The Twelve-Step Approach to PTSD


by Joel Brende, MD

Editor’s Note: It has been stated many times that first responders have a kinship with Vietnam Veterans. Why? Because, like these Vets, they are asking – no, demanding! – help  in coping with the horrific images, nightmares, and the other mental and emotional casualties of their professions. Lewis Epright, Sr., a Vietnam Veteran and firefighter, has asked me to share these twelve steps that he and others have found invaluable in coping with their traumas. Thank you, Lewis, for your service and your friendship.

Step One (Power)
Our first step is to accept the fact that we have become powerless to live meaningful lives. Even though we had the power to survive against the worst combat conditions, we must admit we have become powerless to win the battle against a new enemy—our memories, flashbacks, and combat instincts. Some of us have become powerless over the continuing wish to gain revenge over those sudden impulses to hurt those who cross us or unsuspectingly annoy us. We even hurt those who try to love us, making it impossible to love and care for our friends and family. So we isolate ourselves and cause others to avoid, dislike, or even hate us. Our attempts to live meaningful lives and fight this psychological and emotional hell which imprisons us seems to be in vain. We now find ourselves powerless to change it.

Step Two (Seeking Meaning)

Our next step is to seek meaning in having survived. If we are to survive this new battle, we seek meaning in having survived. We want to believe we have survived for a purpose. We would like to be free from nagging thoughts telling us we should never have left the battlefield alive—the place where our comrades gave their lives in war. We want to believe our lives will serve a better purpose if we are alive rather than dead. Thus, even though we often doubt that living is better than dying, we seek to find meaning in life rather than death, and hope to find life a privilege rather than a burden.

Step Three (Trust)
Our third step is to begin to find relief by seeking help from God as we understand Him, and from persons we can learn to trust. If we are to find relief, we seek a source of help from persons whom we can learn to trust. Many of us also would like to trust God, as individually understood, and ask Him to show us the way out of our mental prisons, renewing our sensitivities to human emotions and spiritual qualities we fear we have lost.

Step Four (Self-Inventory)
We will make a searching, positive inventory of ourselves. After taking the step of seeking and accepting help, we find ourselves aware of many negative qualities. In fact, although we might be willing to trust, we may fear that revealing ourselves to others will only be a negative experience. Thus, we ask a person we trust, and a higher power, to help us see our positive qualities. In that way, we can honestly evaluate the presence of both desirable and undesirable qualities.

Step Five (Rage)
We will admit to ourselves, to God, and to a person whom we trust, all our angry feelings and homicidal rage. With an awareness that we are not alone, with improved self-esteem, and with a newfound desire to trust, we hope to understand the reason for our continuing rage. We will take the risk of revealing our angry feelings to a person we trust and God as individually understood. In so doing, we will discover that our anger is likely to be our only defense against helplessness and experiencing other emotions. Thus, this important step will help us open the door to other painful memories and emotions.

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Step Six (Fear)
We will open the doors to the past and reveal to God and another person whom we trust, our frightening, traumatic memories. After beginning to realize that anger is often a defense against fear, we will now begin to understand the link between the two. In this way, we can begin to accept the fact that fear is normal and relief from fear may be found by facing it with the help of someone we trust and of God, as individually understood.

Step Seven (Guilt)
We will ask forgiveness from God as we understand Him, and recognize we are thus free from condemnation. We ask for and accept forgiveness from God, and a person whom we trust, for committing, participating in, or knowing about acts committed which were unacceptable in our eyes, causing suffering and grief for other persons and now causing us to feel tormented with guilt and self-blame. After having accepted forgiveness from God and from another person(s), we can now forgive ourselves. But we recognize that old habits of self-condemnation are difficult to break. Thus, self-forgiveness must be a daily matter.

Step Eight (Grief)
We seek strength and support from God and another person to finally grieve for those whom we left behind. We seek strength to complete the grieving process for those who have died. We would like to finally be free, shedding tears without being lost in unending grief. This means also being able to understand the link between grief and all the feelings we have harbored for many years: anger at those who left us alone, guilt about surviving while others were killed, remorse for failing to save people who died, and yearnings to join those whose bodies have already been buried.

Step Nine (Forgiveness vs. Self-Condemnation)
We reveal to ourselves, God, and those we trust, all remaining suicidal or self-destructive wishes, and make a commitment to living. We wish to expose and purge those negative forces within us which still may prevent us from making a complete commitment to life. Thus, after further self-evaluation, we reveal to ourselves, to God, and tho those whom we trust, all remaining suicidal wishes, and ask to be purged of the remaining, destructive, death forces which have ourselves and others. Then, we seek and accept God’s daily strength to make a daily commitment to living.

Step Ten (Forgiveness vs. Revenge)
We reveal to ourselves, God, and another person, all remaining wishes for revenge, and ask for God’s strength to give these up. We seek and accept God’s strength to give up our wishes for revenge toward those who hurt us and injured or killed our friends and loved ones so we can learn the full meaning of love of God, of others, and of ourselves.

Step Eleven (Finding Purpose)
We seek knowledge and direction from God for a renewed purpose for our lives. Having been freed from those burdens which have kept us from having meaningful and purposeful lives, we are ready to find a renewed purpose for our lives. Recognizing that God’s power also can be a source of strength to live, we will daily seek freedom from old burdens or new problems through prayer, meditation, and a daily surrender to God. In this way, we can continue to find daily freedom from the past prison of rage, guilty memories, and impacted grief, and gain a knowledge of His purpose for our lives and the endurance to carry it out.

Step Twelve (Loving and Helping Others)
Having experienced spiritual rebirth, we seek God’s strength to love others and to help those who suffer as we have. Having had a spiritual awakening as a result of these steps, we seek to carry this message and to help all those who suffered as we have suffered.

Other pertinent resources:

When Serving Becomes Surviving: Suicide and PTSD in the Fire Service by Peggy Sweeney

Spirituality Today; Winter 1989, Vol.41 No. 3, pp. 319-340.
Post-Traumatic Spiritual Alienation and Recovery in Vietnam Combat Veterans
by Joel Brende and Elmer McDonald: