PTSD-affected war veterans feel isolated and estranged from their communities. Reconnecting with family and faith is a high priority for Native Hawaiian vets. - Photo: Blaine Fergerstrom

By Liza Simon / Ka Wai Ola

When Steve's wife's told him he should be getting help from the military for bringing a hot-headed temper home to Hawai'i from his year of duty in Iraq, the 40-year-old Army Reservist from Hawaiian Homestead land in O'ahu was stunned. Why would he ask the military for help with any kind of problem – let alone one having to do with his emotional well-being? Even when he once had physical injury from a weekend drill in the Army Reserves, he ended up using lā'au lapa'au, which took the place of the military doctor's recommended surgery. Don't let them cut you, the kahuna had told him, because cutting would only “let the pain from outside come inside.”

Steve, who wanted to protect his full identity in KWO, had to admit, however, that the pain of combat in Iraq was hard to keep out of his head. He had just two months to train nine young and raw recruits from a civic affairs background to prepare them for dangerous convoy security detail in Baghdad. In their second of 320 missions in a year, their vehicle was within 100 meters of an explosion that killed Iraqi security force members, leaving “bodies just cut in half, arms and legs everywhere ... just thrown in the trash,” he says, his voice trailing off at the recollection. He returned with the unit to Hawai'i in 2006 – with no injuries to any of his men. For this, he received a Bronze Star award that he shared with the unit members. But several months later, the invisible injuries began to tear open. After waking from a nightmare clutching his chest and beating his fists on the wall, he took his wife's advice, sought help and was diagnosed with post-traumatic stress disorder – known as PTSD.

Five years into the U.S.-led invasion of Iraq, cases like Steve's are a concern to Native Hawaiians and to the nation. Stung by last year's scandalous accounts of mistreated soldiers unable to get the care they need for mental and physical health, Congress enacted policy changes that mandate that soldiers back from Iraq be thoroughly assessed for PTSD and sent to treatment with as few hassles as possible. Veteran eligibility to receive health benefits has also been expanded. But at least one class-action suit filed against the government on behalf of an East Coast veterans group underlines the alleged capriciousness of benefits eligibility.

Ka Wai Ola Cover Story, April 2008 - Photo: Blaine Fergerstrom

Meanwhile, Native Hawaiian health experts are worried that we will see a replay of the Vietnam era when Native Hawaiian vets bore a lot of battle-related trauma. This is according to Hardy Spoehr of Papa Ola Lokahi. In testimony to a U.S. Senate Committee on veterans affairs last year, Spoehr said that half of all Native Hawaiian Vietnam vets were still struggling with mental health problems and unable to get help.

Large numbers of soldiers are expected to return from the Iraq war plagued by PTSD symptoms, including intrusive nightmares and thoughts, avoidance of anything that represents danger and the sleeplessness that comes with feelings of constantly re-experiencing traumatic conflict. Adding to detection problems, PTSD is inherently quirky. A new study shows that returning troops who initially test negative present a different picture within 90 days of deactivation, when there is three-fold increase for screening positive. Complicating treatment, many will likely have mild traumatic brain injury or TBI from concussions that result from frequent car bomb or roadside blasts in Iraq. (TBI and PTSD have similar symptoms but require different treatment, new research shows.)

As Steve's experience illustrates, if left untreated, PTSD can easily disrupt households by triggering domestic stress – raising the likelihood of divorce, job loss, drug use and homelessness. This has troubling implications for tight-knit family-oriented cultures – Native Hawaiians included, which in disproportionately large numbers fill the ranks of the Army Reserves and National Guard engaged in a protracted war.

“These are family men and women in their 40s and 50s who must leave behind children, spouses and careers to go in-country, where the rules of engagement put a bayonet in your hands. You come home and at first it is the honeymoon. But you've been trained as lean, mean killing machine. Now suddenly you're supposed to forget it all. It's not goin' happen that way,” says Clay Park, a case worker for veterans services with the nonprofit Helping Hands Hawai'i.

