. . >> the more risk there is of people being able to combine them in novel ways and kind of undue the privacy protections. and i would just say let's keep in mind the benefit of the data

being made available and not just take this approach. >> i think the principle of the greater good applies. and there will always be some risky judgments of the data and there will always be a position that is unfairly singled out when in fact that person has been. but as jacob said, you have to look at those and the weigh the benefits against the costs. and i think that we keep in mind the benefits that we are receiving and certainly privacy is part of that. >> we use our credit cards all the time even or credit cards are for real. you know, to underworld hacker websites. so our financial system is constantly balancing the benefits of electronic data exchanges against the risks of

bullishness hacker activity. and i think that we are gradually groping our way towards this. >> it is time to thank the panel for the really good job that they have done. [applause] >> we will execute the same thing. we will transfer the to the senior fellow at the brookings institution who will be moderating the idle words.. [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations] >> okay, now we are going to

shift the focus. and we have talked about the data release and several other data releases from the point of view of the researchers and health plan and the policy and one thing we are talking about is the patients and consumers and now he will shift the focus to the patients and consumers and talk about what they need to know and i hope that we can be a bit more visionary and expansive in this panel because we are where we are. where do you want to be? and i hope that these three representatives who have worked very hard on behalf of consumers can help us to think about what do consumers really need and what do they need it for and how can that data be generated.

to help us with this question we have robert, who is the president of the center for the study of services of consumer checkbook and we have robert who is the executive director of community catalyst and consumer advocacy organizations. and we have dorris peters, director of consumer reports as part of the organization of the consumer reports and i think that with robert we have a lot of things.

and that now we are talking about health care and it's really important as we have access of so many people. so let's start with robert. please tell us a bit about what you think consumers need and what they must need in the future. >> first of all, i appreciate being here and i believe that our priority should be to have good raw data readily accessible and the government can do that, which would make it a wonderful achievement. unfortunately, i think the government recognizes that we have made significant progress and i'm very happy with that recent appointment and love the principle statement in the press release citing the governments commitment to frameworks promoting appropriate external

access and use of the data, whether an accurate or granular form. and that is what i think should be the governments role over here. so unfortunately there's still a lot that has happened and there's a lot to be done. and i give you examples of the good and the bad that i have seen in the government making data available over the years and it always gives me some anxiety with things that might not go so well the next time around. in 2006 there was the denial of consumers checkbooks request that we get identify claim so that we can get consumers on the amount of experience at the position has with the procedures and the government siding with the ama after we won and the lower court. and i was disappointed and that

was much more restrictive than what it had to be and the cms rules require that anyone who wanted this data in order to do performance measures nationally, to have matching on medicare data in every region, that is an enormous obstacle that would have to be interpreted. there would be great news this past april and the government's release destroy the position privacy argument against this, so that was an enormous accomplishment and then we see that it was followed by the quick action to get position identifiers in the large data files that we and others have been using for years to evaluate the complication rates and getting those identified rather

ugly with exactly with what needed to be done. and so we recently created the virtual data program by allowing us to be used remotely and still it's more expensive than what i would wish for a single person to use, although cheaper than trying to get those files straight up, which would be in the hundred thousand or more range and unfortunate. but there was bad news with the virtual research data center system that could not be used to produce quality measures on doctors. i couldn't quite figure that one out. and so sometimes the door closes and sometimes it opens and we all need to support them working for openness often in the face

of a strong provider opposition. and so as i say, i believe the focus should be on making raw data available. and he should be the reporter of these measures. but it should be a diverse independent researchers to develop and put those in the public domain where they can be critiqued by researchers and this is part of the face of provider resistance and we worried it would be too cautious to give some the ability to best meet their personal needs with websites that we compare and there would be a real lack of

development information giving one quite a bit of reason for pessimism on the government doing the reports. so the contrast which finds a way to put this in a form that consumers can actually use and be responsive to and to be able to find the data, all of that stuff is really part of private entities that can do a better job than the cms can do. so what measures need more and from a little disruptive perspective, let me share with you what we have seen from consumers. we watched the website come all of the many types of service providers that we have evaluated, with a look at most office our ratings of doctors. so they don't look at this, but they look at it twice as much as

plumbers and auto repair shops and about 13 times as much as they look at ratings of hospitals. so that's kind of interesting as a perspective and we've also done tests of measures of doctor quality and by far the greatest interest was consumer survey ratings of doctors and results of surveys of doctors asking for their recommendations as well. both of these things were chosen at least three times, by at least three times as many website users is ratings based upon board certification and training for based upon whether a doctor follows defined evidence-based clinical guidelines in these type of measures. and so it's different from what we would've expected. but here we have the possible

measures for future expansion and i'm not going to limit myself to that in general. but i think that we are trying to think about anything that we might possibly find useful. and so i think one measure is to expand on whether doctors effectively use electronic medical records and such information can be collected through the meaningful use program. and it needs to be forcefully explain to consumers that this could really matter to you. another opportunity is the specialty board of whether they can let doctors voluntarily identify them as well as performing in the top quarter of other doctors and their certain dimensions and certifications

process. that is something that i've never seen done but it seems that it would be interesting, particularly because it might actually reveal something about the doctor's diagnostic skills, which almost all of our measures out there don't really get to the question of diagnostic skills, which are so critical to having a good physician. another opportunity would be more measures of clinically bad outcomes and the analysis that we have done and we have seen at the physician level, statistically significant level with readmission rates and other rates, this needs to be public and if we had better data, it might be possible to assess whether the doctors are prescribing too many of some kinds of procedures identifying in this initiative. a very important challenge is to

report on patient reported health care outcomes and some other similar types of measures. and calculating some of these types of measures were wires a different database, of course, and there's a continuing need to push forward for all payer databases to be understood that we will be used for provider quality and we have the large national database is like that and they're all payers, as we said. but as far as registries, it is important as far as the rules allow the data to be used for public reporting on provider performance. they collect information that goes well beyond what you're going to find and claims data. and it makes sense to find out whether public reporting which physicians participate at explaining why precipitation

matters that actually puts pressures on doctors and provides us in general to choose to participate. and so the big opportunity is in health information exchange. and this includes performance measurement and various other things that can be a part of it. and so that means that we need to push for continuing expansion of information and electronic health records, including patient reported information and pushing providers to share this information in large and regional national databases. public measure telling us which are participating in these exchanges might actually create incentives, certainly to be a critical component in the government needs to invest heavily in this. thinking of it as the interstate highway system for health care because major investments really

should be a focus. finally i focus and finish on a relatively easy and quick, but strangely neglected path, getting a nationwide database of patient experience survey results on individual doctors. the database that would also be able to be aggregated with this group level, starting with the individual level of doctors. and why the government did not push forward with this is baffling to me. we have a good instrument with our survey, including very it's that gives good information on how well doctors listen, explain things, and keep track of a patient's history, coordinate care, sharing decision-making and its importance to and the doctor can do a good diagnosis unless they listen or come up with treatment plans and if a

