Surviving War Was Only the Beginning | PTSD Part 1

[00:00:00] But really about a year after I got hurt, it kind of hit. The world kind of closed in on me and was like, hey, I'm going to be missing two limbs for the rest of my life. I will have the knowledge and understanding that I lost two of my guys for the rest of my life.

[00:00:22] This is not something that's untreatable. This is not something that we don't have appropriate interventions to help treat it. Post-traumatic stress disorder is not something that makes the person scary or unsafe to be around. This is something that's absolutely treatable.

[00:00:39] It is a complex system that can be very difficult to navigate, especially if you're navigating it in a time when you're perhaps struggling in that moment. And so access to care is a huge piece. So whether it's provider capacity, it's transportation, the ability to afford the care. If veterans are making decisions between paying for their rent or paying for care that they're accessing in the community, that's a problem.

[00:01:06] Hello, and welcome to the At the Waters Edge podcast. Not all war wounds are visible, and sometimes the ones that are hardest to see do the most damage. Over the course of the global war on terror, we saw tremendous advances in how military medicine could treat the physical injuries of war. Service members survived wounds that would have been fatal in previous generations. But we have not seen that same level of progress in how we understand, treat, and talk about the mental injuries of war.

[00:01:34] Today, we are beginning a multi-part series on one of the most widely discussed and most misunderstood of those injuries. Post-traumatic stress disorder. Most people have heard of PTSD, but very few understand what it is, what it isn't, how it affects the mind and body, and what treatment options are available. Somewhat ironically, as awareness of PTSD has spread in the public, so is the stigma associated with communities that are assumed to be most affected by it, particularly the veteran community.

[00:02:03] This series will look at PTSD from a number of angles. What it is, why so many veterans wait so long to get care, how effective current treatments are, and what the future of care may look like. For part one, we start with the Wounded Warrior Project, one of the most prominent veteran service organizations working in this space. You'll hear from Dr. Aaron Fletcher, who leads the Wounded Warrior Project's Warrior Care Network, an accelerated mental and brain health program for veterans and their families.

[00:02:29] You'll hear from Ryan Cools, an Iraq veteran who lost an arm and a leg in an IED attack, later dealt with the mental health impact of that trauma, and now runs Project Odyssey, Wounded Warrior Project's experiential mental health care program. And you'll hear from John Eden, Wounded Warrior Project's vice president of complex care, who oversees the organization's broader mental health continuum, and explains why getting veterans care is often less about one single treatment than it is reducing friction in a complex system.

[00:03:00] Before we get into experimental treatments, psychedelic drugs, and what the future of PTSD care might look like, we need to start with the foundation. What PTSD actually is, why is it so misunderstood, and what recovery can actually look like when veterans get the care they need. With that, let's start with Dr. Fletcher. My name is Erin Fletcher, and I work for Wounded Warrior Project. I am our director of our Warrior Care Network program, which is on our mental health side of the house.

[00:03:30] This is Wounded Warrior Project's investment in a partnership with four academic medical centers across the country that delivers evidence-based, accelerated mental and brain health care to veterans and their families. This is a program designed to help veterans struggling with post-traumatic stress disorder, depression, anxiety, military sexual trauma, traumatic brain injury, things of that nature. PTSD is something that folks hear about a lot in media.

[00:03:55] It's become sort of a buzzword during the global war on terror, but there's also a lot of misconceptions out there about it. What exactly is post-traumatic stress disorder, and what is it not? So post-traumatic stress, if we think about it in the simplest terms, it's a condition that occurs sort of in our brain's response to danger.

[00:04:19] Okay, so an individual has experienced something so terrifying or so overwhelming that it became too much for the brain to process in that moment. And so individuals struggling with these symptoms feel like they're still stuck in that moment. Their brain can't kind of process that they're safe now.

[00:04:39] And so this is where the symptoms of difficulty sleeping, nightmares, the intrusive thoughts show up, the memories of that traumatic event continue to show up in the person's daily life, making it hard to function. And so this is not something that is exclusive to veterans. This is a condition that happens to civilians as well.

[00:05:05] I think something that it's not, I think, is this is not something that's untreatable. This is not something that we don't have appropriate interventions to help treat it. This is not post-traumatic stress disorder is not something that makes the person scary or unsafe to be around. I think there's a lot of misconceptions around that. This is something that's absolutely treatable.

[00:05:34] It is what I consider a very natural human response to an incredibly unnatural experience. And that's and that's our body's way of coping. Yeah, so this isn't necessarily that there's something wrong with this person. They just bumped into something extraordinary. And this is how their body responded and never to protect itself. Correct. And absolutely trying to protect itself.

[00:06:00] And so when we think about treating it, we're learning different ways of responding to those memories, to those intrusive thoughts. And really, you know, teaching that we're that we're safe, that those threats are no longer present and really looking to live a vibrant and thriving life.

[00:06:23] So what's what's going on in someone's brain in the moment where they bump into this horrific event, experience this trauma that causes this long term disorder? What's what's processing in real time in the brain? Yeah. So in that moment, when we think about if it was a terrible car accident, assault, we think about veterans. OK, we can use, you know, service members as an example.

[00:06:50] So if you're deployed somewhere and you're in a terrible, terrifying incident, an IED attack, just any sort of, you know, battle, your brain is taking in an overwhelming amount of stimuli and content. That's pretty, again, unnatural. That's not sort of where we're typically supposed to be. It's not the situations that we typically experience.

[00:07:18] And we sort of get frozen in that. And so the brain looks in the moment to kind of compartmentalize that. Right. Especially if you're deployed somewhere, you're trying to survive. Right. That's our brain's biggest job is to keep us alive and surviving. And so it gets sort of locked into place in that moment. And you carry on and you look to get safe and you look to, you know, come home.

[00:07:46] And then it's hard for the brain then to realize that that threat is not imminent anymore. Almost being we describe as being sort of haunted by those memories. Gotcha. What is it about PTSD where it seems like, you know, two people can experience the same event and then a year later are dealing with it very differently? So how much of post-traumatic stress we're developing is exposure to the event?

[00:08:16] And how much of it is, you know, the characteristics of the person being exposed? That's such a great question. And I don't have the greatest answer for that. The answer is going to be it's very unique to that individual. There's a lot of factors at play. So if we think about protective factors that an individual might have going into that situation, those might be present.

