December 29, 2017
Nikki Wentling | Stars and Stripes
SALT LAKE CITY — AnnaBelle Bryan knows the therapy is working when she hears the laugh.
She hears it through the wall separating her office from her husband’s, and she almost always hears it during a veteran’s fifth or sixth session. She knows that in a few short weeks the person laughing will test negative for post-traumatic stress disorder.
And she’s usually right.
In the basement of Building 73 on the University of Utah campus in Salt Lake City, veterans and psychologists AnnaBelle and Craig Bryan have researched and developed suicide-prevention and PTSD treatments with near-perfect success rates.
In the cramped offices of the National Center for Veterans Studies, which the couple runs, they’ve treated a National Guard spouse who experienced childhood sexual abuse, a burly former Special Forces soldier, homeless Vietnam War veterans who lived with PTSD for decades, and many others.
They’ve conducted studies for the Defense Department about PTSD therapies and crisis-response planning for suicidal veterans and servicemembers. They travel across the country teaching their techniques to as many people as possible to save as many people as possible.
Every day in 2014, an average of 20 veterans succumbed to suicide, according to the latest available data from the Department of Veterans Affairs. At a time when the VA and Defense Department are promising big, bold steps to prevent veteran suicide, the Bryans said they have something that works — and they’re doing their best to spread the message.
Though they receive funding to study treatment methods — not to put them into practice — the Bryans answer calls from patients any time of day, treat them during off-hours and are growing their staff to meet the demand.
Sitting beside his wife this October in a windowless office no bigger than a walk-in closet, Craig Bryan asked: “If it’s not us — then who?”
A second chance at life
Army veteran Dolly Murphy, 52, almost left the Bryans’ 14-day intensive PTSD therapy program with only three days left.
For months, she had been sleeping in the walk-in closet of her large tract home in a Salt Lake City suburb, only leaving the house for quick trips to the grocery store or for one of the many other PTSD therapies that she tried.
Before a session at the local VA last year, she waited in the employee lounge, where she was permitted to go because she didn’t like being around many people. There, she spotted a pamphlet for the Bryans’ session, called the R&R program — two weeks at the National Abilities Center in Park City, combining daily therapy with recreation.
Murphy had tried traditional therapy, group therapy, a recovery-through-sports program and one for women with military sexual trauma. She’d make progress, she said, then backslide.
“At that time, every day I still thought about suicide, that I could die today and nobody would know I was gone,” Murphy said. “I wanted to find something that was going to help.”
She signed up for the Bryans’ next available session in January 2017. She left home five hours earlier than necessary and drove in snow through the Wasatch Mountains to Park City.
A week and a half later, she finished a one-on-one session feeling raw, having faced memories she’d been trying for years not to remember. She had nearly talked herself into leaving the center many times because it was getting too difficult. Murphy packed her car and was on the way back to her room to get the last of her belongings when Craig Bryan stopped her to persuade her to stay.
For the next 6½ hours, the Bryans talked with Murphy as she paced in her room and wrung her hands. She finally calmed down enough to remember she had come there for a purpose and wanted to finish it out.
The program — just one of many projects in which the Bryans are involved — includes one 60- to 90-minute session of cognitive processing therapy each morning and activities in the afternoon. Instead of focusing on reducing symptoms, the therapies aim to boost problem-solving skills and the ability to regulate emotions.
The Bryans have led three of the 14-day sessions, each with about 12 people, about a third of whom struggled with suicidal thoughts or had made attempts. At the end, slightly more than 75 percent recovered from PTSD, Craig Bryan said, and others saw some reduction in their symptoms.
The couple is constantly updating data from their therapies, trying to find trends and evidence to help others.
“How could I not do my best for someone who is that driven to help me get better?,” Murphy said. “That’s what kept me there, through the fears, the triggers — through the whole ordeal.”
Murphy joined the military in 1982 at 17 at a recruiting station in Cedar Rapids, Iowa.
She said she was raped five times during her seven-year career and she has been struggling with the effects. Murphy attempted suicide twice, once at 30 and again in 2012. At the time, she was recently divorced, reeling after the death of her father, had a splintered relationship with her only child and felt trapped in a hostile work environment. She had just moved alone to Utah from her home state of Iowa.
The suicide rate for veterans is significantly higher than for civilians, and for women the difference is even greater. In 2014, 19 female veterans for every 100,000 died by suicide — more than 2 ½ times higher than that of civilian women, according to the latest VA data. From 2001 through 2014, the suicide rate among female veterans increased almost 63 percent.
After her last attempt, Murphy became a recluse. She would peek out her closet window at the good Samaritan neighbors who mowed her yard without being asked. When her dogs, Digby and Sophie, needed to go outside, she sat at the sliding glass door leading to her backyard and peered around blackout curtains until they were done.
