Joseph Grenny is coauthor of four New York Times bestsellers, Crucial Conversations, Crucial Accountability, Influencer, and Change Anything.
During the month of July, we publish “best of” content. The following article was first published on May 4, 2011.
Dear Crucial Skills,
I have a longtime friend who is an Operation Iraqi Freedom veteran, experiences combat stress, and has been diagnosed with Post-Traumatic Stress Disorder. He was being treated at a Veterans Affairs hospital and things seemed to be going well. But recently, I’ve seen a change and increased symptoms—angry outbursts, avoidance, etc.—and can even see the strain reflected on his face. I tried to gently tell him I was worried about him and he told me he’s fine and “not going to group-hug therapy.” And now that he knows I’m concerned, he is avoiding me.
I know many of the veterans who finally get appropriate help do so under extreme duress. Do you have any suggestions on how to broach this with my friend and let him know he should think about modifying his approach to managing his condition?
Signed,
PTSD & Me
Dear PTSD & Me,
I asked for some extra advice on your question from my father—a WWII and Korean War Veteran with a PhD in counseling who still helps dozens of vets from the past seventy years of conflicts, even at age 84. Yes, I’m proud of him. I want to be sure I don’t speak beyond my competence in your very sensitive situation with one of our beloved servicemen—so I forwarded your question to him.
He suggests your friend’s delay in getting help is quite common. There are a host of “stories” he may be telling himself in order to justify delay—anything from minimizing the symptoms to trusting time will heal all wounds to doubting the efficacy of treatment to fearing a loss of self-esteem by admitting he has a mental health problem.
The line you walk in this crucial conversation is determining when you are exerting influence and when you are provoking resistance. Push too hard and your friend will resent your intrusion on his autonomy. Say too little and you’re enabling his illness and unwittingly prolonging his suffering. Each of us is likely in a similar situation with one or more loved ones. Here are some thoughts to keep in mind as you find the balance between influence and patience:
Make it about him not you. When someone ignores counsel, it’s easy to take it personally. You can tell you’re taking it personally when you start feeling hurt and angry rather than concerned and fearful. It’s so easy to begin with well-intended motives, but let them drift into a desire to control others—without even being aware of the seismic shift. Keep focused on what you really want, “For my friend to be as happy as he can be on the time schedule of his choosing.”
Make it safe. Make your motives crystal clear—and don’t just create present safety—create it for the likely future conversations you’ll hold. If your friend is resistant to being treated, get ready for the long haul. When you have your crucial conversation with him, anticipate the likely need of periodic conversations until he concludes he is ready to take action. If this were a dear friend of mine, here’s how it might sound. Please adapt to your own level of relationship and verbal style.
“Hey bro—I want to talk to you again about getting checked for PTSD. Would you please tolerate me for the next two minutes so I can make my pitch? If you think I’m full of it at the end, please know that I am okay with that. Even if you disagree with me, I just want to be sure you know that the only reason I’m bringing it up is because I love you. Also, I want to warn you in advance that if I continue to see things that make me think a real friend should speak up, I’ll probably bug you again. Is that cool?”
Your goal here is to clear a path for future conversations while asking permission to have this one. And of course if he says, “Back off!” you are obligated to do so. But even in doing so, I would make the following statement:
“Okay. I’m sorry to come across as crowding you—but I want you to know I am concerned and if you ever change your mind about involving me, I am here. Until you give me that permission, I’ll honor your request to leave it alone.”
Your goal here is to make sure he interprets your silence in the next few weeks not as agreement that there is no issue, but as respect for his autonomy. Of course, you should break this agreement if he begins to do something that puts himself or others in harm’s way.
Share facts not judgments. If he allows you to have this conversation, watch to see if your words sound like judgments or threats, or make him feel guilty. If so, you’ve crossed over to controlling rather than influencing. “You’re blowing it, dude” or “Your family can’t take any more of this” are attempts to coerce him, not influence him. If he is defensive at this point, you cannot motivate him. All you can do is help him find his own motivation to get attention. An attempt to rush it will cross the line into provoking resistance rather than exerting influence.
When you hold a crucial conversation with your friend on this topic, come armed with a handful of the most persuasive facts you can find to help your friend self-discover the need to be treated. For example, you could share that:
Psychological injuries are common. A recent study showed more than one in five Iraqi war veterans received psychological injury.
Typical symptoms include . . . The Nebraska Government has a brief self-survey on their website—you could pick the two to three symptoms which are most akin to what you see in your friend and use them for reference in your conversation.
Treatment can help. Often people avoid taking action not because they aren’t motivated, but because they doubt the efficacy of solutions. So they try to cope with things as they stand. A brief factoid sharing the percentage of people who see reduced symptoms after a couple of sessions might give him more confidence in trying a new treatment. It could be that his mental image is of lying on a couch for five years regurgitating pain with no real benefit.