[00:08:45] If you have and then somebody who might have come into the situation that doesn't have that, you know, didn't come from a background of having sort of resilient coping skills, didn't have, you know, may have been predisposed to other mental health conditions before this incident happened, that can be a factor. And then I think this is where the field is trying to pinpoint. We haven't pinpointed what...

[00:09:14] We haven't pinpointed your exact question. Why does it happen to some people and why doesn't it happen to others? It's a very unique experience based on that individual. Okay. So I was just curious if there was a way, you know, if there were things that could be identified to help make someone more resilient. Could you fit those into basic training or somewhere in the pipeline or routine training exercises to incorporate? Yes. Sounds like we don't have that fidelity yet in the research. Well, I think that there's certainly...

[00:09:44] It couldn't hurt. And I know that the idea of building in resiliency training and, you know, readiness programs prior to deployment, you know, can be effective. We talk about the training. Mindfulness training has been especially effective in allowing, as we think about deploying.

[00:10:11] Mindfulness talks about the contact with the present moment, right? So we want to be in the moment that we're in, being able to sort of, you know, scan our environments, keep ourselves safe. So having this kind of resiliency training ahead of time can be helpful. This is something that we want to address. We want to talk about things to be aware of. You know, we don't want to... We know that our soldiers and our armed forces have to be battle ready, right?

[00:10:40] So it's a delicate balance between we know you have to stay safe. We know you're going to see things, these unnatural things that we just talked about that sort of lead into PTSD. So we have to create this balance of knowing that the likelihood of that experience is going to happen. And we can't totally prepare for how we're going to respond in that moment. But there are, you know, things that can be done to kind of help sort of process through that.

[00:11:09] And then knowing when you come home, when you're back from that situation, finding time to truly decompress from that, recognize signs and symptoms, seek, you know, treatment sooner rather than later. Those are all important factors. Gotcha. Now, is there... Are there any interventions that can be done? We talked about decompressing. Are there any interventions that can be done either post-deployment

[00:11:35] or post-at-event that have shown to decrease the amount of people that were exposed to that event that eventually develop PTSD? I can't think of the... I can't give you the specific correlation of sort of, we know that if you do this, then your chances of PTSD go down. But what we know about where the symptoms of PTSD turn into the disorder

[00:12:04] and really impact functioning after the experience is over is when we engage in what our natural survival tendency is, which is to avoid all the memories, any sort of triggers to that event. We're looking to kind of stuff that down. I don't want to think about that. If I think about if I just get a job, as long as I come home and I'm out of danger, then I'll be okay. If I get a job, if I'm home with my family, then everything will be fine. I just don't want to think about it anymore. I don't want to remember it.

[00:12:34] That's a very natural response to something horrific that happened. But it's that sort of natural response, that avoidant response that leads to the disordered behaviors, right? We're trying to avoid those memories. And so our world gets smaller and smaller and smaller, trying to avoid these memories and these triggers. All the while, we still feel anxious and on edge and have difficulty sleeping.

[00:13:02] So I would say is being willing to sort of recognize when you're feeling like, and each person's individualized and each person knows sort of when something doesn't feel right, when they feel like, you know what, this is becoming unmanageable and being willing to intervene at that time. So it sounds like there's almost two natural responses leads to this bad long-term outcome.

[00:13:29] You have this natural response from your body to compartmentalize an experience so you can survive the moment. And afterwards, a natural response to avoid ever engaging with it again. And almost like a fever that burns too hot that can kill you, those two natural responses to this memory drive you into this long-term disorder. Yeah. Okay. I would agree with that.

[00:13:53] And that's really what we're trying to sort of interrupt and learn more adaptive and effective ways of dealing with those memories as they come up. Because there's, you know, we don't have that men in black wand that's going to, you know, erase all of your memories. And we, and the good news is we don't, we don't have to, nor should we, right? That's a part of, you know, your human experience.

[00:14:20] And it's going to be there, but it doesn't have to drive all of your decisions and your behaviors and your actions moving forward. There's ways to respond to those things more effectively and in a more adaptive way. Gotcha. You mentioned to you that, you know, PTSD also happens in the civilian world. It's not unique to the military population, but is there anything about, you know, military

[00:14:44] culture that makes veterans either more prone to developing PTSD or more resilient and dealing with trauma? I think it's, I think it's a little bit of both. If we think about being in the armed forces and if you're deployed, like the chances, of you experiencing something traumatic, you know, if you're deployed or even just being

[00:15:13] in the military is an inherently stressful set of experiences. So one could say that you might be predisposed to a more traumatic event than potentially a civilian who would experience a car crash or a terrible assault. Um, so I think that there's, um, there's some likelihood there, but what I've seen, um, in the warriors that I've, uh, been fortunate enough to work with that level of internal resilience,

[00:15:42] that's, that's inherently there is, is an incredible thing to see. And when we think about, um, treating PTSD, it's tapping into that internal resilience that we know is there. And we know when someone's feeling incredibly overwhelmed or just sort of, you know, broken down by these symptoms, what we know is there is that sort of warrior that's always in you.

[00:16:07] I mean, that's the, what separates, um, you know, folks that are willing to join the military for those that aren't, um, there is that inherent drive to be successful, to overcome, to battle through. And that's what we're really looking to tap into because oftentimes when you're feeling overwhelmed by these symptoms, it feels like that, that piece of you is broken or that piece of you is gone. Um, and it's not, we just have to dig down a little bit deeper to pull it back up.

[00:16:36] But I firmly believe that that level of resilience, um, can drive the healing process. Absolutely. Clearly, there's a lot from a clinical standpoint that needs to be unpacked when you're trying to address post-traumatic stress disorder. But what's it like as a veteran who has PTSD and trying to get care? For that part of the story, we go to Ryan. My name is Ryan Cools. I work for Wounded Warrior Product and run our Project Odyssey program, which is an experiential

[00:17:06] education program where we use, um, different events and activities, uh, in nature to, uh, teach coping skills, uh, for individuals that have had some sort of stressful experience, uh, in their military time, uh, and, uh, see some pretty significant benefits to the program, uh, which allows individuals to return to their communities with a new and different perspective on, uh, how they can, uh, be successful in their daily lives. Nice. And what were you doing before Wounded Warrior Project?

[00:17:35] Yeah. So, um, for Wounded Warrior Project, I was in the army, uh, served from 2003 until 2007, uh, was deployed to Iraq in 2005, uh, and, uh, was hurt, um, November 29th of 2005, uh, lost my right arm and left leg. And unfortunately, the two soldiers in the truck, uh, with me, uh, did about, uh, 18 months of, uh, rehabilitation at Walter Reed in DC.

