Places to heal
With PTSD reaching well beyond combat veterans, trauma experts see need for spaces conducive to recovery
During the Vietnam War, Bob Curry flew more than 250 missions, most at night, most just above tree level. The Army intelligence officer tucked himself into a confined cockpit — one of two men strapped into ejection seats. Anti-aircraft fire was a daily fact of life and there was only one way to avoid it: by seeing it coming, assuming it wasn’t raining or foggy.
“And one silently wondered when the explosion would hit, followed by death,” he recalled.
These days, the 66-year-old is one of 653,400 U.S. veterans treated each year by the U.S. Department of Veterans Affairs for post-traumatic stress disorder. He goes out of his way to avoid poorly lighted, claustrophobic spaces in the same way other combat vets avoid July 4th fireworks. A man who once piloted combat aircraft won’t let himself have a driver’s license. He rides the bus everywhere.
And so it’s a cruel irony that he suffered a fullblown anxiety attack last year inside the Zablocki
Veterans Affairs Medical Center in Milwaukee — the very place Curry goes for healing.
He walked past the cramped front lobby with low ceilings and elbow-to-elbow rows of chairs facing a monitor playing daytime TV. He turned down one of the uniformly narrow corridors with hazy artificial lighting, needing to renew prescriptions for anti-anxiety and anti-depression medications.
He took a number, only to learn that his regular mental health specialist had left the VA. “I was asked to wait in the waiting area, which consisted of a very small walled area with no windows or sunlight. Jammed with chairs, vets and the TV blasting a reality murder channel.” His heartbeat accelerated. A nurse told him to fill out a form and keep waiting. He called a VA social worker in the building “but I could see she couldn’t help and she didn’t get it.”
“My anger, chest and blood pressure were pounding,” he journaled the next day. “This placing is triggering everything that brought me here.”
He fled without being treated.
Curry longs for places he calls sanctuaries — therapeutic places conducive to healing and recovery. Like many trauma experts, Curry says there aren’t enough of them. Ten years ago, he co-founded his own: Dryhootch, a coffee shop on Milwaukee’s north side that doesn’t serve alcohol but fosters nonjudgmental peer-to-peer support for vets — or anyone who wants a quiet latte.
When it comes to healing sanctuaries, the need is urgent for combat vets. But as more knowledge is gained about the role trauma plays in everything from poverty to drug abuse to joblessness to mental illness, the need is even more widespread for noncombat, nonmilitary PTSD sufferers.
Given the preponderance of the epidemic, a growing chorus of trauma researchers decry a lack of healing spaces in American culture.
“Most PTSD in this nation comes from causes other than war,” said Paula Schnurr, executive director of the National Center for PTSD, an arm of the VA. “It’s a public health problem.”
The U.S. National Institutes of Health, in the nation’s most recent and comprehensive study, estimates more than 14 million Americans will be diagnosed at some point in their lives with PTSD, as defined in the diagnostic manual of the American Psychiatric Association. That’s more than twice the population of Wisconsin and more than all but four of the 50 U.S. states.
The NIH conducted 36,309 face-to-face interviews to create a nationally representative cross section of the U.S. population. Only a relatively small share of respondents indicated that their most stressful life event stemmed from military combat, prisoner-of-war status, being a civilian in a war zone or being a refugee. Far more identified sexual assault before age 18 or “intimate partner violence.”
As a share of the population, a greater share of the American population with PTSD are located in rural regions (7.3 percent) than urban centers (5.8 percent), NIH data show. Because urban populations are more concentrated, however, PTSD geographically is most concentrated in poor urban communities, where trauma is so commonplace that it incapacitates the workforce and undermines the economy, as the Journal Sentinel reported last year in a multimedia series called A Time to Heal.
Until only recently, civilian trauma had been statistically invisible. Now that empirical metrics exist, however, the data are consistent and staggering. A separate estimate by the National Center for PTSD estimates that 7 percent to 8 percent of the American population would qualify for a PTSD diagnosis in their lifetime.
The enormity of the trauma epidemic lays bare the rampant levels of violence and abuse within American society — urban, suburban and rural.
“For every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes,” wrote Boston psychiatrist Bessel van der Kolk in his 2014 book about trauma, “The Body Keeps the Score.”
Environment design guidelines
The VA itself recently acknowledged the urgency for healing environments, a recognition some say is
overdue. This year, the VA approved its first-ever set of Healing Environment Design Guidelines — a 209-page document meant to influence all future construction, renovation and architecture at VA facilities around the nation.