doctor doesn't explain things, well, the patient won't know or be motivated to do their part in the care and as one article in the journal of american association put it, effective to medication has been linked with better endurance to treatment plans and medical decisions and better outcomes and the measurement should be at the individual physician level including others in general internal medicine that shows that the individual and not the practice where the group accounts for the majority of the communication aspect of the patient experience. why do we have survey results, will be here is that it's too expensive and to prove this wrong the consumer is to the demonstration in collaboration as a local survey at the individual positions level with

significant differences among physicians. it shows that this could all be done at a cost of about $120 per physician and still show these really meaningful results and this is much less then demonstrating this data. and then the hundred $20 can be cut to $60 or $40 per year since it's not nessus or early able to do the survey although this can be unable to do this as they choose and this is a big immediate opportunity to easily make happen with the financial support of encouragement. thank you so much.

>> we have more income with consumers on where we have been historically fighting this glass box and being supportive of this and others as well. and i think it is important to look at consumers from two perspectives and one is the role of the user and payer and the other in terms of their public policy role. and with the trend towards posturing and health plans, it has become more important for consumers to be good purchasers and with the implementation of this, millions of people are looking at the exchanges to choose health plans. and so i think we have a lot of experience with that.

and we are either not looking at that or they are looking at it through this lens. because there is a lot of problems. and consumers and unions and payers find the most basic information at times upsetting. the urban institute recently came out with a report that it's difficult to get information from many marketplaces about websites and marketplace websites about whether what providers are in the network and what are the cost sharing differences associated with that. so the low income consumers, this data is complex and very difficult to understand. and it's clear that one side does not fit all understand. and it's clear that one side does not fit all and information needs are very different than the information needs of someone coming to the checkbook. so in terms of we what we are

talking about today, i think that we need to start with getting the basics right and we need better information about who and what is in a network and what are the costs to consumers. charlie mentioned the importance of accuracy and data needs to be made more understandable to take into account the we have an effort to develop a single quality measure that could be broken down into component parts focusing on this particular need to consumers. we agree with the patient reported information and we see collecting patient activation as a quality measure and a focus on outcome and finally in terms of consumers they need help doing this. and the average person is not going to be able to make the

kind of cost quality equation so we need in terms of coming up with values of support. medicare beneficiaries get assistance for state assistance programs and we have a consumer assistance program is part of people focusing on enrollment and we need to sort of think about expanding a program. so in terms of public policy, there are important pieces to think about. a community catalyst is one of the verse to push for transparency around the conflicts of interest of pharmaceutical companies and physicians. and it was actually the court did open that data up. they took a database and made it into an effective tool for

looking at what is the relationship of the pharmaceutical industry to the physicians. and that perhaps hasn't helped in terms of allowing the individual consumers make choices about this or their providers. but it's had a significant impact on medical schools and hospitals from a public policy standpoint which has made an important change. the other area that we have been working on around hospitals and community benefits, hospitals want to seek what the community benefits are and the value of those community benefits, which is a mystery to consumers. can community organizers want to have that information we have been working hard to get a database of information around the schedule which provides some

of the community benefit data at george washington university. we are looking to move forward and in proving that kind of data for consumers. consumers need to understand on the basics of health care the idea of some of the broader transient health care to consumers and the government and consumer organizations need to push hard for opening that up. >> thank you. >> i direct this reading center and we are talking about how our role is really into trying to change that to consumers and to try to get in contact and raise awareness and bring to life. so that's really what we focus on. so it's about having people use the data and not just having the

data available. by using a we are able to identify strengths and weaknesses of that data. so where we work where we have a group of scientists and doctors and consumers and writers who take data from various sources and translate this and we look at the areas of preventative services like cancer screenings and hospital quality, position qualities and also a health plan quality and so we have been doing this for about 10 years and we've reached about 20 million consumers per month. even more through our partners which are not just online, but often those that can reach other audiences. so you're probably more familiar with cars and electronics and we often compete with those areas and we make fun of each other. and so i'd be rather and hospitals and all that. [laughter] and so it's a healthy rivalry.

but i was looking at data the other day and i was really excited to see that in our own measurement of how our readers use data and how we understand the stories that are stories on health care cost and quality, whether it's about physicians will cost totals were jugs, sometimes the rate higher than stories about cars and electronics. so it's really the areas of cost and quality and consumers can understand and use the information. the common question i get asked is about can't consumers not really use that. but they do use it. we hear from them about it and we care about the changes that they've made either in the hospital that they've chosen were the drugs that they take or more importantly the discussions that they have with their providers in this drives people to have discussions with their nurse practitioner about the drugs or the hospital and it's

important to reinforce that relationship. so the thing is that we really appreciate what has been done and we have used it to release the data. the important thing that i see that it's sort of been skipped over is a issue of safety. i'm wondering because it's really hard to measure and we seem to have jumped from the process measures all the way to patient reported measures like whether we can climb the stairs but skip task in measuring patient safety. and we've actually asked consumers about this and there were about 30% of people experiencing one or more areas in the hospital and that's probably a huge under estimate. so it's not so much may be something that is unnoticed to them. so i really feel that not only in the series of collection but how we measure this, this is an important thing for us to focus on.

another way to do this is through registry data, which is probably the most powerful in this panel and i think that that is an area where we would like to push more together to make it available to the public. we been able to be successful in a small area and we have worked with heart surgeons that have voluntarily release their data to the public and we have hospitals and doctors who are high-performing and even ones that are low performing that have agreed to release their data and i think that this is the most powerful decision that decisions consumers can make. and they could undergo bypass surgery and find those hospitals and physicians that performed in these ratings of quality and they both have looked at outcomes and competitions and reliable way. that is what we would ask that we sort of made more public and i think that the cms will bear the power that they have to

require these systems as they start making that more legal requirement in terms of being reimbursed by cns. and then another request is to not try to reinvent the wheel. i think that we sort of required to do this as well and it kind of makes a lot of confusion at the level to the consumer because those websites that are out there now that the government puts out a really difficult for consumers to understand. so i would suggest that they focus more on the data and the quality of the data and the requirements of reporting the data rather than the consumer side. the final thing that was just kind of part about was not to forget about infrastructure, those of us that use the data have to deal with the structure of the data in the missing elements of the data that make it hard to release accurate and

timely reports to the public. so thank you. >> we have heard a lot about choosing doctors. we have heard about some of us choosing health plans. i would like to each of you to say a word about how you would hope the feedback to the providers themselves would improve the situation over time. because this is ultimately what we hope consumers have better information in this way and are accomplished. >> we have watched this most carefully and try to work with societies to tell doctors how they can improve and where they can find resources to improve. and i don't think they've been particularly successful, but i think that's probably because were not very good at it. we tend to be a measurement