[00:18:04] You have this incident in Iraq, you lose an arm and a leg, you go through 18 months of physical therapy. Obviously that's incredibly physically draining and taxing. Um, it's a real rough way to transition out of the military. Um, but did you have any symptoms of trauma, any PTSD, anything like that, that accompanied your physical ailments? No, I did for sure. Uh, so, um, when, when I got, um, uh, hurt and, uh, woke up in the hospital, you know,

[00:18:32] two weeks after, um, an IED attack in Iraq, uh, it was very much a slow process and, and highly medicated and, um, uh, waking up and realizing that I was missing an arm and leg was, um, you know, uh, not something that I'd wish on anybody.

[00:18:53] And then I think the, uh, honestly, the, uh, her thing was, uh, realizing that, uh, uh, two

[00:19:22] remaining leg was broken, my remaining arm was broken. So there was not a whole lot of me that worked for, uh, quite a little bit of time. Um, uh, but really about a year after, uh, I got hurt. Um, it kind of hit that, that the world kind of like closed in on me and it's like, Hey, I'm going to be missing two limbs for the rest of my life. Um, uh, I will have the knowledge and understanding that I lost two of my guys for the rest of my life.

[00:19:52] And it was, uh, it was a challenge. Uh, and it was, they were at that point, I wasn't, uh, receiving care through the VA for any mental health, uh, stuff. I wasn't, uh, using any resources or, um, anything like that to address that kind of stuff. And, uh, it was, it was crushing. Uh, and, and I, I mean, I can remember, I can, as I'm talking about it right now, in picture exactly where I was when I kind of all, like all those, uh, that wall crumbled.

[00:20:20] And it was very fortunate to be able to talk to some of the guys that, uh, I was with when I was deployed. I was able to receive best and care and support through, uh, the VA, uh, and fortunately had, um, the care and supportive wound to worry product as well. As, uh, it's kind of coincided with, um, going into that transition of becoming, um, an employee. Uh, it was not a great, uh, place. I've been very happy to have come out of it.

[00:20:50] And then, um, I'm glad I experienced it then. Uh, and was able to kind of start building from there. Gotcha. When did you realize that in addition to the physical problem you're done with, you had this massive mental hurdle, um, that you had to overcome and, and deal with? When did that click for you that this was a whole nother set of problems that you had to tackle and ask for help with?

[00:21:18] Yeah, it, yeah, it, um, it honestly really kind of crept up on me. Uh, it was, uh, it was, uh, being as a self-focused on the, the physical aspect of, of getting, um, back up and walking and, and very much, uh, was realizing, um, at that point in time. Uh, there was a, a lot of, um, wounded coming back from Iraq. So Walter Rudin was relatively cool.

[00:21:43] So it was almost, um, uh, a competition between, you know, other warriors that were there to see who was going to get walking first and, and be able to do this, that, and the other thing first. So that was, uh, that focusing on that physical aspect was very much a driving force at that point. And you kind of put, uh, some of the mental stuff on the side, uh, but it, it, uh, was still there and it very much, uh, you know, crept up on me.

[00:22:10] And I, I didn't address it until, uh, it's kind of, uh, hit all at once. And it was really kind of like I said about that, you know, 10, 10 months to a year after, uh, injuries really were just kind of hitting and there was an issue like, Hey, I got to figure this out, uh, because it was very much a, a barrier for me to being able to move forward. So I didn't have, uh, any, uh, perspective as far as kind of what was next, uh, and being

[00:22:39] able to kind of take, uh, take that on and work, work on it was, uh, certainly something that, um, allowed me to continue to move forward with my life. And that's not to say that, you know, it's, uh, that was, it would have been, you know, almost 20 years ago now. And that's not to say that, you know, don't deal with, uh, some stuff, even to this day, um, from the mental health aspect, but, um, I kind of know it and can, can kind of feel

[00:23:06] it and kind of, um, understand how I work with all that stuff. So it's certainly something that's, uh, that's managed, uh, but not, not anything that's, um, uh, kind of hit me when it, when it, like it did, um, a couple of decades ago. Ryan's story is incredible. Something that stood out to me though, is how long there was between him experiencing a traumatic event and receiving treatment for PTSD. He was at Walter Reed for an incredibly long time, receiving treatment for his physical

[00:23:34] ailments after coming home from Iraq, but no clinician caught what was going to happen next for him after he left. And the path to treatment certainly wasn't laid out clearly at the onset. What is it about our system of care that can make it so challenging for veterans to receive help when they need it? For help answering that, let's go to John. So my name is John Eden, and I have the privilege of serving as the vice president for complex care at Winded Warrior Project. Um, and in that role, I, I am able to lead our entire mental health continuum of care,

[00:24:04] both clinical and non-clinical services for the warriors we serve. And when you guys are out there trying to help veterans get access to care and latest innovative treatments, you know, what are the biggest challenges in the system end to end that prevent either active service members or veterans from accessing the care that they need? Is it resources? Is it stigma? Is it money? Is it just physical access? What's out there? I mean, you just, you named several of the factors at play.

[00:24:32] And if you think about boiling it down, really, it's, it's, uh, it's friction. There, it is a complex system that can be very difficult to navigate, especially if you're navigating it in a time when you're perhaps struggling, um, in that moment. And so access to care is a huge piece and, and that boils into many different subsets. So whether it's provider capacity, um, we've had in the mental health civilian space as well, um, shortages since the seventies. And we predict that will continue on into the future.

[00:25:01] Um, but it's not just capacity. It's, it's transportation. It's having it within, um, a reliable distance and, and also the ability to, um, to, to afford the care, right? If, if veterans and are making decisions between paying for their rent or paying for care that they're accessing in the community, that's a problem. Right. And so we see those trade-offs happening now, um, which is what we're working to close the gaps on. And in between that, you still also see the stigma.