Nearly one year after the Bryans’ 14-day program, Murphy no longer meets the clinical criteria for PTSD.
Murphy joined the Mormon church and is active in her local congregation. She bakes cookies every week for homeless veterans. She sleeps in her own bed. She walks her dog. She interacts with her neighbors.
The Bryans have worked with hundreds of veterans and servicemembers during their careers. Even so, they saw Murphy as one of their most dramatic turnarounds. She went from struggling with suicidal thoughts every day to being almost rid of them.
During her therapy, Murphy created a crisis-response plan, steps someone should take when thinking about suicide. She keeps her plan on a piece of paper tucked inside a binder full of information she received from the Bryans and from other PTSD programs.
“Someone like Dolly, who really struggled with suicidal thoughts, this gave us a platform to work with her, to say, ‘You got this. I know it’s hard. I know it’s challenging. But we believe in you, and you have a list of things you can do to take care of yourself,’ ” Craig Bryan said.
Murphy’s treatment is ongoing. Craig Bryan took her through a separate suicide-prevention therapy program, and Murphy has the help of a VA social worker. She uses a telehealth appliance called a Health Buddy to take her weight and blood pressure every day. It prompts her to answer questions such as, “Did you complete your journal entry last night?” and “Did you avoid contact with people today?”
There are times when Murphy worries she’s backsliding. When that happens, she’ll message AnnaBelle or Craig Bryan, or try to imagine what they’d tell her.
“I have to remind myself, had I not gone through all that I’ve gone through, I wouldn’t be the person I am,” Murphy said. “I wouldn’t be so driven. I wouldn’t be where I am now.”
A trip to the grocery store used to take days of planning, gearing herself up to go from Point A to Point B. Now, Murphy is spontaneous. She explores. She takes the back roads.
“I feel like I have my life back,” Murphy said. “What came out of this treatment was, I can face things and deal with them. I have a second chance at life, and I’m going to live it.”
On a Saturday morning in late October, 30 motorcyclists with the Combat Veterans Motorcycle Association drove along the highway across Great Salt Lake into Antelope Island State Park. Near a memorial to 12 troops who were killed in a helicopter crash there in 1992, the leather-clad veterans handed over a check to Craig and AnnaBelle Bryan for $35,000.
It was the proceeds of their annual Ride to Zero fundraiser, and for the third year, they’ve given the check to the National Center for Veterans Studies.
Utah’s veterans suicide rate is significantly higher than the national average, according to information released by the VA this year. It’s more than 62 veterans for every 100,000, while the national rate is more than 38.
The same is true for other western and rural parts of the country, such as Montana, Nevada and New Mexico. The report suggests lack of access to health care, gun ownership and opioid addiction might play a role.
The motorcycle group knows the statistics, and it continues to contribute to local suicide-prevention efforts. For Ryan Fleischman, executive officer of the chapter, choosing who should receive the Ride to Zero money was personal. The group was searching for a recipient just after his former sergeant in Afghanistan committed suicide.
“That was a driving factor for me personally,” Fleischman said. “We found NCVS in our own backyard. It was a no-brainer to try to raise money for them. Their programs are proven to work and save lives.”
The military community in Utah is taking more notice of the center. The Bryans help with peer-support programs at the Utah Air National Guard and trained some mental-health professionals in crisis response at the VA Salt Lake City Health Care System.
The Salt Lake City chapter of 100 Women Who Care, a national organization of local chapters that raise money for charities, gave $14,000 last year to send six local veterans to the Bryans’ two-week program in Park City. Another nonprofit, Project Unbreakable, is trying to get treatment for veterans outside Utah.
Husband-and-wife Justin and Kimberly Lee run Project Unbreakable from their home in Ogden, Utah. Both are Air Force veterans of Operation Iraqi Freedom, and they’ve both struggled with suicidal thoughts and PTSD.
They‘ve also both been through the R&R program with Craig Bryan. Now, they refer others to Bryan and help pay their travel expenses.
“We’ve both been to a point where we wanted to take our own lives, so we started this foundation to help other people through their struggles,” Kimberly Lee said. “There have been so many years of war, and not enough mental health resources to take care of everybody who is damaged by that war.”
For Kimberly Lee, the treatment at the center was different than others she’d tried. They directed her more toward identifying and understanding PTSD symptoms than focusing on trauma.
It also helped that Bryan was a veteran, she said. She deployed to Iraq with him in 2009. She knew he understood.
The consequences of war
The thought of joining the military first came to Craig Bryan in 2003 while he sat in a graduate-level psychotherapy class at Baylor University in Waco, Texas, on the morning after the invasion of Iraq.
“My instructor started class with a discussion about what was happening in the world,” Bryan recalled. “His argument was, as a nation, we weren’t talking enough about the consequences of war and what the implications of military action would be in Iraq and Afghanistan. He said as psychologists, we will play a very critical role of addressing those consequences.”