organization and not an improvement organization. but there is the potential there. but i don't think that and yes, that is one of the objectives, but i do think that we can find the good ones and bad if you could care as well and we do have the professional society stepping up and understanding that there are implications to the conflicts of interest and addressing those changing policies within the medical schools and within academic medical centers. and there is a necessary means for partnership and i don't think the market is going to move it away from all providers and we are going to need to rely

upon this with hospitals, doctors, consumers really did it right. >> we really do see a big response by hospitals. and they tell us that we are focusing on the things every report on. so take you. [laughter] >> [inaudible] >> that is one area that we see changing and we also see areas where hospitals will call us and say thank you, we didn't know this or that, now we are going to look more into it and try to see why it is part of the problem. because i see we have people that we really care about. and then we also hear about patience canceling procedures

and surgeries and then moving revenue. so there is some market change going on and there is something happening. >> we have touched about getting this out there and the government should definitely consider this. but we have those that really haven't seen this interpretation as we saw in the release that triggered this event. >> there will always be some risk and the way that they have it in the first place, it can always be misinterpreted. and i'm always troubled by that response and we've had a lot of experience and we've had those that we've tried to put out. we've asked the federal

government if we can have the description of benefits and the coinsurance for each of these plans that we can have an actuarial estimate for each of these and so you can really make this a good comparison that we have a chance of doing and so on like them we're talking about here, the government said oh, no, we can't give you that data. and then they finally said we will give you this data before the enrollment starts. and these estimates take many weeks and very complicated calculations to do. and so one of the reasons is the parents wouldn't like it and the other is that we might put out something that is confusing or that is wrong and i believe in

the marketplace of ideas and that nobody listens to you again and we take some chances on that as opposed to not getting the information out. >> we are focusing on how big companies don't like it very much either. and it's timed from the audience to take questions. and we have one right there, a question back here. >> hello, i was actually speaking about 28 years ago about the breakup. and hello, alice. i followed a little bit more closely and i'm curious about

the mayo clinic or cleveland clinic brought something called wellness medicine that is happening. i don't know how to define a, there is different medicine but i never thought in those terms until i read it a couple of years ago. so my purity curiosities to ask each of the panelists how do you evaluate what is happening and how do you measure it and how do you describe it. has this wellness movement been around for two years or six years or nine years? i don't want to establish or connected to some personalities on tv. i want to connect it to the university of michigan or yell university. but the question is data. so if i move 10,000 steps a day, big deal, it supposed to make me healthier, how do you measure that? you get my point?

>> i think i understand what you're trying to say. the movement has been around for a long time and so you have that as well. and then we take it into the form of the preventive services and we think that's one of the areas that we focus on helping people understand preventative services and i'm not so sure that that is on the line of what you're thinking of but that is our focus. >> hello, i think that there is a trend towards payment reform that would move you in the direction and move hospitals in pairs in the direction of treating a person this way. i certainly have been around for a long time, but i think it's gained a lot more traction. >> some of it's not medical. and it's either a system that is evaluating back to that.

>> if you think about the dual demonstration process, i think that there are evaluations going on now that, and that is really working to take the medicare and medicaid payments combining it to that of nursing homes and others as well, and that's something that i think that research is doing right now. >> i think that there is the visibility of patient self-help and medicine that has increased over time and are a lot of things that we can look at including many health plans are looking for alternative ways to help members, hoping that this will solve problems and reduce health plan costs. and so, these provide a

checkbook in regards to this day that sort of thing than some things that we don't really know or something like that, some are much harder than others to do, but we some of those computing get meaningful feedback on the quality of those providers including explaining things and i had a miracle cure by an acupuncturist and so you have to listen and then he put on music and let me sleep for a half-hour. and they say, how does that work, but it was terrific. and when he was talking to me, i was just thinking that how can you beat that. did i lock my bike out front? [laughter] people have very different views on how this affects them.

[inaudible] >> we haven't done much in general, but it is a bigger part of the system and the economy and i don't see it as having the same level of visibility that we are trying to see in the red regular medical care system. >> i have a question that comes from twitter, is there any information about increasing consumer engagement through transparent cost and quality data, and how can we increase engagement? >> i can speak in how we speak with increase in both the data that we are providing and the consumers telling stories to us and i think to make it more

useful them except more personable, all the things that we heard today, making it part of the day-to-day decisions about the procedures that we have enough time to make, such as paternity, knee replacement, things like that. >> i think there's been a lot of literature as to why the consumers get involved or not involved and i think from low income consumers it's been somewhat different. and you need to think about how to engage this and that is where we think that this is important. including the medicare program has assistance in choosing plans. sumac yes? on a lot. >> there are some providers and

organizations in the business to help people. and there are others that are in the business to make money. and i'm just wondering if you can differentiate one from the other. but a lot. >> i don't think that we can get to the heart of the motivation, but i think that we can look at their performance and we can see if they are keeping costs feasible and if they are overprescribing. or even some of those things that i talked about by choosing wisely. you know, in the assessment, which is obviously very important and we don't know how to do that. we are going to need better data to really decide and really help

those as opposed to those getting referrals from somebody who actually needs that. >> let me ask each of you very quickly if you look ahead 10 years, what would you like to see in this world of consumer information about health care and consumer choice. and what will it look like 10 years now in this dimension? >> going back to where i was before. >> this includes having ways for her many to understand errors, hospital clerical errors or surgeons. >> and there are fewer risks as

well. >> i think we need to consolidate information and make it easier for the consumer view, that we need to focus more on outcomes and the patient experience. >> we have to push towards us, we have those who have no chronic conditions and it's not much interested in outcomes except they avoid something going wrong, but they have a serious chronic condition really looking at measures and etc., so those things have to be telling to the patience or the consumers. >> thank you very much, to all of you, it's been a very good panel, and i hope that some of these things come to pass quite

soon. so let me turn it back and let me give you a round of applause. [applause] >> thank you. >> let me turn it back for the final remarks. >> i want to thank our panelists again and are excellent staff areas and there are a number of people that helped to make sure that everybody was as comfortable as possible and we are going to have several more briefs that talk about how this is covered today and i wanted to be a little bit provocative in what might be coming after today's conversation when we talked about things that are consumer centric and what

happens if this can be used to create high-value networks that we are seeing in the marketplace as well as on the health insurance exchanges. and what if we could give researchers together and do a crowd sourcing valuable research case or findings were things that we all find interesting that we don't necessarily have taking the lead responsibility for, but that we could work with nonprofits research organizations as well as consumers on what they find interesting and try to put that together in a way that is not contingent on what they would do. and then finally talking about safety and errors, it wasn't that long ago that we had in the quality with other colleagues who highlighted these problems and will be remiss to think that we solved all of them and how can we be pointing towards

places to improve and think about concentrating efforts from the transparency and data in order to show people what we can do to improve the infrastructure of health care in our countries. and so i want to point to the conversation today that we are going to be doing future publications as well as hopefully it done in this in other ways and so i thank you for your time and attention and have a great rest of the afternoon. take care. [inaudible conversations] [inaudible conversations] >> coming up next, a look at post-hermetic stress disorder

and soldiers. in a conversation on black friday. >> on "washington journal", steve king of iowa talks about his attempts to stop the presidents executive order on immigration and then we hear from congressman jim mcdermott of washington state on negotiations to fund the federal government amid the tensions over immigration. "washington journal" is live every morning at 7:00 a.m. eastern on c-span and you can join the conversation on facebook and also twitter. >> c-span city's tour. this weekend we partnered with a visit to waco, texas.