[00:25:28] I do feel that the stigma is reducing, um, but it certainly is a factor, especially when you're considering accessing care in a preventative way. So preventative, is that for, we're talking about folks who are still in the military? Yeah, I think it's still in the military. That's certainly a factor, but also, you know, it's, um, there's a statistic. That shows that on average, the on between the first time that an individual feels a symptom

[00:25:56] related to mental health and the first time they receive care, it's 13 years. And I know we can imagine the, how much life happens within those 13 years. Right. And so whether it's, you know, minimizing what you're feeling or whether you're getting kind of stuck in the system, that's a really dangerous gap. Even within, um, when the word projects alumni, um, there is a nine year gap between separation from service and becoming an alumni at Winderware Project. And typically it's, you know, to have some support for, um, whether it's mental health,

[00:26:26] uh, you know, financial health or so being. And so the, uh, the hope there is what could we do if we intervened nine years earlier before to really be preventative and support, you know, mental fitness versus maybe having to, um, um, you know, step in in a timely manner. Yeah. It's interesting that you said that cause it's, I was just thinking it's been five years since I've attempted to go talk to a care provider for mental health. Um, so you're saying what I got eight more years on the clock before I'm likely to circle back and finish a program.

[00:26:56] Okay. Well, I, I, I like your, in the reality, I think that, um, and, and maybe that's a part of the fact that we're having the conversation right now is, um, just really, it's, it's exciting and, and it reduces the stigma. Uh, just a quick story. I, um, growing up, many of my best friends from high school went on to serve in the military, um, and, and seeing them come back from appointments, we could, I didn't have the words as a 20 year old, younger, uh, uh, adult.

[00:27:23] Um, we didn't talk about PTSD, depression, anxiety, and I saw them go through that journey for 10 to 15 years. And thankfully it ended up, uh, they ended in a good spot, but I think today we're more educated, aware, um, and open to talking about that, at least to have a name to it. It's not perfect. Um, but I see a change over the last 20 years. Do you think there's any misconceptions, uh, amongst command teams in the military about

[00:27:48] what PTSD and how to approach it, um, is that might be barriers to soldiers receiving treatment? Um, so I think this is true again, inherently for any sort of mental health treatment. Um, there's a, a significant amount of stigma around this of seeking care of number one, acknowledging that I'm struggling. Um, you know, there's a lot of misconceptions that if I acknowledge I'm having a hard time,

[00:28:14] that I'm weak, that I'm broken, that I'm dangerous, that I'm scary, that I, you know, um, there's something wrong with me. And then, so this is something that I just have to sort of white knuckle my way through. Um, and like I said, if I can just get to that next thing, if it's a new job, if it's, um, a better relationship, if I just focus on my, you know, work, if I just put everything into my

[00:28:41] faith, if I just never think about it again, then I'll be okay. Um, and I think those are the misconceptions. What we, what I want to, the message that, that I want to say is that treatment, um, is not a sign of weakness. Struggling with these symptoms is not a sign of weakness. Um, it's never too late to intervene and we have treatment that works. So I think, you know, previously the other misconception is like, you know, especially

[00:29:08] with PTSD, holy smokes, this is going to be something that I have to deal with. That I have to gut out for the rest of my life. Like it's, you know, progress is going to come so slow. It's going to be agonizing. It's going to be excruciating. I can't think about, you know, this, this pain anymore. Um, and that's not, that doesn't have to be the case. We have interventions that work. We have interventions that work pretty quickly.

[00:29:35] So, you know, one of the things that, one of the surprising things that came up when I was going through the medical retirement process a few years ago, I was getting med boarded with a whole bunch of guys, um, with all sorts of issues. And, you know, one of the common things that folks talked about was if you are having problems, you do not want to get diagnosed with PTSD because if you get diagnosed with PTSD, you're not going to be able to keep your security clearance, which will impact your ability to maintain employment in the federal government, especially if you're still trying to get, you know, 20 years of federal service for your pension.

[00:30:05] Um, also different states you go to, if you're diagnosed with PTSD, it's almost impossible to hold on the firearm. So the trick is go get diagnosed with TBI because the symptoms are similar enough and then you can still get access to treatment later. Um, but you can avoid having any sort of mental health diagnosis on your record. Do you think there's misconceptions on how, you know, mental health is treated, uh, versus physical health, um, in society's broader institutions?

[00:30:34] Because it does seem like if you get a PTSD diagnosis, you do suffer the consequences, um, in different spaces. I think there's, I think there's a good amount of, um, sort of truth to that myth as it were. Right. Um, I think that people would be much more willing to acknowledge I have diabetes, heart disease,

[00:31:00] high cholesterol, cancer, um, than I have a mental health diagnosis. Um, you can, you know, and again, that's related to the stigma of, you know, sort of what's wrong with you? Why can't you just get over it? You know, everybody gets sad sometimes. Um, the world's a stressful place. Um, you know, I'm coping, you know, figure it out. Um, and that's, again, just, uh, it's a really unfortunate belief that I think a lot

[00:31:29] of people, um, hold. And I think you having these platforms to kind of say it out loud that we really want mental health to be talked about the same way people are open to talk about their diabetes, their high cholesterol, their, you know, cancer diagnoses. The quieter we are about this, um, the sicker people stay in the prolonged suffering that comes

[00:31:56] from this, um, mental health treatment for a variety of, you know, mental health conditions continue to advance. Um, and I think there's so many people missing out on living a vibrant and meaningful life because they're afraid or ashamed, um, to talk about it. Cause what does it say about me? Like, again, people are going to think, quit being weird, you know, just get over it. Um, have you, you know, tried not thinking about it?

[00:32:24] You know, if you just, if you tried being happy, um, right. Oh, yeah. Why am I thinking that? Um, I mean, it's just, and I'm, I'm laughing cause it's just, we should think about it as being just that absurd. You wouldn't tell a cancer patient, have you just tried willing it away? Have you just tried, um, not being sick? You know, like that's just, it's, it's absurd.

[00:32:51] So something that occurred to me while I was talking to all these lovely folks from the Wounded Warrior Project who were doing, you know, great work trying to address this problem is we have a Department of Veterans Affairs that's mandated to provide treatment to veterans. We have a Department of Defense or Department of War, whatever you want to call it these days, that cares for active duty service members. Why is there a need for an organization like the Wounded Warrior Project? Why after over 20 years of the global war on terror, are nonprofits still stepping in

[00:33:20] to help out with this stuff? It seems like in a well-run system, they shouldn't have a job here. This might be a little on the nose, but why does an organization like Wounded Warrior Project even have a role to play here? Because between the Department of Defense for active duty soldiers and Department of Veterans Affairs for those who got out, it seems weird that there's even a role for a nonprofit to play in this space. Yeah, you know, the government, both in those settings you mentioned, play a critical role

[00:33:50] in care today. And what we know is that a large, massive, complex system, oftentimes warriors may not be, could fall through the cracks at times. And so we really see our efforts as a support and connection to those systems you mentioned, right? It's not a competition, but more so how can we work as a partner in the system of care within the DOD and VA. And one of the things I think what we appreciate is the ability to rapidly innovate and change care today.

