangs, would be susceptible to PTSD.

“We had people tell us that we’d see a lot of people who were gang-bangers, and they wouldn’t develop PTSD, because they were already hardened to that kind of life,” said Grant Marshall, a behavioral scientist who studied patients at a Los Angeles trauma center. “We didn’t find that to be the case at all. People in gangs were just as likely as anyone else to develop PTSD.”

In fact, trauma appears to have a cumulative effect. Young men with violent injuries may be more likely to develop symptoms if they have been attacked before.

The Los Angeles study found that 27 percent of the men interviewed three months after they were injured had symptoms consistent with PTSD.

“Most people still think that all the people who get shot were doing something they didn’t need to be doing,” said Porter, the trauma surgeon from Jackson, Miss. “I’m not saying it’s the racist thing, but everybody thinks it’s a young black men’s disease: They get shot, they’re out selling drugs. We’re not going to spend more time on them.”

While post-traumatic stress often does not show up until several months after an injury, experts say many trauma centers are missing the chance to evaluate patients early for risk of PTSD and to use clinical follow-ups – when patients come back to have their physical wounds examined – to check if patients are developing symptoms.

Doctors say hospitals are unlikely to make significant progress until the American College of Surgeons makes systematic PTSD screening a requirement for all top-level trauma centers.


“If someone gets shot, and I save their life, and they can’t go out and function – did I technically save their life? Probably not.”

An ACS requirement would be “a much better hammer to show the administration,” said Michael Foreman, chief of trauma surgery at Baylor University Medical Center in Dallas. Baylor, one of the few trauma centers to have a full-time psychologist on staff, surveyed 200 patients and found that roughly a quarter experienced post-traumatic stress. But Foreman said the center would not systematically screen all its patients until the ACS mandates it.

It’s not clear when that will happen. The organization’s recognition of PTSD screening as a recommended practice is a first step. Those new guidelines will be released in March 2014, according to Chris Cribari, who chairs the subcommittee that evaluates whether hospitals are meeting ACS standards. Cribari declined to say when PTSD screening might become a requirement. He said the timing will depend on what hurdles hospitals encounter – such as patient privacy – when some of them start screenings.

Cribari acknowledged that at some hospitals, “unless it’s a regulation, they’re not going to spend the money on it.”

At minimum, experts say, hospitals should provide all trauma patients with basic education about post-traumatic stress.

“The number one thing we do,” is simply “tell everybody in the trauma center about PTSD,” said John Nanney, a Department of Veterans Affairs researcher who developed a program for violently injured patients at the Spirit of Charity in New Orleans.

Without education about symptoms, patients who have flashbacks or constant nightmares may have “these catastrophic beliefs” about what is happening to them, Nanney said. “Just say, ‘This is something you might notice. If you do notice it, it doesn’t mean you’re going crazy. It doesn’t mean you’re weak. This is something that happens—don’t freak out.’ ”

 

The city of Philadelphia has begun to focus on trauma as a major public health issue. Philadelphia is working with local mental health providers to screen for PTSD more systematically – and to focus on post-traumatic stress as part of drug and alcohol treatment. The city has also paid to train local therapists in prolonged exposure, a proven treatment for PTSD– the same kind of training the U.S. Department of Veterans Affairs has paid for its therapists to receive.

For violently injured Philadelphia residents, there’s also Drexel University’s Healing Hurt People, a program that’s become a national model for addressing trauma and PTSD.

Healing Hurt People reaches out to violently injured adults and children at two local hospitals and offers them intensive services. The program accepts a broad range of patients — from high-schoolers to siblings of young men who have been shot to former drug dealers. (One of Healing Hurt People’s clients talked about his post-traumatic stress in 2013 on This American Life.)

The program’s social workers screen all clients for PTSD symptoms and host discussions in which clients can share their experiences with one another. It’s a way of fighting stigma around mental-health symptoms. Instead of thinking that they’re going crazy, the conversations help them realize, “OK, this is normal,” as one client put it.

One of the program’s central goals is to discourage victims of crimes from retaliating against their attackers and to help them focus on staying safe and rebuilding their own lives.

The program’s therapists and social workers remind clients that the aftereffects of trauma may make them overreact and help them plan how to identify and avoid events that might trigger them. In one discussion last fall, a therapist sketched a cliff on a whiteboard, with a stick man on the top, close to the edge. The question: How do you recognize when you’re getting close to the cliff edge—and learn to walk away?

“Our thing is education,” social worker Tony Thompson said. The more clients “understand what’s going on in their body and their mind, the more prepared they are to deal with it.”

Intensive casework like this has shown good results, but it’s not cheap. Healing Hurt People is relatively small: Its programs served 129 new clients in 2013 and offered briefer education or assistance to a few hundred more. Its annual budget in 2013 was roughly $300,000, not including the cost of the office space that Drexel donates to the program.

Other researchers have been working to develop quicker, more modest interventions for PTSD, including some that use laptops and smartphones—programs that could easily be extended to more patients and still have some positive effect.

Whatever the approach, there “is untapped potential,” said Joseph, the surgeon at Chicago’s Cook County Hospital. Healing Hurt People is a model for what she wants to create. “These are kids, for the most part. When a 17-year-old kid crashes their parents’ car, and they were drinking, we don’t say, ‘Oh, that kid’s hopeless, let’s just give up on them.’ ”

“We’ve certainly had decades of trying to apply political solutions and social solutions to our inner cities’ financial problems and violence problem, and they haven’t been successful,” said Ressler, the Atlanta researcher. “If we could do a better job of identification, intervention and treatment, I think there would be less violence, and people would have an easier time doing well in school, getting a job.”

–Lois Beckett, ProPublica

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11 Responses for “Ignoring PTSD Crisis at Home: Americans Shot and Stabbed In Their Own Neighborhoods”

  1. happening now says:

    Its about time!!!

    • Jeff Eastman says:

      “PTSD is not just caused by military combat.

      It happens in life all the time caused by severe emotional trauma.”

      Most soldiers AND civilians with PTSD symptoms never seek treatment.

      Similar to EMDR, an anonymous online computer therapy program for PTSD at PTSDSTRESS.COM reduces the symptoms of PTSD. Developed in part by a National Institute of Health PTSD researcher, the user follows an easy-to-use program on their home computer. There is no registration required.

      The cost is $10 per session and accepts credit cards but does not require a cardholder name for further anonymity and confidentiality. Military and non-military men and women users including victims of trauma like sexual assault report results on PTSDSTRESS.COM home page.

  2. Steve Wolfe says:

    “When you think about it, if someone gets shot, and I save their life, and they can’t go out and function, did I technically save their life? Probably not.” Absurd. Of course the surgeon has saved a life. If the surgeon is referring to his commitment to the whole person, and he believes that he has simply revived a zombie, then perhaps it is the surgeon who is having trouble coping. He did his job.

    That said, I do believe this syndrome exists. When I think about someone who has been attacked, stabbed, shot, or raped, I can well appreciate that there can be natural psychological responses, and those deserve treatment if indicated–hopefully not just pharmaceuticals. I fear, though, that once identified, victims will become further victimized by the health system itself, which could flag them in records that will then prohibit them from getting the self protection they seek, such as a firearm, or a job, or anything else I haven’t imagined. They could be pegged as a new class of “undesirables,” people with stigma attached to them on top of the trauma they already faced, which could inhibit them from moving forward in life. Then, of course, once another well-intentioned government fixit goes wrong, as a new class of victim is further victimized, the government will raise its hand to say, “I can fit that, too! All we need is another multi-million dollar annual budget (increasing annually, of course), a new tall, non-descript glass building in Northern Virginia, and about 10,000 more bureaucrats, and our own database in a pear tree.” Pure and simple self-perpetuating government goo.

    So, I am confident that funding will be found, since health care has a new partner in the government, which is always looking for reasons to increase funding to itself, and another victim designation is all they need to build another bureaucracy, which will then have to have its own multi-million dollar annual budget, and will never go away. But yes, these people are truly victims, and they may have suffered psychological harm that manifests in anti-social behavior at any point in the future. But all sorts of terrible things happen in life, and a government program could well sprout for any circumstance we may encounter. Should we have government mandated counseling when a loved one passes? What about the trauma of a vehicular accident? What about simply viewing a deadly crash at a NASCAR race? Having your taxes audited? Falling off a ladder? Losing the lottery? Dropping a carton of eggs in the kitchen? Ruining a new pair of socks?