Bryan graduated in 2006 with a doctorate in psychology. By then, the Iraq War was raging.
One of his instructors, David Rudd, a former Army psychologist who founded the National Center for Veterans Studies, encouraged Bryan to enlist.
“I just remember thinking that as a psychologist you can work at counseling centers, hospitals, the VA, but there are very few opportunities to work side-by-side with those who are bearing this burden,” Bryan said. “I joined because I could make a difference. I could be there with them in a way I would never be able to if I remained a civilian.”
Bryan was trained as an Air Force psychologist and deployed to Iraq in 2009 to work in primary care. He started to develop his short-term, goal-oriented method for PTSD therapy.
Deployed troops often refused to seek mental health care. Many arrived at primary care complaining of trouble sleeping, agitation, headaches — obvious symptoms of PTSD, Bryan said.
He began offering brief, targeted interventions about servicemembers’ day-to-day stressors. Bryan tracked data on the outcomes and realized the therapy was working.
“The question in Iraq was, how can we treat PTSD when we only have four or five days to work with someone?” Bryan said. “Now, our R&R program, where we meet with a veteran every single day – that was based on what we were doing in Iraq.”
Six years after Bryan deployed to Iraq, the National Center for Veterans Studies conducted a study of 156 active-duty soldiers who had been hospitalized for suicidal ideation, pitting their method — “brief cognitive behavioral therapy” — against “treatment as usual.” Standard treatment included group therapy, medication, substance abuse therapy and support groups overseen by military mental health clinicians.
Their treatment method amounted to 12 outpatient psychotherapy sessions, usually one each week, from 60 to 90 minutes and taught crisis-resolution and emotion-regulation skills, such as relaxation and mindfulness, and targeted feelings of hopelessness and guilt. They found the 12 sessions led to a 60 percent decrease in suicide attempts.
After two years, eight soldiers who went through the 12 sessions had attempted suicide. Of those who went through treatment as usual, 18 attempted suicide.
AnnaBelle Bryan was also deployed in 2009 to Iraq, where she served as a public health technician with the Air Force and met Craig Bryan.
Two weeks after he returned to the United States, Bryan left the military and joined Rudd at the University of Utah. He and AnnaBelle began dating a couple of months later, and they married in 2011. After she retired from active duty in 2012, AnnaBelle joined her husband at the National Center for Veterans Studies.
For a while, the couple shared a desk. Now, they’re running the operation and trying to grow their team.
The last Monday in October, the Bryans were in their offices until after 7 p.m., which is typical. Four veterans had called the previous week and asked to start the 12-session therapy program.
Craig Bryan testified to a Senate committee in September about suicide prevention. At the time, the Bryans told Senate staff that they were worried for the day when they’d get a call from a veteran seeking treatment and, because their small team is overloaded with work, they’d have to start a wait list.
“A week or two later, it started happening,” AnnaBelle Bryan said. “Fortunately, we had two people who stepped up to help, so we’ve been able to stay ahead of it. But it’s now going to happen again.”
Teaching others to save lives
While lecturing, Craig Bryan strode through a conference room at the Salt Lake City courthouse Oct. 27, where about 35 juvenile administrators sat at a half-dozen tables taking notes.
“People do have reasons for living, even in their darkest moments,” Bryan told them. “Our job is to help them remember that.”
As with veteran suicide rates, Utah and other western mountain states have a consistently high rate of youth suicide.
From 2012 to 2014, Utah ranked eighth nationally in youth suicides, and it’s the largest cause of death for Utah’s population of 10- to 17-year-olds, according to the latest report from the Utah Department of Health.
According to a 2011 study published in the National Library of Medicine, 63 percent of youth who die by suicide in Utah were involved with the juvenile court system.
Most minors in Utah’s juvenile court system cross paths, at some point, with someone in that conference room.
The state of Utah pays Bryan to train groups of people across the state who are in positions to intervene. He takes them through crisis-response planning techniques that he developed for veterans and servicemembers, in which the person in crisis is directed to write an individualized plan onto an index card.
The plan includes warning signs for that person, things they can do on their own to calm down and a list of what they see as their reasons for living. Phone numbers for people they can contact, such as a friend or family member, are also on the card, as well as numbers for emergency support services and a final direction to call 9-1-1 or go to the hospital.
The intervention involves more than writing out a plan on a card. The court workers were instructed to ask certain questions, with the intention of changing peoples’ thinking.
“We get down to the bottom. We start changing their capacity to regulate their emotion, and we also change how they think about themselves in the world,” Bryan told the group. “We force them, in this intervention, to look at the bigger picture.”
Bryan directed the court administrators to split into pairs and role-play, one person as someone going through crisis and the other leading an intervention. The process took about 30 minutes, and then they switched roles and did it again.