Former Vietnam combat medic Clay Park knows about PTSD from the inside. This has inspired him to reach out to local vets as a case manager for Helping Hands Hawai'i. - Photo: Blaine Fergerstrom

The need for communities to take action in healing what many see as a community problem has long been a priority for Native Hawaiians. Recommendations given to Congress have also been implemented in collaborative programs for Native Hawaiian veterans. In April, for example, the Native Hawaiian Health Care Systems will present cultural sensitivity training to boost the success of mental-health care providers in the local community.

“If there is one thing we have learned from treating (combat-related) PTSD in recent years, it's the strength of the community and how much that can lead to such a tremendous pain, if the individual shuts it out and how much it means when there is a reconnection,” said Dr. Kenneth Hirsch, manager of the Traumatic Stress Disorders Program for Veterans Affairs in Hawai'i, which includes the only residential PTSD treatment program in the Pacific Basin.

Hirsch was also one of several nationally noted PTSD experts featured last month at a Honolulu conference, where social workers, police, mental heath care providers and military officials came together to discuss ways that community resilience can be used in treating the impacts of stress, violence and trauma.

Despite these efforts, many say that the needs of Native Hawaiian veterans are not being fully met. A major barrier is stigma associated with mental health problems. “Bad enough you've been dealing with the stereotype of wanting to do nothing but eat and sleep all the time. Now you're going to be told that you're crazy,” says case worker Park, a Native Hawaiian who went to Vietnam in 1965 and endured some of the conflict's most intense fighting alongside classmates from Waialua High School.

Vet Centers provide readjustment counseling and keep records strictly confidentiality, but Native Hawaiian victims of PTSD may not bring themselves to walk in, if they are either in denial or feeling distrustful of sharing mental health information.

In fact, health records in the military and the Veterans Health Administration (administratively separate from Vet Centers) are not confidential; certain reports on mental health problems can adversely affect chances for career advancement as well as eligibility for compensation. Park says he has assisted veterans who sought treatment for PTSD, but were instead diagnosed with schizophrenia, which, unlike PTSD, may bring a dishonorable discharge and a denial of benefits eligibilty.

Meanwhile, Park fields calls 24/7 from island vets who shy away from the PTSD label but should not. They are living in “caves, parks and homeless shelters … and unfortunately they have never even looked into filing claims.

“You don't have jump up and down, but I tell them get all the possible documentation together because you did your duty. Now, it is time to collect on premiums.”

At a public event last year, Park remembers being tentatively approached for the first time by Steve, who reported to Park his difficulties with the benefits-application process in the Army Reserves. Park advised him about his option to take military retirement and file with the VA; he proceeded with success. Others aren't so lucky and even get redeployed after a PTSD diagnosis, which doesn't necessarily end active duty military status. “Maybe someday we will re-create rituals of cleansing for our warriors similar to those practiced by Native Hawaiians during traditional times,” says Park, who says he was angry after Vietnam but found solace in studying both lua and lā'au lapa'au – and in bonding with other vets. “Never tell someone who has been to war that you know what it's like, because you don't,” he says.

One of the main hallmarks of PTSD is a tendency of the victim to self-impose social isolation – something that is at odds with traditional Hawaiian values, says Dr. Hirsch in explaining the approach of the VA's PTSD residential program. “So by the time he comes in here, the veteran from a traditional background has usually been unsuccessful in something that normally works – like reaching out to an elder for solving a mental health problem.” This is where Cognitive Processing Therapy comes in – one of two main methods of psychotherapy the VA uses to treat PTSD. “CPE has a number of components challenging beliefs that have resulted from traumatic experiences – things like the world is no longer safe, or I am no longer worthy of God's love,” said Hirsch. Scientific measurements show that CPE is successful in returning PTSD-affected vets to normal life, but Hirsch adds that the group in treatment is ethnically diverse. “So we still have a long ways to go in finding cross-cultural rituals to deal with grief, guilt, fear and low self-esteem.”