[00:34:20] On average, it's shocking to me, but there is a delta of 17 years between research and where that comes into practice. What we see with Warrior Care Network and the research that we're able to lead is that we're these rapid accelerators and infusion of what the learning we're seeing into the care models today. All that being said, though, going back to kind of where I started, it's important that we work together as a team. And what we've really appreciated with the VA is that we actually have VA employees embedded

[00:34:49] within the care teams of our clinical sites. We see that not only it's, you know, helping to get warriors, you know, engage with the VA and make their decision about where they receive their care, it reduces barriers to helping bring those care gaps together. And what we're seeing is that the overwhelming majority of veterans are engaging with what we call VA liaison, and it's supporting them into getting into their system of care if that's what they want to do.

[00:35:16] So what does it look like in practice when a veteran realizes they have a problem and they actually try to reach out and get care? Well, what do they typically experience in that process, depending on whether or not, you know, they've recently transitioned or they've been out for a few years? But what does that look like and how do they end up in the Warrior Care Network? Yeah. So no wrong door approach is truly how we look at it. You know, typically the first thing that a warrior would do, whether they're perhaps brought,

[00:35:45] they see an ad on TV, on social media. We know that one of the biggest referral sources are other veterans who have served through the program as well. And so when they come in, they register with Wind Warrior Project, which is an easy online process and automated API feed with the VA to be able to go through those registration criteria. But the first step is our resource center. And so being able to talk about anything you're looking for, whether it's, again, in

[00:36:13] those dimensions, financial, physical health, connection events and mental health. And the front door to our mental health team is our mental health triage team. And so these are really amazing individuals who will do a screening. It's really a conversation to really understand what your needs are and what are you looking for? It's not about pushing any, you know, preconceived, you know, approach on a warrior. It's about how can we make it individualized, personalized care?

[00:36:41] And so that triage teammate will make the appropriate recommendations. And if the warrior is open to it, connect them to Warrior Care Network. Throughout the whole process, it's very, we're trying to reduce the friction, high touch, and help to remove any barriers between where we are today and getting you into that care. And so, and that involves financial barriers. And I think it's really important to say, too, all of this, all WWP programming comes at no cost to our warriors.

[00:37:09] And so we really try hard to remove any barrier to care and continue to always get to a yes, whatever it takes. Now, clearly getting veterans with PTSD in the door and in front of a clinician who can help treat them is a critical step. But what does that treatment actually look like? What have we learned over the 20 years of the global war on terror? Certainly, we have to know more in 2026 than we did in 2001 when the global war on terror started. And what innovative treatments are currently in development that might change the outcome

[00:37:38] of veterans in the future? You mentioned before, you know, evidence-based treatment for PTSD. What has evolved in PTSD treatment over the global war on terror? And where does that stand now? What are the current best practices for treatment? So the great question. Could talk for days about this. What?

[00:38:02] So when we say evidence-based treatment, the two gold standards of treatment that have been the gold standards for 20 to 30 years at this point are cognitive processing therapy and prolonged exposure therapy. Both of these interventions, they're sort of a manualized treatment where the full dose of the treatment is 10 to 12 sessions.

[00:38:31] And these interventions are looking to, again, respond differently and more adaptively to the thoughts and the beliefs that you hold about yourself in relation to these pain, this traumatic event, right? And then also learning to respond differently and more effectively to all of the physical sensations that come up in your body as, you know, as these memories or as, you know,

[00:39:00] the thoughts of this trauma come up. So we know that those two interventions, when you get that full dose, are incredibly effective. And so when I talked about the Warrior Care Network, this model of treatment uses both of those gold standard treatments delivered in an accelerated way. And why is the accelerated piece so important? We want the folks coming into our care to get that full dose.

[00:39:29] It's like finishing your full Z-Pak. It's like finishing your full antibiotic pack. It works the best when you take all, you know, seven pills, even if you start to feel better, take them all so that you get, you know, your full sort of full dose of that. And that's what Warrior Care Network provides. You're going to get that treatment in an accelerated way, meaning you're either coming on site to one

[00:39:57] of the academic medical centers that are across the country. This treatment is also being delivered virtually for people that can't travel, you know, don't want to, you know, come on site. We can do this virtually. We're removing all the barriers that we can think of to get you, you know, into this care. And getting it done in this accelerated way ensures that you're going to get that full course of treatment.

[00:40:23] So over, we, the Warrior Care Network has over a 90% completion rate for this treatment. Which is incredible. If you think about your typical outpatient therapy, one hour a week, and to get those 12 sessions, that's going to take you about 90 days. If you go, you know, once a week, the dropout rate there is around 50%. We know life happens, things get in the way. As you approach this trauma, if you're approaching those memories and all that, it can feel very overwhelming.

[00:40:53] So there's a lot of stopping and starting, prolongs the process. Getting it in this accelerated format means you're going to get everything that you need. You complete it, and then you go back home. You have a discharge plan. You're following up with, you know, therapy when you're home to kind of maintain those gains. But what we've found is warriors that complete this program are achieving the clinically significant reductions in their symptoms. So what does this mean?

[00:41:23] You'll come in at a very high level of PTSD. So what does that look like in your life? You're having a hard time working. Your family relationships are struggling. You're not sleeping. You're irritable. You're on edge. It's just white-knuckling your way through life. That's what you come in at. And when you leave this program, you know, after two weeks, you're at a mild to moderate level of PTSD, which is manageable. You're engaging in your life.

[00:41:52] You're showing up as the husband, wife, brother, sister, father that you want to be. You know, work has gotten better. And you're maintaining those gains for a year post-treatment. So this model works. And we know that if you get all of it, you're going to get better faster and you're going to stay better longer in the most simplest of terms. Get better faster. Stay better longer. Gotcha.

[00:42:18] Well, I want to ask you too, when somebody is going through, you know, the previous gold standards of treatment, either prolonged surgery therapy or cognitive processing therapy, you know, what actually is going on in their mind as they're going through treatment? Is this, you know, you're sitting in a room, you're talking about stuff. You have some kumbaya moments, either one-on-one or as a group. Like beyond just being a feel-good session, what about these treatments actually makes them effective? What's going on with the brain?