    Yes, that was intentionally absurd. I wanted to highlight the way the government acts. Perhaps there should first be a search for private funding for each trauma center’s own PTSD initiative, which would create an environment for innovation in the many separate endeavors. Government will just muck it up, because the government will create a “one size fits all” program based on a bunch of nonsensical bureaucratese. Such private funding should be supplemented by labor performed by criminal aggressors (imagine that). When victims suffer consequences of trauma from aggressors, the aggressors should suffer consequences besides incarceration, which does little to compensate their victims. I know, that sounds like an ACLU lawsuit charging “cruel and unusual punishment.” I ask, was there anything “kind and ordinary” about their attack? If justice sounds cruel, just smoke another bowl in front of the TV, while you wait for the government program to treat PTSD for freaking out over criminals actually paying for what they did.

  3. Outsider says:

    I am so glad the left is here to straighten these things out for us. On the one hand, if anyone is shot for any reason in the state of Florida, it is because of those xenophobic, racist, conservative Tea Party members coupled with the Stand Your Ground law. If someone is shot in the inner city of Chicago, it is because of the lasting effects of the can of whoop ass the perp’s mother opened up on him when he was four for breaking her favorite vase. This lead to the condition normally associated with soldiers who witnessed the most horrific events war can dish out, thus making the abhorrent act of the perpetrator no less acceptable, but certainly understandable. Thank you for clearing that up.

  4. A.S.F. says:

    @Steve Wolfe says–Obviously, you have never worked in the Mental Health field. First of all, PTSD most certainly DOES exist and, if there are ‘prejudices” against it that keep people from seeking treatment, it is part and parcel of the same stigma that exists as pertains to all Psychiatric Diagnoses. Thanks to Obamacare (I know you are not a fan), insurers will no longer have the luxury of cherry-picking which psychiatric services they will deign to pay for, if they deigned to pay for them at all. It stands to reason that people with acute PTSD should not be around firearms. They are much more likely to be victims of suicide, homicides and even accidents. People with PTSD run the entire spectrum, as far as functioning is concerned, and their fitness for work should be determined on a case by case basis. Forcing someone with an acute Psychiatric Disorder such as PTSD into a stressful work situation before they are ready could be a disaster in the making. Their recovery should be their job, first and foremost–just as would be the case with someone with any other serious medical condition. If the government you despise so much can offer PTSD sufferers protections under the law that might help them through the recovery process, so much the better. Perhaps you should leave this one to the experts.

    • Steve Wolfe says:

      Thank you, Ms. ASF, for your scorn. Now I know I’ve arrived! No, I haven’t checked psychiatry off my bucket list, but your specialty seems to be “heaping scorn.” Sounds painful. I’m sure there will be a program for that soon.

      I did, however, work in the Federal Government for 37 years, and I lived in Northern VA for 57 years. There is an easily recognized pattern to the conduct of the Federal Government. It has always grown incrementally, but in such a diverse manner that no one can keep up with it. It has a life of its own, and it is a monster bent on expanding and consuming. One of the criteria used to justify expansion is “helping people,” which it does by stepping on them. If you went to your doctor for an ingrown toenail, and he told you, “This will only hurt a little, for the rest of everyone else’s life,” would you expect good medicine from him, or run away? That is what we have, and Obamacare is just the latest grotesque limb to pop out of the monster. Too many people think “the government should do it for everybody,” when what they are really getting is, “the government will do it to everyone.” During the 60’s, the “Great Society” was born. The poor people were thrown under the bus first. The monster still has one of its feet on their throats. Then other agencies were born, and one by one, other citizens started getting mowed down. In the name of “care” they come, while what they engineer is control.

      We are all witnesses to this, but I can’t make you see it.