>> we begin turning over the ability of what we were able to receive. first off, it was not widely heard in the right community. the flip side would hurt even less. and what we discovered quickly was how little as long as we would directly related to the civil rights movement. some sort of them were complete, we had very good songs including there is no segregation and have intent of songs, they had various dangerous things in the deep south but that sort of thing is a risk. >> the texas ranger hall of fame set up in 1970s next for the 175th anniversary and at this point honors 30 rangers who made

major contributions to the service or give their lives under heroic circumstances and they began with stephen austin that was very successful and they not only managed to make the area area reasonably safe, but when the texas war for independence broke out, the rangers played a major role in texas gaining independence by stating off this long enough to allow the colonists to build their own army and develop a strategy and as a result texas became an independent nation for about 10 years. >> watch oliver events from waco on saturday on booktv and sunday afternoons at 2:00 o'clock on american history tv on c-span3. >> coming up next, wendy moffatt

explains treating post-hermetic stress disorder or ptsd and soldiers. she is joined by the ap reporter who talks about her own experience after 2006 car bombing in iraq. dickinson college in pennsylvania hosted this event. >> good evening. i'm a student project manager at the college. on the half of everyone here, i would like to welcome you to tonight's event. ptsd, a panel discussion. in the past decade post-hermetic stress disorder were at ptsd has come to the forefront of national discussion. in part because of its problems in the wars of a rack iraq and afghanistan.

it is not a new medical condition. it was observed and soldiers from world wars and it was called shell shock at the time. anyone who has endured a dramatic event can experience nightmares and anxiety, flashback and difficulty sleeping to characterize this. tonight we have experts in several fields would all have different perspectives. kimberly dozier, the current chair for strategic leadership, has first-hand experience. in 2006 while reporting for cbs news, she was injured in a car bombing that killed members of her crew and their military exploits. she would approve of the experience and herb recovery process entitled breathing the fire and fighting to survive and get back in the fight.

and wendy moffat is a professor in college and she is researching and writing, both of whom were engaged in the events of the first world war. rebecca porter is currently the commander of the u.s. army health clinic. previously she served as director of psychological health for the army and she is a behavioral health physician at office of the army surgeon general. she is also a fellow of the american psychological association and a member of the military order of medical merit. david wood is a senior military correspondent for the huffington post.

and in 2012 he wrote about the wounded veterans of iraq and afghanistan wars. and tonight's event will be live tweeted. you can follow these hash tags, or ptsd. a question and answer will follow the panel discussion, so please hold all questions until then. because tonight's event is televised and available or live streaming, it is imperative that you wait for the microphone before speaking. and now please join me in welcoming our moderator and panel discuss her, wendy moffat. [applause] >> at evening, thank you for coming. thank you for coming on this veterans day. i'm going to be talking about one of two of my subjects,

including the first psychiatrists in any american army and in early discoverer and tweeter amongst the expeditionary forces in the first world war between 1914 and 1918. he was born in 1876 and died quite young in 1927. but his work is very important in the history of understanding. and i have to say that even though he was a figure, that it would've been utterly bewildering to him. he came from a public health perspective and he began as someone who was an advocate for mental health and the prevention of mental illness and also for

training doctors who understand that mental health was a legitimate form of medicine. this is at a time when many of the people who were incarcerated in institutions where they are for reasons that were not what we would think of is medical illness that many people who had syphilis had mental illness kinds of symptoms, many people that had chronic alcoholism and people that we would think of as developments we disabled and people would cerebral palsy and the great range of disabilities that made people remark as sub normal. so this worked in several lights in the national community for hygiene trying to differentiate between the kinds of things we were confident could be cured and the kinds of mental illness that were caused by organic brain injury and other sorts of things. this is not as easy in the

pre-mri time frame that you might imagine. the united states entered the war better late compared to the other allies. that offered him a chance to see not only what was shell shocked with this terrible mental disability of soldiers at the front, but also the ways in which the allies screwed up the treatment of people who have these problems. and he became almost incandescent with anxiety about what was part of the expeditionary force. and this includes the headquarters here at his office in 1918 in the summer of 1918. and he was a person with a really intense beautiful

clinical mind and he was sympathetic as a doctor and he also had a systematic mind and he understood that treating the soldiers was going to be an important and complex matter. this was one of the temporary hospitals in this part of the battle line and you could probably knock them down and i know that this was some of his doctors. they built these on-the-fly. here's the doctor on the right-hand side. and he was shoehorned into this because he came from a public health and private sector place. so he forced his way in and

became the only psychiatrists in the army to run this whole enormous set up. and what he discovered about dramatic injury and mental injury in particular is that it was mitigated by treating it immediately. it was mitigated by the process of leaving the people could get well and it's very true. and it was mitigated by intense activity to help the patient's right away. so when we have that psychiatry now, which we have expectation of recovery, it's really something that he supervised on his own with other people thinking it through. so this is a map from the american front here and you can see this is where the headquarters were and what was

discovered is that if you put hospitals in the field and train doctors who had these mental symptoms, but you could filter out and this is going up and down here. you can see here the advanced or logical hospitals. and this includes when they exhibited the kinds of things that you associate. in this includes the only dedicated psychiatric hospital and the entire army.