The book, principally authored by architect Paul Alt, who grew up in Milwaukee, advocates natural light, easy access to nature and airy spaces that evoke safety and serenity. Healing spaces offer places to be alone and contemplative (“alienation and self-imposed isolation are major issues affecting the health and well-being of veterans,” the guidelines report). If vets seek peer-to-peer support, a healing “ecosystem” offers uncrowded spaces for discreet conversation without the loud drone of a TV, the guidelines advocate.
Ideally, healing settings integrate splashing water and plants and spill outside into the grounds with paths, trees, birds and gardens. Healing spaces are meant to calm anxiety, depression and guilt. Because the average VA hospital or clinic is 60 years old, the guidelines are meant to avoid a repeat of the cramped and dim medical mazes that are now offered to vets across the country.
At the core of the guidelines are arguments of economic efficiency. In an age of rationed care, which is meant to sink medical costs, it is counterproductive to add stress to patients on their way to mental health therapy appointments that only last 45 minutes, Alt said.
“The idea is to de-stress the patient and make the medical appointment more efficient. The doctor doesn’t need to spend time to get them to calm down, which wastes time,” Alt said.
Nearly identical symptoms
It wasn’t until 1980 that the American Psychiatric Association included the term PTSD in its diagnostic manual, mainly in response to mental health problems among Vietnam War vets. It didn’t take long, however, before nonmilitary public health workers recognized near-identical PTSD symptoms in the nation’s inner cities.
By the early ‘90s, psychiatrists treating urban residents were diagnosing sleep disorders, extreme startle responses, flashbacks, lost hope for the future, homelessness, alcoholism, suicide and even biochemical changes in the brain.
That’s when Alt became involved in healing spaces. As a young architect in Chicago, he was appalled by the violence in public housing projects, where children live amid chronic anxiety and too often died senselessly.
Alt took a special interest in DuSable High School on Chicago’s South Side. A few decades earlier, DuSable’s community had been known as Bronzeville and had a middle class. That changed after Chicago built the Robert Taylor homes, the largest housing project in the nation at the time: 28 high-rises of 16 stories each, spanning two miles of concentrated concrete, poverty, drugs and violence.
“If an environment can make people suffer, can’t a person’s environment make people heal,” Alt postulated.
The young architect taught for a semester at DuSable and encountered students walking the hallways “with thousand-mile stares,” skipping classes. Alt studied works on healing, secular and sacred. Eventually he designed a healing space meant for DuSable’s halfacre courtyard. He called it the Urban Ecology Sanctuary Project.
Now 57, Alt has known firsthand about the invisible scars of trauma since he was 8 years old. Living in a middleclass Milwaukee community in 1969, Alt witnessed a speeding car run over his 6year-old brother Leslie. “That’s how I relate to DuSable kids who held their bleeding brothers.”
Leslie Alt lives with traumatic brain injury in a nursing home in Chicago, a mile from Alt, who continues to care for him. “My brother is also the biggest inspiration of my life.”
Alt’s DuSable urban sanctuary was never built. In the mid-’90s it became clear that the Taylor homes were slated for eventual demolition, which drained the project of fundraising urgency and sponsors. But the young architect pressed ahead on other healing-centric projects. In 2007, he joined a think tank at the Walter Reed National Military Medical Center in Bethesda, Md., where he studied healing environments for mental health. “The U.S. military was desperate. They were fearful they couldn’t field enough combat-ready units because the ranks (of existing troops) were rife with PTSD.”
Alt began to work with vets, only to notice the similarities with traumatized DuSable kids. “You have to understand the level of injury. They had survivors guilt. And some had moral injury because they killed other people,” Alt said. “It’s not unlike what the kids experience in inner-city situations.”
The guidelines Alt put together for the VA are “built on the foundations of some of those kids’ ghosts,” the architect said.
Community war zones
Research in the last 10 years shows that civilian trauma is most prevalent in homes with chronic economic uncertainty or communities with shrinking economies.
It might be a cliché to call the inner city a war zone; to psychiatrists, however, there’s often little difference. Traumatized people often see the world as threatening and danger ridden. Flashbacks, anxiety attacks, sleep disorders and trouble breathing are common, along with depression and emotional numbness. PTSD is linked to hypervigilance to the point of creating so much toxic stress within the body that it leads to heart problems and physical ailments.
PTSD often traces back to a searingly horrific event that divides someone’s life into a “before” and “after.” Some repress the mental repeat loop of traumatizing memories through alcohol and drug abuse. People with PTSD are at heightened risk of homelessness, bipolar disorder and suicide. Often trauma ripples from generation to generation as traumatized parents inflict trauma on their own children.