      Each agency is a fiefdom, often run by a political appointee with little or no expertise in the duties of the agency. All of them are structured top-down, so the political orders permeate. Only brown-nosers advance, so the fiefdom is preserved at the expense of innovation, progress, and, oh yes, service. They all have gargantuan budgets to run their agencies, and waste is purely intentional. (Each agency must prove that they spent all their allowance for the fiscal year, or else they will not get an increase the following year, which is actually a sign of failure for an agency head. New furniture, computer systems, training excursions, parties, Star Trek movies, and more employees are but a few of the wasteful tactics used to throw our money overboard.)

      I will voice my opinion, expertise or not. I don’t need your blessing. You should look upon the diversity of comments here as an opportunity for enrichment, so you might understand, rather than scorn, people that you can’t see eye-to-eye with. Everyone has something to offer, and everyone can’t be you. We are not enemies, you and I. If I ever get to meet you, I actually want to hug you first, then sit down and enjoy some of your wit and wisdom. I’m not poison, I’m just another copy of the DNA, like you, only my life took me a different direction then yours did. That’s why we should meet on this journey and share our stories, not snipe at each other from behind a box of wires and circuit boards.

  5. A.S.F. says:

    @Steve Wolfe says–You voiced an opinion, which you are certainly entitled to, but, on this particular subject, your 37 years working for the Federal Government makes you no kind of expert on PTSD. This article was just another opportunity for to bash the hand that apparently fed you for 37 years (and, if you are receiving a pension, continues to feed you.) I feel entitled to correct you because I have a Master’s Degree in Social Work, am licensed as a Certified Social Worker in Clinical Practice and have many years of experience working on a Behavioral Health Unit in an acute Care Hospital. And your expertise in Mental Health Issues would be…?

  6. A.S.F. says:

    @Steve Wolfe–By the way, I agree with you that, when and if we ever meet each other, we would certainly be able to enjoy each other’s company as long as we refrained from discussing politics at the dinner table.

    • Steve Wolfe says:

      I apologize, I must have missed the rules of the comment section opening it only to “experts.”

      I thought that this is an open forum, and that every offering is cleared by Pierre, not you. Or maybe I’m just too stupid to butt out when there is an expert in the room.

      I did succeed in provoking you to attempt to cast a shadow over me with your airy credentials. Will you come back down to earth now, so you can hear little ol’ dummy me? My great aunt held a PhD, but she never spoke down to me. She helped build my mind.

      Now would you re-read what I wrote and remind me what I said that is an attempt at an expert opinion on PTSD? In fact, I glibly offered a validation of the condition sited in the article, then diverted to offer my FEARS of what the government will do with the patient information, based solely on sad history, including recent history. I didn’t attempt a dissertation, and in no way invoked expertise, so get off my back with your blow-hard self aggrandizement. (Sheesh!)

      If we are ever asked to solve the matter written about in the article through the comment section of Flagler Live, I will certainly wait for the oxygen to seep back into the room to be sure you are finished before I utter my layman’s thoughts.

      Also: the hand that fed and continues to feed me is the Taxpayer’s hand, according to a contract they are honoring for my faithful service to them. The government is just the middle man, servicing the contract. I owe NO special allegiance to the Federal Government, and the first amendment covers me as much it as does you. Have you never known the concept that the government is supposed to serve US, and that we are not beholden to it, but quite the other way around (“Rule by consent of the governed”)? Indeed, the Founding Fathers wrote that it is much more healthy when the government fears US, as opposed to the current relationship. That concept has been unraveled thanks to the unchecked growth of the government, and that is most unfortunate for this nation. I don’t understand how you, with your trained and proven intellect, can believe that medicine can serve people better when it is controlled by centralized, bureaucratic, over-grown government. Don’t you still heal people one at a time?

      By the way, with your credentials and experience, why are you spending so much time here? Shouldn’t you be billing me for your time?

      Lastly, I am flattered by your conciliatory final thoughts. Actually, some of my best friends have Master’s. I was only thinking small, like coffee, but you have offered dinner (I like charred flesh). The offer of an introductory free hug stands. (I really think I would like you!) We can talk about the weather at dinner, if you prefer, or jazz (which would put you in MY house). But we MUST at some point discuss politics, say over an after dinner drink. We can “disagree without being disagreeable.” Certainly, you in no way imagine that you would be challenged intellectually by my “Neanderthal’s Conservatism.” Before we part, we will choose our water pistols, loaded with Gran Marnier. At 20 paces….turn, and FIRE! at my gaping maw.