and this includes if they don't get well and 72 hours. it's a simple protocol that it's quite remarkable. and that includes when they are shaking so hard that they can't stop and they have symptoms that gives them troubles, and so he's empiricist, so he watches. and so we might not be talking about this here, we may be talking about simple exhaustion and combat fatigue. this is the view from the top of the château in france and they commandeered this and built a

hospital in the summer 1918 with three patients and by january 1919 had more than 600 and treated in total more than 500 people at that hospital. and so this is in the middle of the argonne forest which is where some of the tents were set up in the middle here. and we can see that the offices were billeted down down the road here. so very primitive conditions that they lived in and so someone was quite a remarkable sketch artist, ambidextrous and he did a lot of beautiful sketching of things and these

are not very clear, by and see that he is sketching the line on the left-hand side there as it goes up and down. so we've actually stood up where this is towards the end of the war in which the allies and americans are pushing up. and this is a photograph that he took on the 18th of november of 1919. and he was touring around and he moved around and at the end of his life he became very worried and concerned about the treatment of veterans and he advocated for a veterans bureau, which is said to be a forerunner in the early 20s of the va and he viewed it of the failure of

his life that he was unable to get some things that we now think of as central for mental health, mental health parity, that is that their health should be on par with physical health, the stigmatizing people with mental illness, believe that they could get better. and probably most importantly the we have to pay for what the veterans need. and so he was very much caught in a huge rats nest and so i will leave it there and i'm sure that you will have questions. thank you. >> the panelists can come up and say it. because i am the last of the

speakers. [inaudible conversations] >> would like to ask a couple questions. >> i am obviously taking the moderator role. [laughter] and so i was watching the pictures and thinking, okay, this is always a problem that is with us. with the work that he was able to do we went to france and had to dig us out. how widespread was the lessons learned across the military. >> i think there was a lot of resistance within the army at

the time, there was a huge aftermath in 1920 in 1921, there was an interest in all the lessons that one can get. and there is a huge volume in which they put all of that they are, all of their insides and a lot of them that have been written are in those. and so there's a lot of anxiety is the army goes down and there's a lot of disinterest in funding veterans and others and so it gets down to a lot of these records were in san antonio at the archives and i talked to one individual that said he couldn't believe this and he said that we never had

better weapons but this is a perennial problem. and so i think that the doctor would want us to build on the knowledge that we have and not dismantle it in peacetime in the hopes that we didn't have to pay for it. [inaudible] >> can anyone hear me? [inaudible] >> we will project. >> sled like to know more about the mechanism of this. because you know there's a lot among military doctors and others in the belief that we have these reverberations that caused this with a lot of patients that were jittery in this way. so what is the understanding

enact. >> his understanding is that it is being taken up as the british doctors there. >> i've never he heard it used in that context. >> they are sort of trying to frame what is this new iteration of behavior that they're seeing in the soldiers. and many of them had never been subjected and so the idea that it is shellshocked doesn't make any sense and they are aware that there are mood changes that happen with traumatic brain injury that might not mean the same thing as what we would call with poster maxus disorder. so he viewed this as a purposely rational curable response to the conditions of combat. and he actually were mark but it is only a surprise that more soldiers don't have it. so he understands it is an

unconscious phenomenon and he is aware of the apparatus of individual ways of developing this behavior and so forth and he is a pragmatist. but he has this idea that the mechanical quality was somehow of the first world war, somehow the instigator of this. and so we probably had something like this as well. but he said as something that is part of these modern conditions. >> i think that we can go way back to see what we now call ptsd. >> look at jonathan and the idea that can see some of this. so it's really interesting to make sure that the people who

are injured get treated and get better. he's not a philosopher of the long-term, but he does notice that they do have an incident. and there is suicide amongst the people that he treated. and so he thought that he was seriously eating better. and there's a big debate as to whether or not it even works. including proximity and getting better and they say it is treating people right at the front as they need more treatment. of course the idea of venice is to get them back in shape. so we are not trying to get them out of this but to get them so

dead they can continue. >> i want to ask you a question that might lead into this presentation. did he have a hierarchy is to determine what caused the worse shellshocked, was it everything from being too close to the explosion to moral injury? >> he doesn't differentiate and it may be that the american experience was so compressed that he doesn't get to say these things. but what he does do that is interesting is that he insists on longitudinal studies for the people that were affected. so there's a survey and the study and another one in 1924 and that would've gone right through. he wanted to follow up and he followed them back in the states, he fought very hard and on privatization of medical

facilities and he was absolutely furious that the first thing that they did to save money was ask all of them if they would like to be in a mental hospital or if they would like to go home. and they all said that we would like to go home. and then they said, problem evaporated, no need for this. so his speeches are just unbelievable, but you will have to read my book. [laughter] >> what did he find out six years later? >> he found that the people get better. >> actually that is what we found an army medicine right now, we estimate that 80% of soldiers treated for ptsd to

recover if they complete the treatment. the problem is so many don't complete treatment. and what we've also seen, and the reason i'm not looking at you is because of this over here. [laughter] >> will we have seen coming out is that five to 10% of soldiers will meet the diagnostic criteria of ptsd. that's a sizable number that will have other behavioral health conditions are wired some kind of treatment. system 2007 it has been something they have appropriated money to develop these health services line that coordinate and synchronize this into a system that builds upon the proximity and the expectation that people will get better and

so what we have done is we have embedded teams that are in the brigade combat teams and those are primarily part of venice. there are other aspects that are part of the organizations and we have these behavioral health clinics, especially clinics that are in these footprints. but we found is that that make sense more likely that a soldier will come in and get help and he doesn't have to get as much time off work or write to the hospital, he or she can come right in and see a professional. and so what we've done is align those professionals with specific brigades. so if they have more pointedly certain experiences while they were deployed, the health professional knows what that

experience was and can take it into account with treatment. and we find that in most cases we have pure behaviors than those that have been embedded in we have fewer suicide attempts and others in those organizations as well. the behavioral health providers grow to have a sense of trust of command teams in their organizations and if they have to share information about the safety of a soldier, that can use the information responsibly. similarly the commanders trust that the providers will let them know there's a soldier who was in danger. so it's really been kind of the hallmark of the health teams that are right there with the units even in garrison.

>> it's a little bit awkward with the microphone over here. >> certainly there is stigma. but we have found that we have really come a long way towards addressing that and we also have several leaders that have come out and said that i have poster maxus disorder or i am in treatment. and i have been with different treatment facilities were even the general officers would say i don't want special treatment but i want to sit in the waiting room so that everyone can see it having some kind of an impact from being in combat is not dependent upon your rank. so i think that that has meant a lot, but we still have a way to go.