[00:42:47] Yeah, it's sort of getting the brain unstuck, right? If we talk about this danger response that I'm stuck in this high alert, on guard, I feel like the threat is imminent. And then I get caught, particularly with PTSD, I get caught in this loop of the coulda, woulda, shouldas. If I had better intel, I wouldn't have gone down that road and then the Humvee wouldn't have

[00:43:17] exploded. If I was paying more attention, I, you know, would have noticed, I don't know, this sniper that was, you know, waiting for me. If I wasn't aware, if we think about, you know, sexual assault survivors, if I wasn't wearing the red dress, this never would have happened to me. And so getting stuck, our brain getting stuck on those beliefs makes it really hard to take

[00:43:43] in sort of any new information about the world around me. And so when we think about cognitive processing therapy, it's really finding those stuck points. So what are those beliefs that you're, that you're stuck on? Is it this, I shouldn't have worn the, I shouldn't have gone down that road. Had I not gone down that road, I wouldn't have hit the IED. So now it's my fault.

[00:44:09] And so learning to sort of loosen the grip on that belief. Cognitive processing therapy focuses on finding evidence that that belief, that we don't have to hold that belief as absolute fact, right? Prolonged exposure therapy is really looking at how are we approaching, being willing to

[00:44:35] approach triggers to those, to that traumatic event. And so at Emory Healthcare Veterans Program, they're using prolonged exposure coupled with virtual reality therapy to really bring in a very safe fashion. Because I know when people think about, remember when people think about confronting their trauma, it sounds awful like, well, why would I want to relive that? Like, that's fine.

[00:45:02] I'll just stuff that down and, you know, continue about my life. I don't want to, you know, revisit that. But as I mentioned, that avoidance is what's keeping you stuck. And so looking at prolonged exposure in virtual reality therapy, we, the providers at Emory can recreate your sort of traumatic event. They can, you put on the VR, the virtual reality goggles.

[00:45:30] And if you were sitting, you know, if you were the passenger in the Humvee, then that's your point of view in this virtual reality environment. There's, you know, we can, the sounds are there. The sites was this Afghanistan versus Iraq. We know that the terrain is different and we know that the situations are different. So we create that virtual reality environment. And as in the name, we expose you to that.

[00:46:01] And learning, and I'm going to, again, dumb this down into a way that is a quick sort of sound but here to teach you that you, your body, that you can get through this, that, you know, the heart racing, the sweating, the shortness of breath, the, my chest is tight. And I feel this, you know, sense of panic that we can approach that, move through it and come

[00:46:25] out on the other side, knowing that that event is not defining my experience anymore, that these physical symptoms aren't going to kill me. They're not going to, this is not something that if I let myself feel it again, that I will be so broken, you won't be able to put me back together. That's what we're really trying to reshape. Because that's what we're trying to avoid.

[00:46:50] No one wants to, no one wants to wake up at the thought every day of, it's my fault. My buddies were killed. Um, you know, it's my fault that I was assaulted. Um, I'm a bad person or I'm broken beyond repair. You know, these beliefs, um, are terrible. Um, and so these interventions are really looking to, um, kind of reshape how we view ourselves

[00:47:19] in response to that trauma. Now, what exactly is Project Odyssey? Because it seems like a very unique way to approach treating and helping veterans. Uh, it really is. So, uh, Odyssey is very much a, um, it's a non-clinical model. Uh, we certainly see, uh, see some, uh, clinical benefits to, um, to the outcomes. It's, uh, after the program.

[00:47:45] Uh, and, uh, we, uh, are really just, uh, creating an environment where, uh, individuals can learn and grow on their own. Because we find that going through experiences, um, like being up on a high ropes course and being a little bit stressed and, and, um, anxious. And then having, uh, that experience with a cohort of other, um, veterans and being able

[00:48:11] to do that and being guided along in that process with, uh, kind of taking a step back and, uh, getting a different perspective on, uh, what their experience is, uh, is, um, I think a great opportunity to take that and be able to use, um, those, uh, you know, those opportunities and experiences to, uh, help and benefit in, uh, everyday life. So, Odyssey, uh, tends to look like a, uh, a week-long in-person workshop where we bring,

[00:48:39] uh, veterans from across the country to one of the 30 plus, uh, venues that we use, uh, to facilitate these programs. Uh, Odyssey can be for, uh, individual veterans. So, all-male cohorts, all-female cohorts or co-ed cohorts. Uh, we also run, uh, programs for couples and then programs for families as well. So, lots of different opportunities for, uh, veterans or active service members to get

[00:49:05] out, uh, have some experiences that can certainly be transformative in their, uh, recovery from, um, military experiences or, uh, utilize those experiences to help, uh, you know, be better active, active service members as well. Now, where does this fit into, you know, treatment and prevention for PTSD? Is this symptom management? Is it a replacement or something with clinical therapy? Is this prevention more than a cure? How does this fit into solving that problem?

[00:49:35] I think really where this, uh, this fits in, in solving that problem is, uh, I think, um, it is certainly, it is probably, you know, uh, there's not a one size, uh, one thing that fits everybody, uh, approach. Uh, so I think this can, uh, certainly be a, a method for individuals that are experiencing, uh, PTSD to get the different perspective and everything they need to, uh, not be in a position

[00:50:03] where, uh, the symptoms of their PTSD are controlling, uh, their everyday life. Uh, but I think for others, uh, Odyssey can certainly be an opportunity where they have an experience with us and, and see like, oh, hey, I actually need a little bit more care and support. So, uh, we were able to help them transition to, um, an accelerated outpatient program or, uh, help them transition into, uh, one-on-one counseling support or whatever makes the most sense for them.

[00:50:31] So, it's not, um, it's not the, uh, it's not the, uh, it's not the cure, uh, by itself, uh, in solidarity, but it's certainly an opportunity to, uh, open individuals' eyes to what's out there and, and a good opportunity to be able to give a new perspective on, uh, some stuff that, uh, folks, you know, maybe you just need a little bit of an extra, uh, push to get there. Wow. So, folks can actually go through this program and discover that maybe they need some help

[00:51:01] in a new area that they weren't aware of. Uh, for sure. And that's, uh, that's something that we see on, on a regular basis. We have, uh, individuals that will go through, uh, an intensive outpatient program and come to us after that, or we'll have individuals come through our program and go to it, um, uh, go to one of those programs. Or, uh, we have individuals that will come and participate in an odyssey and then, uh, be

[00:51:26] in a position where, uh, they're, uh, wanting to give back to others. Uh, we have an opportunity for each odyssey to have a peer mentor there. So that's someone that's been through the program, been through some rough stuff and is able to utilize that program to help out and, and kind of really live the logo, uh, that we have at Winter Warrior Project and be that individual that is carrying those other, uh, folks off the battlefield. Okay. So this isn't like a one and done.

[00:51:56] You go through this week long experiential event and you get like a pamphlet and a scorecard at the end. This actually puts you, gets you plugged into a community of care. Most, uh, most certainly. And the, uh, the week long, uh, workshop is, um, within Project Odyssey is not done in isolation. So, uh, after the, uh, participants returned home from the in-person portion, they have up to 12 weeks of follow-up with our teammates.

[00:52:24] And that follow-up looks like, uh, video, uh, uh, group calls that could be one-on-one calls, uh, that could be an opportunity to kind of be reintegrated to some of the curriculum that we teach on Odyssey. So, uh, for our individual, um, Odysseys, we utilize acceptance and commitment therapy, uh, as kind of like the framework, uh, that, um, we use to help teach those coping skills and, and help introduce that new perspective.

[00:52:53] For our couples Odysseys, we, uh, utilize, um, uh, the Gottman's sound relationship house, uh, to teach couples how their relationship, um, is working, how they can, uh, kind of build the floors of their house to ensure that, uh, it strengthens the resilience of their relationship. So, uh, it's certainly something that just going through the workshop is only a portion of it.

[00:53:18] The, uh, the follow-up and care they get afterwards and potentially the additional referrals they get to another program or service as an opportunity to really have that holistic model of support. So we've got a new method for providing treatment, which condenses it down to increase throughput rates for veterans actually trying to get treatment. Uh, things like virtual reality is being used to enhance the treatment experience. You've got machine learning that I'm assuming AI trying to figure out how to put together

[00:53:47] a treatment plan that accounts for all comorbidity somebody might have along with PTSD. Is there any other innovations coming up in the future or how, uh, PTSD is treated and is, you know, for your organization, do you think that you get a bigger bang for your buck when you explore novel treatments or when you try to increase access to current treatments?

[00:54:16] I, again, a great fundamental question. And for Wounded Warrior Project, we're committed to doing both. Okay. Um, if you've, I know you've, uh, interviewed Walt Pyatt, um, our CEO who has given us, um, who, you know, our incredible task, right? If we're going to save a million lives, we're going to end veteran suicide. We're going to cure PTSD. Um, and we have to do both.

[00:54:41] We have to continue using what we have that we know works, right? And that's the, and doing it in a accelerated, condensed format. We know that works. And so we're going to keep putting, um, warriors, veterans and active duty service members through that program. And we're still going to keep pursuing innovative treatments, um, so that everybody's going to get that same kind of, um, result.

[00:55:07] And so if we think about, so machine learning, that's new research. Um, we could probably have a whole nother podcast around, um, psychedelics in the treatment of PTSD. And this is, uh, Wounded Warrior Project is collaborating with Emory Healthcare Veterans Program, studying, um, MDA in conjunction with prolonged exposure, um, in the treatment model, in the, um, accelerated treatment program.

[00:55:35] Um, we're using, um, RTMS. So repetitive transcranial, um, stimulation for, uh, treatment resistant depression coupled with PTSD. And so, um, this is something if you came through Warrior Care Network, in addition to using the evidence-based treatment, we're using measurement-based care. And so we're assessing, um, warriors and their symptoms on a daily basis.

[00:56:05] And so we can see around day three or four of you coming into, of you being in the program, if you're on the kind of trajectory to get that full clinical benefit from treatment. And if you're not, um, then we start augmenting care. Maybe we need, maybe we bring in the RTMS. Maybe this is looking at, we're going to spend some more time in some individual sessions. If we're going to bring in more emotion regulation, um, you know, groups for you to be in.

[00:56:34] I mean, this is that level of innovation that, um, our Warrior Care Network partners are committed to. So short and long story long, we have to do both. You know, we've seen a lot of progress with treatments for PTSD, but a lot there still unpacked. What do you think the next frontier of treatment for PTSD is going to look like? Wow.

[00:56:58] Yeah, this is, um, if I could use this term, you know, it's a very encouraging time. Um, when you think about PTSD treatment, there has been, it's probably not a shock to you. Uh, there has been, uh, no FDA approved treatment for PTSD, um, in the last 20 plus years, um, since there's been a new treatment. Right. Um, but if you look right now, we are in this rapid field type of innovation, uh, over the next two years, we'll see more, more, uh, innovation than we have in the last two decades.

[00:57:28] And so, you know, some areas where we're seeing that take place today is, um, is one is around the idea of personalized mental health care. Today, um, there's no mechanism to understand if you would be a higher responder in outpatient cognitive processing therapy or, uh, outpatient prolonged exposure therapy. Um, but when you compare, um, that to where we see in the future, we, we think that we,

[00:57:54] and we were already seeing it now can based on your unique environment, your symptoms, your demographics, um, provide you with a more, uh, cultivated prescriptive understanding of where you're going to have the most effective care. And so this idea of precision mental health care is rapidly innovating and it's driving how we're serving, uh, veterans today. And the whole goal there is that we know that 75% of warriors that leave our accelerated brain health program are leaving with clinically significant reductions in their symptoms.

[00:58:23] Many times that means not meeting a diagnostic threshold, uh, for, uh, PTSD. Um, and our goal is to how can we close that gap and continue to increase the amount of, uh, warriors who are receiving the full benefit of care. The only other piece I would add to that, which is, um, very timely as well as the, our growing understanding on the potential implication and benefits of psyche, uh, psychedelic, um, assisted treatment.

[00:58:51] And so we're, um, we're an early adopter in research around, um, MDMA assisted treatment with, uh, with our partners at Warrior Care Network and the understanding that, and the growing research that psychedelics can unlock this neuroplastic window that can, when paired with evidence-based treatment can make it even more effective as an area we're exploring today. Um, and, and really gives us a lot of hope for what the future can be. Wow.

[00:59:18] So the fact that no new PTSD treatments have been developed in that length of time was actually rather shocking because we knew PTSD was a huge issue coming out of Vietnam, you know, global war and terror, lots of issues with PTSD, lots of all many folks out there. Like what's the big barrier to developing a new treatment? Is it FDA approval? Is it the medical community? Is it awareness? Like, I think you mentioned before, like 17 year flash to bang on research application.