Some say that the service providers who treat Native Hawaiian veterans should look to the 'āina for guidance. “Perhaps less words and more feeling for the place that really owns us. We don't own the place,” says VA hospital readjustment counselor William Kilauano, who is able to conduct counseling sessions in 'ōlelo Hawai'i, which he learned from his grandfather. “The long and the short of it is that Hawaiians come to institutions and find an absence of warmth. It's different when you kūkākūkā. 'Oh, where you from?' and stuff like that establishes rapport and relationship. The Western view might say, you are becoming over-familiar. I think from our standpoint, it shows you trust someone with your background and your thoughts.”

With PTSD cases, Kilauano, who served as a Navy medic in Vietnam, says the pono approach is to recognize that veterans are using outwardly irrational conduct to work through spiritual challenges resulting from seeing or doing “some pretty terrible things in war.” As an example, he talks about the Korean War veteran plagued by visions of a disembodied little girl. The man's wife told Kilauano that her husband would go off the deep end with these visions every time they shopped in cold-food section of the supermarket. Kilauano discovered why the cold temperature was a trigger, when the man revealed that while in combat he found a corpse of a little girl charred by an American incendiary weapon. This happened in the Korean winter in the snow. For many years, Kilauano encouraged the man to speak about his visions – until one day the man initiated the conversation, where he came to terms with the realization that girl was simply 'uhane – a ghost and he could let her go. Today, the man is vastly improved.

For more information on veterans benefits: www.va.gov/rcs - Photo: Blaine Fergerstrom

“That's what we Hawaiians are great at – you know speaking the unspoken … and not saying it but saying it – the hidden meaning in something – and very often, when there is culture – you can work with the language of dreams – there is where we have to be operating from if we expect to make any progress. You say he didn't respond to treatment? No, it's that you didn't respond to him. You didn't look for the kaona – hidden meaning – the use of words is to create images in the mind.”

Kilauano echoes the sentiments of many others who work with veterans when he says that Hawaiians have a long and proud history of warrior culture. Once a history major at the University of Hawai'i, he says Hawaiian warriors prided themselves on reciprocity in battle going back to the time of Kamehameha I, where the people and the ali'i loved one another and parlayed the love into valor in combat. “That established a precedent for competency and courage on the battlefield, so that you ask any commander today and they will tell you Hawaiians make the best soldiers.”

Warfare is always brutal, but he sees many Native Hawaiian vets, who are shattered by acute emptiness of modern warfare. “It is why many guys come here. Often they are brought in by their fathers who are Vietnam vets, 'I no like him come like me.' ”

Some Native Hawaiian veterans say that the Native Hawaiian warrior ethic has been exploited in modern times. For instance, Hawaiian charter school teacher-assistant Andre Perez recalls joining the Army right of high school. “I had to. It was all about economic reasons, no matter what the recruiter said about bravery. This was my ride off the rock.” He was shipped to Korea and sent in to quell a student uprising against U.S. military presence. “The students looked like local kids and there I was with artillery guns pointed down but in their direction.” For years after being discharged he was a homeless vet on the beach in Wai'anae. He found recovery – perhaps redemption, he says – when he went to work for the Kaho'olawe Island Reserve Commission, cleaning up an island where he had once participated in bombing maneuvers. “I believe that military service is a contradiction to indigenous identity,” he says.

For Steve, still shaken from his experience in Iraq, the search for meaning in military service may be too much right now. On a breezy Hawai'i morning, he says he often wants to be left to himself these days. Occasionally he gets to reconnect with the men in his unit. “We go really crazy – in a good way,” he says. One of them was in bad shape recently. Steve blames the psychotherapy treatment in Maui that “made him talk about Iraq.” Squinting into the sun – he is smiling that all-American local boy smile, his tired eyes the only hint of PTSD. With a flick of his right wrist, he makes like he is playing guitar. “I just want to kick back and listen to good Hawaiian music sometimes. I am in control. I'll be okay. I am just not sure for how long.”

For more information on veterans benefits: www.va.gov/rcs