>> the moment someone admits to having ptsd, there are problems with the next promotion and then it's like if you don't promote them, him or her, now that they have admitted to having this issue, if we don't promote them for some other reason, everyone is going to think it is because of the stigma. >> when an amazing general admitted that he was suffering from this dramatic stress disorder, it's like, okay, we can't talk about it. and the sad thing was when he got that, people were like oh, yes, everyone in the army like every major organization, there is parity and pecking order and

so many of them were saying, okay, now they have to give it to him and that was one of those issues there because they had me over there to speak to the team after i was injured so that we could track his career. >> if you seek that, this doesn't work. and so i think it's a case where i spent almost my entire career where we have the junior officers, the people that make things happen.

one knows itu seek to behavioral and they decide you know, they should get treatment. and so there is that situation. >> is that more kind of an urban myth that that happened? >> i don't have any data, but i think it's probably half-and-half, i think people probably believe it and everyone knows someone. but certainly there is the working class fears that if they seek help it will somehow impact their career and the impact won't be good.

and i know general odierno has been very adamant about this. so if you have a problem, go get help. i did a piece on suicide prevention where we had the first lady, michele obama videotape be sure for us where she said the same thing and she says we don't do that. and it is a continuing struggle. >> we have special operations and the intelligence forces. and we will make you talk into this here next. until first of all, they found that the best way to get care to the operators was to was to send

out counselors who write nothing down and they buy these amazing coffee makers that are like $2000 for espresso machines, everyone does this and the chaplain is right there in their couple doors down and that's a great way to kind of make it okay. one of the things before he left command, one of the things he was struggling with was he had managed to fix this, this is somewhere the clearance would be affected if they admitted to having counseling for ptsd. but all the support it, when people see "zero dark thirty", they think of this, if it's 10

people in the mission, it's something like 200 people supporting that. so the intel officers are working with is are under fire just as much having had a lot of the same issues with combat stress and they couldn't go get it the counseling because it's still what effect their parents that could get cold. and at a mcraven talk about it openly and seek a left the command this summer. my research in this, some of the other claims as well. >> i talked to the special operations officers who worked upon rescuing someone's career who went to a counseling and

then had a large investigation because they admitted to having trouble with combat and that once you have this investigation, it can derail your whole career. >> i think it's important to differentiate because maybe they could not successfully make this treatment. so that doesn't necessarily mean that their clearance would be revoked. but if they are not successful in treatment, maybe that could lead to their career getting revoked or that they will have to leave the service. but it's not because they don't care. >> we have to move on to our other presentation. >> what is the mechanism of the danger of ptsd? how do people get it? what causes are the

ramifications? >> can i explain? >> no. >> no, i want the doctor to explain. what is ptsd? >> it's just like what she said, the normal reaction to a horrific incident. it could be raped, it could be combat, if you have fear of losing her life, it's a normal reaction to something terrible like that. >> as i understand it, you know, i was trying to think about it and if you are like me, the first thing that happens is your face blushes, and it's actually the beginning of the involuntary physical reaction where your body says, oh, everything is

this huge problem, which is your bloodstream, your heart rate goes up, can fight your way through a battle were other things as well, and so i think when you go through this cycle over and over again, you have that reptilian part of your brain that kicks off things and you're eating with your wife, and then all of a sudden that stuff starts happening and then you're not sleeping so good. so the way i understand it and how guys have described it to me is that when that happens people

get angry and punch walls and they have problems. and so there are lots of guys, for example, that a guy comes home and family and friends are invited to wal-mart, it's going to be a big deal and they walk in and they say, i can't do that. to say they're going to have one of those things happen and they can't control it, it's involuntary. and they say that i can't do this. and they say, what is wrong? and then they get into the argument. >> i don't know if you're familiar with this book, he talks about that very phenomenon and how a combat environment,

that is actually the problem when they come back. and so he talks about it as a response becoming hardwired again and again and that is a phenomenon about how it comes to be. >> can you talk about your relationship with ptsd and the work you are doing right now? >> yes, let's talk about moral injury, which in my experience is something that is experienced or suffered by almost everyone that goes to war. when i say that, it's not in the finger wagging sense that you did something wrong. we are not talking about people that are broken or anything like that, but here's the thing and again, this is something that i have learned from spending 35

years reporting this, is that we all think that we are good people. i'm a good person. and, okay, i don't always live up to it and in fact most of the time i do not, but i know when i do good i feel good. and i sort of expect other people to be that way. we're not going to expect it now , a suicide bomber out there because we are all good people and we expect other people to be good and we expect the world to be pretty good as well. and so whatever moral codes that we have, do onto others, all of these things that we learned at church or synagogue or mosque, it adds into that moral code and we go to war and bad stuff happens and it just does. when that happens what happens

to the picture of ourselves as good people and our sense of moral foundation. let me give you an example because this is a hard concept to grasp and it took me a long time to figure this out. and so a guy named nick rudolph, 22 years old, going through this kind of quickly because it is a long story and we've written about it and you can look it up if you want. it was a bad firefight, firing at these marines that are out there, trying to take cover. at some point he sees the guy running round the corner of the building spraying ak-47 fire at them and he raises this and get this person in his sights and realizes that it is a kid. and i said then what happens and he said well, we kept on chasing

the taliban. because in that moment he couldn't stop to think about it. so here's the thing about his story is that in that moment in afghanistan, killing that person was the tactically right thing to do in the legally right thing to do and the morally right thing to do. because tactically he is the enemy. ..

two good people killed children? not really so that's a moral injury. i picked a dramatic coverage because it's fairly easy to understand and we can put ourselves in that situation. people range from serious stuff and i just kind of feel bad. i know a lot of people who for example signed up, got into the military, went to iraq or afghanistan not to kill the enemy but to do good. because those were wars of

battlefield victories although there was a lot of fighting needless to say but the point of being bear there was we were helping people. i know a chaplain who went to iraq and for that very purpose. he was going to go help people any realize after a year-long tour we are not helping people but destroyed a lot of stuff and people are getting killed and they hate us. this was a chaplain. he got back after couple of years so that was a moral injury. here's the important thing. what is our part and moral injury for our troops. we send kids like rick rudolph off to war and we don't tell them bad stuff is going to

happen. we don't tell them that. we don't even tell ourselves. we are like barack let's go award. right after 9/11, let's go do it. it invade iraq, let's do it. the schakett on all that and we don't ever tell ourselves or the people we send that stuff is going to happen and it's inevitable and you will suffer. on this veterans day hope you can take a minute to say to ourselves in a war is bad and sometimes you got to do it i get that but war does bad things to people and made to be honest about that and listen to our veterans but find a way to listen to their stories and a validating way. and by validating this is something i learned from therapists, very few therapists who are working with people with injury. don't say to you nick rudolph you kill that child that you

didn't mean to or it was war, it was not your fault. it's okay to worry about it. no he does worry about it. it was his fault and you can't undo that. so listening in a validating way means yeah's summaries often say i was screwed up. let's just put it out there. but it doesn't have to define you for the rest of your life. i'm sorry. >> that sounds like a segue to kim's story. >> okay, so for those who aren't familiar with my story i was a cbs news correspondent for a number of years based in jerusalem from 2001 to around 2003 and then i moved over to iraq and i was in iraq from other three and 206. then i got hit by a car bomb. i was told by the doctors and the psychologist who is trading at the time that much to my surprise though i had many of