The VA commissioned the healing guidelines after it realized it couldn’t find a working definition of a “healing environment” and how it related to veteran needs, said Gary Fischer, a senior health care architect in the VA Office of Construction & Facilities Management.
The Milwaukee VA center, known as the Zablocki, was designed two decades before the term PTSD even existed — in the same era as the Taylor homes.
These days, one in four of all VA patients is treated for mental health issues and more than half of them are treated for PTSD. The VA has over 200 specialized programs to treat PTSD. But some vets at some VA facilities don’t even make it to their VA appointments, Fischer said, echoing a common complaint. “It’s a factor of their PTSD,” Fischer said. “These older buildings are a product of their times.”
Gary Kunich, a spokesman for the Zablocki medical center, said the Milwaukee facility has been undergoing almost continuous renovations for years. “Every construction project we do, every renovation we do, is with a veteran in mind, to create an optimal healing environment,” Kunich said.
Those seeking quiet can sit in the library on the sixth floor. Most recently, one of the two main entryways was renovated to add space and a wall of glass (the well-trafficked entry off the parking lot is the one that Curry used last year on the day of his panic attack).
The Zablocki does have extensive spaces conducive to healing, but they are outdoors — a broad expanse of pastoral space and historic nonmedical buildings. It owes its inheritance of parkland to a fluke of history: in 1865, when Milwaukee still was mainly prairie land, then-President Abraham Lincoln chose Milwaukee as one of the first three National Homes for Disabled Volunteer Soldiers, which evolved over time into the VA.
Milwaukee’s VA grounds still have ponds where Civil War vets once relaxed in rowboats. The ironwork roof of Miller Park stadium is visible over the treeline.
Homegrown healing space
Bob Curry has gone to the Zablocki for 15 years. Many vets never even bother with the VA, he said. “I call this ‘Soviet 1950s design’ — very utilitarian,” Curry said, pausing in a first-floor hallway in the Zablocki.
Curry knows he’s not the only one who never made it through the fluorescent maze to a therapist appointment. “If your blood pressure isn’t through the ceiling, it will be by the time you get to your appointment — if you get to your appointment,” Curry said. “They put those TVs in here with no regard for the people who come into the building.”
Curry served in Vietnam in the early ‘70s. After returning to the United States, he didn’t want to think about the war. He had stable employment for years doing tech work at IBM and AT&T.
He became a binge-drinking alcoholic who lived in denial of his addiction. His life changed in 2002 when he woke up one day in police custody. The police told him that he’d driven into a motorcyclist and killed him. He had no clue what happened.
“I was thrown in jail and tried to commit suicide that night. And I was pissed it didn’t work.”
Curry says he owes his recovery to peer support. Other vets helped him stay sober. He lived in a halfway house run by a Vietnam vet. A Gulf War Marine who became an attorney won an acquittal for Curry on mental health grounds, citing PTSD.
Peer recovery centers, either civilian or military, work on the same idea: for many, the bridge to healing is to trust a peer enough to share one’s pain, a peer who has gone through a similar ordeal, a peer who can empathize. It’s an authentic rapport that’s found less frequently with institutional therapists who have tight time slots.
Brainstorming with other vets led Curry to co-found one of Milwaukee’s most successful homegrown healing spaces: the Dryhootch coffeehouse.
The healing environment Curry cocreated is named after a “hootch,” military jargon for a shelter or bunker. It opened 10 years ago on Brady Street as a dry drop-in center for vets who can talk to other vets in a nonjudgmental place, often beginning with “where did you serve?”
It’s a nonprofit, funded by grants and donations, and open to the public. It might look like a homey independent latte shop where one can plug in a laptop — save for the metal ammo box repurposed as a tip jar or an occasional pamphlet on the 12-step program. More often than not, the barista is a vet.
Curry has observed vets who come into Dryhootch and sit by themselves for weeks, quietly observing everyone else before they engage in conversations.
Five years ago, a second Dryhootch opened on National Avenue across the street from the Zablocki — the “Dryhootch Forward Operating Base.” Then one opened in Madison. Dryhootch cafes in Chicago and Atlanta are in the works. Each will be operated and supported by local vets.
President Barack Obama honored Curry at the White House in 2013. Last year, Curry was named to the Milwaukee County Mental Health Board.
And Alt enshrined the idea of Dryhootch in the guidelines, endorsing the idea of peer-to-peer cafes in all VA facilities across the nation.
But the need for healing spaces reaches far into American society, Alt argues.
“The guidelines can be applied to any civilian center or school or hospital, so it’s the VA’s gift to the nation,” Alt said.