Invite dialogue about his views. The only way to help a resistant person find motivation to change is to help him or her discover his or her own reasons for changing. You could open that possibility by ending this little monologue with a statement like, “Are things working out the way you’d like lately? If so, then I’m off base. If not, let’s talk about what’s going on, what you don’t like, and what it might cost you in the future if it continues or escalates. We don’t have to have that conversation now—but I’m here when you want to have it.”
I hope something in what my father and I have said provides a useful direction for you and for him. You have my heartfelt and sincere best wishes for your positive influence on this good man.
Warmly,
Joseph
To all who are suffering from PTSD, or whose loved ones are, I’d like to add a resource: a new acupressure technique is having good results in helping with PTSD. It’s called Meridian Tapping, and some examples are TFT, EFT, and TAT. Google these acronyms with the word “tapping” to find more info.
I fully support crucial conversations, but the brain has to be able to process them. Sufferers from major trauma have the limbic system of the brain (where fight and flight is activated) constantly activated, overriding their brain centers that think and reason rationally. The amygdala reacts in terror and rage several milliseconds before the reasoning centers of the brain can kick in and process. This is a completely natural reaction out of the conscious control of the person it’s happening to.
The acupressure techniques help calm this reaction so that the reasoning brain can function again. Acupuncture with needles is also helping a great deal. I have to pass these things on, they can help change the lives of trauma sufferers.
My heart goes out to this guy who gave so much for us. I am an RN who has worked briefly with some of these vets. They hide a lot. I wanted to share about a program that showed dog therapy, or having a dog to alert them, helps them feel safer. They are now without their buddies and sometimes a gun. Many of them do have guns still. The dog is not only a friend, but brings confort in alerting them to wierd sounds or movements.
Joseph,
Your response to this was outstanding. I was diagnosed with PTSD from years of sexual and emotional abuse as a child. I grew up in a very unsafe and hostile home environment, where my ex-Marine father ruled with fear and an iron fist. As a result, I have suffered with both depression and PTSD most of my life. However, after years of personal internal work, safe friendships and professional counseling, I can say that I live free from the results of what I endured. It took time, the right counselor and willingness to expose what often drove me to seek safety or withdrawal.
I appreciate your humility and recognition of the fact your insight was limited, and you therefore included your father. That incited deep respect from me instantly. Working through those issues was not easy, but it was worthwhile. And having loving friends around me like the original write of the question, was invaluable to my wellbeing. Thank God for friends who are true friends and that can speak a kind, truthful word in due season!! Those kind of friends are priceless.
Your advice overall was thorough and considerate. Thank you.
Gail
Joseph,
I have a brother who had a stroke recently, and is going through a very pained adjustment to the new facts about his health. Most of his frustration is expressed as anger, belligerence, and criticism of everyone’s attempts to help him. Your column is like manna from heaven today. Many of the soldier’s issues/problems apply in my brother’s case as well, and I needed some good, solid advice on how to help me deal with him. Thank you so much. Know that you have made a difference in more than one life today.
Peace & love,
Steven
As the significant other of a Viet Nam vet with PTSD, I’ve been through a lot in years past. I became co-dependent just as if he were suffering from an addiction. My life was miserable just as his was. A subsequent negative event sent him nearly to the edge of suicide. It took a monumental amount of effort to get him to counseling and a support group. Fortunately, his counselor had a group for significant others and I was able to get help as well. I truely believe the support groups saved our marriage, if not our lives. My comment to PTSD & Me: you can only change what you do, you cannot change your friend. Learn as much as you can about the subject and be ready for the tiny moment in which your friend will be receptive. Thanks.
As the first poster mentioned conversations are very important, but other approaches can also help. Sometimes with problems of this nature a head on approach can backfire.
You might suggest to your friend that he check out an online program.
Some people prefer the online approach because they feel less exposed and more in control. There are several good programs out there – of course check out the program before suggesting it – one I’m aware of is Vets Prevail. Just a note, I don’t work for them and have not used the service, but they seem to have a good program. Here is their website:
http://www.vetsprevail.org/
As a veteran and the sister of a veteran of the Iraq war I thank you for your concern. All the best to your friend.
Thank you to everyone for these comments. Thank you to Gail & Steve for your encouraging words about my advice. I’m sitting in the airport heading to Boston and feeling joyful that something I said might be useful to others. Thanks also to those who have offered additional resources. It shows you care.
@Gail
@Steven Chamblee
I am an Iraq veteran, have been diagnosed with PTSD. The situation sounds an awful lot like what I went through, prior to going through with treatment. One thing I can say is that I am so grateful for the people in my life that stuck with me and kept with me until I did go to treatment. If you have a vet in your life with PTSD, remember this: there are times that the PTSD is going to talk, point blank. Second, remember that they have PTSD, and this is going to shape their feelings. Third, we feel embarassed afterwards (I did anyways). The what I came up with in treatment is there are really three things that you have to agree with before you can even think about treatment, they are:
1. Belive you can be better
2. Be willing to put your heart into it
3. Know that you are worth it
Everyday that passes you may not feel like you are making much progress, the real progress is to look back and see how far you have actually came.
Joseph,
Thank you for this very valuable article. It is helpful in so many ways.
Thank you first and formost for the courage to address this issue. It helps remove the stigma of mental illness from veterans suffering from PTSD and others who suffer from a variety of mental illnesses.
As the daughter of a WWII/Korean War Vet and the ex-wife of a Vietnam War vet, I gratefully thank you for your thoughtful and sensitive approach to helping someone you love seek help for PTSD.
As the mother of a mentally-ill,treatment-resistant son who is deep in denial, the dialogue example you provided is absolutely invaluable in providing the language that is influencing rather than controlling.
I attend Family to Family class offered by our local National Alliance on Mental Illness (NAMI). The http://www.nami.com website also has some helpful suggestions for people dealing with PTSD.
Many in our class have family that suffer from PTSD and other mental illnesses. We continually search for ways to communicate our love and concern to family members in a way that is respectful and sensitive and ultimately effective. I will share this helpful article with them.
Lastly, many thanks to Ange Finn for her recommendation to try “tapping.” I, too, have PTSD and have found this treatment extremely effective. I also highly recommend EMDR, hypnosis and acupuncture.
Hello Joseph, As a result of attending a two day CC training in Chicago several years ago I have, on many occasions, recommended your book and website both professionally as EAP counselor at a large hopsital and personally to friends and loved ones.
In Chicago the trainer strongly discouraged our using the word “but” (I believed he called it a “but slap”) because using that word essentially negates whatever words preceded it. He recommended using “and” instead. So I am surprised to see it occasionally in the Crucial Skills newsletters and it appeared over five times in your excellent response regarding PTSD. So I am wondering if I missed something at the training. Can you shed any light on your use of the word but?
Thanks,
John
Great job! Love the article.
Thanks for the question John. I looked back over my posting and if I read it right, the word “but” appears twice in my recommended statements to the vet. The other appearances are in the text itself. My view is that it’s very wise to avoid use of “but” when it serves to negate the meaning someone else is sharing. Other than that, it’s a perfectly useful word. I like the trainer’s term “but slap” because I think it emphasizes this caution well. If you tell me, “People with PTSD have nightmares. I don’t have nightmares” and I begin my response with, “But you do overreact to loud noises!” I’ve essentially turned a dialogue into a debate. And there was no need to do so. Responding instead with, “I’m glad to hear that. That fact does raise doubt on whether or not you have PTSD” as your initial response helps get you out of the “but slap” trap. You point out what you agree with, then add additional meaning, without positioning is as contradicting that which the other shared when it’s unnecessary to do so. Does that make sense?
As I look at my two uses of “but” in the recommended statements I don’t think they appear to contradict a hypothetical statement from the vet. Do you? If so, then I would definitely change them!
Great point!
Lou Tice and the Pacific Institute have developed a PTSD training called “discovering the power in me” http://www.thepacificinstitute.us/v2/files/pdfs/BRO-DPM.pdf
I’ve facilitated the capstone curriculum (IIE) but not this. This is not marketed specifically for PTSD (perhaps for legal reasons) but I think it would help regardless.
Stephen
An excellent book, focused towards bi-polar and other behavioral health issues is “I’m Not Sick and I Don’t Need help”. This book was a saving grace when my adult son was diagnosed and going through a ver rough time. Through this book helping me to understand how to communicate with him, and by the grace of God he is doing so well now that to outsiders there is no problem at all. I know PTSD is a different disorder, but perhaps this book and guidance would help. I dearly hope so. God bless those effected and their caregivers and loved ones.
Joseph, I would be really interested to know what feedback you receievd in the two years since the original email was published from PTSD & Me about your/your Dad’s suggestions and the healing of his Vet friend.
Many thanks
Vernon
I delayed 10+ years seeking treatment from the VA “because other veterans are more seriously injured than I am.” Several of my friends pointed out that the traumatic injury vets and I would not be seeking help from the same clinic. Therefore, I would not be in front of a more seriously injured vet and it is OK for me to seek treatment for my injuries.
Joseph, I, like Vernon, was immediately curious about what happened with this serviceman. Have you received any feedback?
Also, I want you to know that I posted your letter on our company’s employee website. I’m a member of the Wellness Committee and decided this was a great letter to share the day before Independence Day. Hopefully, someone who’s experiencing the same situation as PTSD & Me will benefit from your wonderful advice.
Susan
It seems to me that this is very close to the kind of language you would use when a friend has an addiction or is making what you see as really bad choices. We have a family friend who is in that space between high school and what do I do next. He sometimes drinks and drives and probably uses recreational drugs a bit too much. He has moved into selling. He doesn’t need money it’s just more risk taking behaviour. I’ve had a few very careful conversations with him and then backed off. I’m excited because the words I used are almost exactly the same as you used. It isn’t working though … so is there a next place that the conversation can go?