the symptoms that you associate with ptsd that phrase we have been throwing around up here i never actually had ptsd. i had post-traumatic stress which the practitioners who were treating me at the time to find as everything from hypervigilance, flashbacks, anxiety, a grab bag of nightmares, that fact, because that only lasted four to six weeks, and it didn't interfere with my daily life after that time that therefore it was not the disorder. is that still the way it's defined? so i had pts and pts became what, the phrase they used to define what happens when you have processed your pain and

move beyond it, post-traumatic growth. so that is a phrase i would love to see out there are more. every time i speak i try to use that phrase. it defines 80% of people that you are saying move on from their post-traumatic stress experience. so just to give you a little bit of an idea of what it's like to be in the middle of it, the first time this started happening to me was there was a bombing campaign as with the israelis in my list in israel have to the israelis have encircle ramallah and you can get into who started what and what it amounted to me for -- two for me was i was driving to baghdad to report on demonstrations or i was driving furiously around jerusalem that

top speed to get to a suicide bomb that had just come gone off. i got very good at identifying which won the bombers were against the dead bodies. it was usually one with the bare ribcage and the head was popped off because that is what a suicide bombing vests does to a body. after couple of years of this and we counted once out of 60 suicide bombings we got 230 of them. the cameraman and i had. i developed a survival skill of hypervigilance. you didn't go anywhere in israel without thinking if you are going to a café there is always the choke point at the door where they check your bags because that's often where the suicide bombers would try to move in and blow themselves up amongst the line of people

waiting for their bags to get checked. once you got past that choke point and into the safety of the restaurant then i would start replaying all of the bomb scenes in my head. okay, if at the bomb goes off outside of the building the plate glass windows will come flying this way. i'm going to choose that table there because it's behind a large supporting column or if there is no column to hide behind i'm at least going to sit with my back facing the door so that the glass won't hit my face. it will just hit the back of my neck. so that was my reality way before i got into iraq. and in iraq the first six months was a rebuilding mission that was pretty safe. and then the insurgency campaign began. it started with an attack on a u.n. compound and then they hit the jordanian embassy, the red cross and then i started hitting small hotels with foreigners and

them that were not very well protected. after you have covered a few of those and you know what a car bomb can do to a small poorly built hotel you basically shares off half the hotel. you are looking 15 feet into the back half of the place. i would go back to my own small hotel, poorly defended. we watched the guards outside regularly lead in their brother without looking in the back of the car and park beneath the window and then i tried to go to sleep. as you can imagine sleep wasn't easy after that. some nights i ended up sleeping in the bathtub. i later found out richard engel was doing the same thing and a few other people. you have all these crazy bargains with yourself because you just need a few hours sleep. i learned to basically handle it for three to four weeks until

all my symptoms of hypervigilance so intensely interfered with my ability to work that i wasn't functional anymore. i could barely do a live shot because i couldn't straighten my thoughts together. i hadn't had enough sleep. i was freaked out all the time so that's how i developed over that three-year period that i was there before i left rather unwillingly. i would be in for 46 weeks before the symptoms would get so bad that i was not functioning. i would also start snapping at everyone and i noticed all of our staff would do the same thing could i go out it would take me two weeks to down regulate is the phrase that i've heard used in clinical settings. it basically means to me that i got my adrenaline back in order. so 2006, my team was out with the fourth infantry division patrol and they got hit by a car bomb. we got ambushed and he killed the captain and a translator.

it killed my camera crew. i woke up in a medical center in pretty horrible pain with shattered femur's comic eardrums blown out. they had already tunick craniotomy and i had burns from my hips to my ankles so they kept taking me in and out of surgery to debris the dead flesh from what was left of the living. i -- they did it with a fire hose. it was a horrible painful experience and i really wanted to get back into the states because i thought once i got to the regional medical center in the states things would get better and that's when i started getting hit by post-traumatic stress. when i took the ambulance ride with all the other wounded from watched a hospital to ram stein airbase i was convinced that every car riding around us on

this beautiful road to the german forest was an al qaeda suicide bomber bent on blowing us up. i was like shrinking away from the window, terrified until we got to the plane. then of course i was convinced the plane was going to crash. you name it, once i got to bethesda naval hospital i had nightmares. i started having flashbacks where would feel the force of the bomb throwing me forward in the bed. then i would come to them i would be in his hospital bed unable to move because of the injuries. i wanted to talk about the bombing. because i had a brain injury my doctors basically had an internal fight. the majority opinion was i should not talk about the bombing and i didn't care. everybody who walks through the door, i would start telling them what i could remember.

i had this desperate need to try to remember everything that i could see. finally two weeks and a psychotherapist on his reserve duty came in and he was like so, i hear you or the patient. shut up. i will work with you if you really want a warning i normally work with marine so i'm going to swear a lot. very good with back? i'm like yeah. he said wait one more thing, i can already tell you of our talk or so occasion i will tell you to shut up and move on. that's how i ended up talking with him every day. you would come and stay for an hour and just what you are talking about in that very first experiment or series of patients at the doctor treated back in world war i, treating them immediately and the prospect of getting well, those were the things that i instinctively went for a needed. i had a doctor became an nsaid a

psychologist who said trust your instincts and when we talk about or talk about it and when you trust your instincts he will be fine but keep talking until you don't need to talk anymore. so what i found was sent apparently it's common for a lot of folks, i needed to have this illusion of control over the bombing by figuring out exactly what happened. i spent the next year and a half trying to track down everyone who had been there. one of the most reassuring things in that year-long process was when i found a powerpoint of the bomb scene where everyone was laying. that confirmed to me that my memories of where i was laying and he was treating me and who was talking to me that i had it all right. it was very reassuring. so after five weeks in, my nightmares stopped, my hypervigilance stop. i stop being afraid that the

mill car was going to blow up. i still didn't like the food and that faded. now what didn't fade was survivor's guilt and grief. i had lost my guys. i had never expected to lose somebody in the field. when i found out that the families were all furious with me, the families of the dead soldiers, their families of the cameraman and the soundman, i blamed myself too. the other thing i found is that one of the things in the stages of grief afterwards as you find someone to blame. in my case it was me. finally what release me from that was bob woodruff had been hit for months to the day before i had so abc news correspondent so he came in to see me. we talked on the phone because he was still in his recovery because it hit him in the head. the bombing hit him and he said

look paul and james i understand that you feel bad that you lost them, but am paul douglas and james brolin are cbs team. those guys chose where they went, when they went, why they went. if you are trying to take responsibility for them being there that day you are dishonoring their memory. you didn't order them to be there. that became one of these lifelines. i realize he's right but i still every memorial day i basically go into a fog because that is when it would hit, memorial day. now i just know i'm like okay i'm just going to have to check out her the next three days. i'm going to be miserable and i'm going to be depressed and asking myself why am i still here into amazing professionals who have survived so many wars