[00:59:49] You know, that's shocking actually, uh, cause we can innovate in so many other treatments so quickly. Why, why this one? Why is this so hard? Yeah, that's a great question. And I, I think the translation from research to practice is an area we could focus on more. Um, and again, that's really how we look at Warrior Care Network. It's an incubator for research on a relatively smaller scale that we can rapidly integrate within our care model.

[01:00:17] Um, and then it's on us, pardon me, a responsibility to disseminate that across the public. Right. And so that's part of our effort today. Warrior Care Network, or this model is, uh, proven effective, but it has not been adopted yet today, uh, broadly speaking. And I, and that really goes back to how have we disseminated it? And so as we, it's now our responsibility to, um, bring this model to be the standard of care for the way that veterans and civilians in the future, uh, are, are their PTSD is addressed.

[01:00:47] Um, so that's one thing. Um, and, and for the psychedelic space, it's, um, as you can imagine, such a, um, nuanced, uh, topic, um, just the, the, the preparation to conduct this research can take upwards of 18 to 24 months. And so the, the, the pre-work to all of this, um, it's the world we're in today can just, uh, be time sensitive. But what we know is we don't have the time, uh, to waste, right? We're, we feel a sense of urgency.

[01:01:16] Something that you learn early in your time in the military is that anytime you set up to do something, you should begin with the end in mind. Every operation comes with a defined end state that you should be working towards. Now we've talked about the science of treatment, barriers to access, friction in the system, but what's the actual end state for veterans who are receiving care? How is their life meaningfully better after receiving treatment?

[01:01:42] What's the, uh, the coolest thing that has shown up in your life since you've, you know, gone through the physical rehabilitation process, sought treatment, you're now helping other veterans, you know, life post dealing with the initial stress of all that. What, what, what's the coolest thing about it, you think? Yeah, I, I think that really the coolest thing for me about, um, um, kind of seeing some of this is really seeing the success of others. I was very fortunate. Uh, it would have been about, uh, eight or nine years ago.

[01:02:12] Um, was, uh, on a project out of C2, uh, hang out with some of my, uh, teammates and see how they were doing. And, uh, we were waiting for all the participants to, uh, come in to the program. Uh, and everybody had showed up except for, for one guy. Uh, last guy shows up, uh, he walks in, in the room, looks at me and says, Lieutenant Cools, is that you?

[01:02:36] And it turns out that, uh, it was, uh, um, one of the service members that, uh, had secured the site, uh, from when I had been, um, uh, struck by an IED. Uh, he was pulling security there. I was called in. He was on the QRF team, uh, that day. Uh, so he gets, um, you know, pulled, uh, to that site, uh, sees that, uh, two service members had been killed in one.

[01:03:00] I was being evacuated and we had had some interactions, uh, uh, while we would, so, uh, knew each other just, um, uh, more in passing. And then, uh, he goes home. Um, ends up, uh, leaving the military and never knew kind of what, um, had happened to me. Uh, didn't really pull up. And then come, uh, 10, 12 years later, he's in a position where he needs to ask for help, uh, and to go into a product Odyssey.

[01:03:27] And lo and behold, we run into each other and are able to kind of have that full, that journey, uh, come full circle. So we're able to use that week on the time to, uh, kind of catch up, um, with that. Uh, on last time. Uh, and he's able to see the, even though, uh, that was a pretty horrible day for, uh, him to have to see all that stuff. Uh, there was some good that came out of it. And I think that's, um, I know I benefited a lot from that.

[01:03:57] We've stayed in contact over time. Uh, and I, I know that he's benefited a lot from it as well. That's pretty cool. Now I also heard from somebody that you have a Guinness world record. I do. Um, what's up with that? Yeah. So, um, I, uh, was hurt about, uh, 20 years ago is, uh, is my alive day.

[01:04:19] Um, so November 29th of, um, this past year was 20 years since my injury and wanted to, um, mark, uh, that occasion and really take an opportunity to, uh, recognize how long I had come from, uh, that time. And, um, about COVID time, uh, really got, um, uh, started, uh, indoor rowing. Um, certainly something that's, uh, with my injuries, I was able to adapt and, and make, uh, work for me.

[01:04:49] Uh, and kind of during that time saw that, uh, really gravitated toward it and, and really liked, uh, doing it. Uh, so was able to, uh, work with a word product, work with, uh, Guinness, uh, world records. And on, uh, December 1st of this past year, uh, set three, um, uh, records, uh, on, on indoor row, uh, which was the longest distance over an hour, uh, fastest, uh, marathon and fastest ultra marathon.

[01:05:17] Uh, it was really cool because I was able to have, um, do that, uh, that record at the, uh, in the Baltimore Ravens locker room and had, um, a battalion commander from, uh, when I was deployed, uh, out there, uh, rolling alongside me. I had, uh, a couple of my best friends that, uh, was deployed with, uh, rolling, uh, along with me. I had, uh, some, uh, wounded warriors from the local area, had some wounded warriors about our teammates, some family members.

[01:05:45] So it was, um, it was a really special day to, um, uh, put in all that work, but then be able to kind of mark, like, hey, this is 20 years later and this is something I'm able to, to go out and do and, and do, um, you know, faster than anybody has done it before. If there is a veteran out there right now or an active duty service member and they think they might have some stuff and need some help with, what would you want to say to them? What would you hope they hear?

[01:06:12] Really, uh, what I would hope that, uh, individual hears is, um, asking for help and asking for support is not a sign of weakness, uh, very much a sign of strength. And, uh, and realizing that there's an opportunity to be able to, uh, to grow and, and be able to be in a better spot. Um, not only physically, but mentally as well, uh, is really an opportunity to take advantage of the, the one life that we're, uh, given to live, uh, and being able to do that and take

[01:06:42] advantage of that support that's out there. Uh, is that first step is, is difficult, uh, and it can be difficult. Uh, but certainly once you take that, uh, those important resources there to help with that healing. Thank you for joining us for our first installment of our series looking at PTSD and treatment for veterans. Our next installment will look at psychedelic drugs, how the veteran community came to accept them as a treatment for PTSD, despite a lack of FDA approval, what the process of

[01:07:09] mainstreaming them into modern medicine will be, and what barriers still exist to adopting new and innovative treatments that have already shown to have success helping veterans. Look forward to be available on June 17th on YouTube and wherever you listen to podcasts. Thank you.