  7. A.S.F. says:

    Boy, I may have a Master’s Degree but YOU really know how to rationalize your thoughts to a crispy turn! I believe you, yourself, stated that you worked for the government for 37 years. I have to wonder how you could stand working for an entity that you appear to distrust and dislike to the degree that you describe in some of your posts. You may feel that you performed your duties for a needy citizenry as the ultimate sacrifice–but, the fact remains, you chose to work for an entity of the US government. And, apparently, you ARE receiving a pension of some sort ( I deduce that from your own rather convoluted inferences.) Call it part of a contract with your fellow citizens, if you want. The fact remains, the big bad government is paying you for services rendered. I find it a little sad that you are so disillusioned that you can find nothing positive to say about it, after all your years of service. What I was take special exception to is your using the very serious problem of PTSD as yet another hammer to chip away at your favorite target–the US government. I take exception to that because I have seen the very real pain that PTSD causes its sufferers and the price it exacts on families and on our society as a whole. I don’t like seeing it reduced to a throwaway “punchline” by a disgruntled Conservative. However, I do like jazz…At least, we seem to have THAT in common!

    • Steve Wolfe says:

      So I guess this means dinner is off?

      Alright, I don’t know how much of this space Pierre is willing to waste on a personal spat. I won’t waste any more time after this trying to convince you that I only wrote what I wrote, not what you keep insisting I wrote. That tactic seems to be right out of Alinsky’s handbook.

      “…I have seen the very real pain that PTSD causes its sufferers and the price it exacts on families and on our society as a whole.” Good grief, I am WITH YOU there. I gave MORE sympathy to the victims of PTSD because I have seen the very real pain caused by the government databases which will be populated with negative impressions of the victims, eventually causing them more harm. Their data mining has nothing to do with improving the quality of victim’s lives. It has to do with justifying more bureaucracy to monitor people whom the government deems “damaged.” We’ve all seen the value of that in the way veterans are treated.

      How do you think it is working to try to shame me for receiving my due? That’s disingenuous prattle. If aspersion is all you got, you lose. “What difference does it at this point make” if I am a pensioner? I EARNED it. They write the checks. Case closed. I’m sorry if that creates a conflict for you.

      I will not be a shill for the Federal Government because I worked on the inside. Your conclusion that I must have been miserable working for an institution that I am critical of is rather presumptuous and immaterial. Critical thinking allows me to be critical of anything. Experience allows me to be sure. If you want me to praise something about the Federal Government, I might come close to that if the issue were the military. There just isn’t as much to praise about a bloated, ever-growing, monolithic monster. I don’t have to goose-step with the rest of the government because I worked there.

      While my vocation was not my greatest passion (my wife is in first place, followed by jazz), my work ethic directed me to perform at my best. My faithful performance has finally resulted in the ability to sit here and yack with you, but I tire of it now.

      If you could not be critical of your own profession, where necessary, then you would be remiss in your duty to your profession. In our discourse over these last several comments, you have revealed a pattern of repeatedly wasting your great mind on aspersions and repetition, with persistence over the irrelevant matter of my pension and your insistence that I wrote something that I didn’t. Now I question whether we could actually have productive conversation, because you attempt to hover above me on your airy credentials, refusing any constructive intellectual process. But politically, you write like a novice, favoring tactics to marginalize your opponent in order to avoid substantive discourse. Get over yourself, mam. The way you have chased me around here, pointing to the splinter in my eye, while oblivious to the telephone pole in your own eye, hasn’t resulted in one bit of support for PTSD victims. For the last time (stop chasing me, stand still, and listen again), I have taken no position counter to the reality of PTSD in civilian experience. I have simply pointed out, based on my observation as a citizen of this nation, the abuse that the victims of PTSD will face at the hands of another bureaucracy. I hope you, the informed, educated health care provider, can be a better source of light to the victims without big brother’s unprofessional interference.

      I have enjoyed our banter as I would speaking with my sister. You can have the last word. I said my piece. I’ll read your reply, so you can be satisfied that your final strike connected. Let’s move on to something else. Maybe we’ll agree on it. I need a beer and a nap now.

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