that have families and children, why are they gone and then i will try to keep paying it forward when the holiday has passed. so i got past all that. the hardest part was coming out of there to find that no matter how far along i thought i was that the american public that i bed on the street where i got out of the hospital would not let me out at the injury box. everyone thought i was a walking ptsd timebomb because of what they had seen in hollywood, because of some of the stories we in the media have put out. so we did this yeoman's effort of trying to teach the public that there were people within the military who needed help from their war injuries and yet we somehow tired the whole force with that brush. so i shared a few times with

other folks who have come back from overseas and there is always like knowing nods around the room including a special operations community. one major who had been from mogadishu to the worst places among afghanistan on iraq no matter how many times i tell my mom i don't have ptsd she doesn't believe me. the harder part is that becomes a self-fulfilling prophecy. if you are experiencing bad symptoms of post-traumatic stress and you are not an obnoxious over talkative news correspondent in her 40s from the opera generation are you going to seek help like i did? are you going to fight through that wall? that's what i'm worried about. we are putting this message out there even with that very dramatic and provocative poster for tonight's event, that's not

an image of someone you want to be. it's a guy like this. i want people to see the post-traumatic growth part so that they know there's an endpoint to shoot for and i don't know how we are going to shift the balance from wow everybody is broken to there are some people, 10%, 8% who have something that they may always have with them. then there's a larger part of the bell curve of people who will take this experience, make it part of their wisdom, their resilience, their life story and they will be able to share those lessons to help people through every other hard thing in life. >> i think we want some time for your questions and that seems like an opening to your question.

>> we will now begin the q&a. if you have a question please raise your hand and wait for justin to bring you the microphone. >> the microphone is traveling across the room. >> whether any thoughts on that higher rates of post-traumatic stress and post-traumatic stress disorder from urban combat and the jungle combat versus say that tradition open plain or open field like you mentioned jonathan shea's book by the talked about the constant and not just a cycle but psychobut the constant journal and bend comes from having to be vigilant and a jungle environment where you can't see and i suspect it's

similar in city fighting. but that creates a greater reaction and what are your thoughts on that? >> i think david was going to talk about that. >> i just wanted to validate what you were saying. in both iraq and afghanistan i think the majority of firefights which i witnessed were one way which was inoa sniper would open up. they would be an ambush or there would be an ied that would go off for a car bomb and then there would be nobody to shoot back at. it just makes guys and when i say guys by the way mean men and women, that makes guys go berserk. i was in with a marine battalion once and we were hunkered down in this farm compound. somebody shot an rpg and

exploded amongst us. nobody was hurt but man you should have seen those marines. finally we get to fight back but you look out there and it was quiet. nobody out there. they were such a huge amount of frustration and that happens day after day after day after day after day. which explains some of the incredible violence in the the firefights were they to fight an enemy and they go after them tooth and nail. i think that adds up to a pretty significant psychological burden after a while. jonathan chase talked about this quite a bit in relation to vietnam. and you can find us, i think you mentioned you can find echoes of this at home. it goes way way back. this is not good stuff but these wars in particular because the enemy has been so elusive have been particularly hard psychologically.

>> hi. based on what you are saying about tts versus ptsd do you think the difference comes from the treatment like what you received or is it more kind of derived from the actual incidents that caused? >> well as it was explained to me it's all post-traumatic stress but one only gets diagnosed with the disorder that interferes with your daily life and that's generally after four to six weeks if it still keeps going. >> typically the post part of it when you're talking about the disorder has to do with the arrival of symptoms. it may not be immediate. it might be months or years down the road before you start to have the symptoms read what you have probably would be more accurately called acute stress because it was immediate.

and actually what i was thinking so much of the semantics of this are almost irrelevant to the person who's going through it. really for a lot of the treatment as well. you have clinical practice guidelines that tell us what are the best treatments, and evidence tells us what are the best treatments for ptsd? we don't have that acute stress or what we called an in the army combat and operational stress reaction. we don't have that necessarily but it doesn't mean that you can't pull from most other aspects. >> wait a minute, you don't have a way to treat stress? >> no i didn't say that. >> i misunderstood that. >> we have clinical practice guidelines that the doa and the dod published the tell us based on the evidence and research what are the three best ways to treat ptsd.

>> what are the three? >> paris prolonged exposure. >> i guess that's what i did actually by going over and over and over the incident. >> bears cognitive processing and then there's another therapy called emd are. i've movement. i.e. familiar with it? i've movement desensitization. i've got it written down because i always forget. >> you know what's strange about this is to have those three are things that -- and i think people ask about what his methods were even in the absence of these particular notes. he worked individually with people. he was patient with them and stayed up all night talking to them. that's how long it needed to be. he listened to people talking about their fears and their experience.

he didn't think it was magic but it was very humane and i think one of the things that's frustrating to us now is that medical systems are delivered in 15 minute increments or we don't have enough time to follow through with somebody. this is as true in civilian life as an military life. that is going to take as much as it takes to do this. i think just in terms of the social compact we ought to be willing to pay for what it costs to do the war so we did and that's really what it was about. it's anticipating this huge mental health crisis on the first world war. in insisting that it be something that was paid for. >> can you give us a quick dick and jane on what the rapid eye movement is? >> i won't be able to explain the mechanism of it but it is a process that uses and then you may be able to explain it better

than i can, but it's a way and he had to be trained how to do it on top of for example having a ph.d. in clinical psychology. additional training that you get a person to focus on for example my hand going back and forth like this. there's something that happens while they're doing that and talking about the event that seems to, remember i mentioned the hardware in earlier. there's something about that seems to break that so they are able to process the event better. >> so by having the eyes follow something going back and forth it must be affecting the right and left side of the brain. >> i don't actually know and i'm not sure that there's anybody who knows exactly what the mechanism is but to what the research tells us is that there's evidence that it works. >> i actually have a question

for someone watching livestreaming. are there any observable differences in ptsd between male and female soldiers and do they cope with it differently and are there symptoms similar? >> the diagnostic criteria are the same for men and women. an individual might have a different constellation of the symptoms are relieved that diagnostic criteria are the same for men and women. i think that women are more likely to have a concomitant depression with it that men aren't but that's only speaking very generally. between individuals i don't think you can specifically say there are differences between the genders. >> individuals that have been suspected as having ptsd have they exhibited an eagerness to -- because you said that

hypervigilance, anxiety and fear. you can't act that way at walmart so do they want to go back to war or any sort of violence so they feel they are acting normally or they are feeling comfortable? >> i think it's more accurate to say they feel more comfortable back in a combat environment so it's not necessarily that they want to be engaged in combat but they feel more at home in that environment oftentimes is what i have heard. >> i know guys who literally feel comfortable in combat. >> i have to say some of the reasons you would like to go back to a combat zone is not to be in combat but it's the people you're within a shared mission which is very hard to find stateside. there is the since when you're overseas whether you are on a news crew or diplomats were