“We don’t actually need long-term treatment to reduce suicidal behavior,” Bryan said. “One conversation — 30 to 60 minutes — if you do it in a certain way, reduces suicide attempts dramatically.”
According to the study of crisis-response planning conducted by the National Center for Veterans Studies, crisis-response planning reduces suicide attempts among military personnel by 76 percent.
Back in August, Bryan traveled to Blanding, Utah, five hours southeast of Salt Lake City, and spent the day teaching crisis-response planning to clinicians, teachers, faith leaders, correctional facility staff and community leaders — about 50 people in total near the more than 17 million acres comprising the Navajo Nation Reservation, where there’s been an increase in teen suicide, Bryan said. It’s remote, with little access to health care providers. Like with the juvenile court administrators, the state of Utah sent Bryan there to coach people what to do when approached by someone in a mental health crisis.
The Bryans also recently held a training at Fort Belvoir in Virginia and were planning trips this winter to teach at conferences in San Diego and Colorado Springs.
The Defense Department has provided grants for Craig Bryan’s research into crisis-response planning, as well as the 12-session PTSD therapy developed and tested by the National Center for Veterans Studies. So far, the studies show the methods are effective in preventing suicide attempts in veterans and servicemembers. Though one study was published almost three years ago and the other last January, leadership hasn’t made moves yet to widely share the approach to suicide prevention among the military health system. Bryan says the department is waiting on more research on the treatment method before pushing it out.
AnnaBelle Bryan explained the methods are practiced only by the small pockets of people whom she and her husband have time to train.
Changing a culture
When President Donald Trump’s VA secretary, David Shulkin, arrived in office, he quickly named suicide prevention as his top clinical priority and promised increased access to mental health care.
In July, the VA began offering urgent mental health care to veterans with other-than-honorable discharges, who previously were not eligible. The agency opened a new call center for its veterans crisis hotline in September.
In October, Shulkin promised lawmakers “big, bold” steps in suicide prevention, and he designated November as “Veterans Month,” during which he issued a public-service announcement asking the public to reach out to veterans in crisis. Actor Tom Hanks narrates over photos of veterans and servicemembers in the PSA, encouraging people to reach out to veterans in crisis with “a handshake, a phone call, a simple gesture.” The video initiated the monthlong social media campaign #BeThere.
VA data shows veterans not enrolled in VA health care commit suicide at a higher rate than VA patients. Of the 20 veterans who succumb to suicide each day, 14 don’t receive VA treatment.
Shulkin called it a national public health issue that will require a concerted, national approach.
“When we make the decision to send our young men and women into harm’s way, we have to be prepared for the impact of that decades and decades later,” Shulkin said in a November interview.
Craig Bryan agrees.
Bryan has some critiques about the therapies that the VA chooses to uphold. The latest example, he said, was the VA’s decision this month to offer hyperbaric oxygen therapy to some veterans with PTSD. The therapy has been studied profusely with some positive results, but it isn’t approved by the Food and Drug Administration as a PTSD treatment. Shulkin acknowledged it was an off-label use of the therapy but argued the VA must be open to new ideas.
While the agency is lifting up alternative suicide-prevention strategies, the Bryans are growing frustrated their evidence-based therapies don’t get enough support.
Even with his criticisms, Bryan said the VA is the standard-bearer in mental health care, and the rest of the field needs to catch up.
“In order to reverse the trend of veteran suicide, we need to adopt the newest strategies that have garnered the most scientific support, even though they may depart from existing procedures,” Bryan told a Senate committee this fall. “The changes should not just target the VA and DOD, but all clinicians in all settings. We’re at a critical turning-point; effective strategies have been identified.”
He’s appealed to Congress and the Utah legislature that future mental-health providers need better education on evidence-based therapies while still in school. According to a report by the American Association of Suicidology in 2012, only half of psychologists received training in suicide risk-assessment and intervention during graduate school.
Bryan is also attempting to eradicate the idea that PTSD is a chronic condition with no effective treatment, which he says is a myth that pervades the field. Over the years, that notion has prevented many patients from getting better, he said.
“What bugs me to no end is this mindset of, ‘My patient can’t handle it. Because when you tell that to your patient, the message you send is, ‘You’re broken. There’s something wrong with you, and I think you’re too fragile to handle this,’” Bryan said. “Our approach is, ‘You can handle this. You’ll feel overwhelmed, but I will support you. This is how we can recover.’”
The Bryans have lofty goals for the National Center for Veterans Studies. They want to successfully treat PTSD and bring down suicide rates. Maybe the most ambitious is to change the culture of mental health care in the United States.
When some of their patients arrive to their office on the university campus for the first time, they tell Craig or AnnaBelle Bryan that other therapists insisted they’d have to treatment for the rest of their lives.
The Bryans say it takes 12 weeks.
And sometime during the fifth or sixth session, AnnaBelle can usually tell whether that will be the case.