Capt. Robert Koffman performs acupuncture on a patient. Koffman works at the National Intrepid Center of Excellence in Bethesda, Md., which offers new approaches to treating psychologic and stress disorders, such as post-traumatic stress and traumatic brain injuries. (National Intrepid Center of Excellence)
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Psychiatrist Capt. Robert Koffman has more than 20 years of operational medicine and combat stress expertise, but he’s probably best known for sticking lots of needles in special operators.
Koffman, a mental health expert at the National Intrepid Center of Excellence in Bethesda, Md., uses acupuncture to treat troops with ongoing psychological complications from traumatic brain injuries.
Talk therapy and medication have their place, he said, but he’s seen firsthand how alternative treatments such as acupuncture and meditation have helped troops manage their anxiety and chronic pain.
In December, U.S. Special Operations Command presented Koffman with the Patriot Award for his work with treating more than 600 special operators at NICOE since it opened in 2010. At any given time, 20 patients are rotating in and out of the facility.
“All of the individuals who come here, come here because they have not recovered sufficiently with the level of services at their particular duty station,” Koffman said. “We wish we would see more people, but our model is very intensive and doesn’t allow us to open our gates as widely as we’d like to.” He added that the center focuses its efforts on those “who are continuing to suffer despite the best efforts of their home station providers.”
With a referral from their primary care doctor, active-duty service members can come to NICOE on orders for four weeks of treatment. They’ll be evaluated over that time and sent home with long-term treatments and techniques to manage their conditions.
“The folks that come in here all have TBI, they all have some forms of psychological health [issues] and they frequently have co-morbidity of frequent pain made worse by years of insomnia,” Koffman said.
Navy Times spoke to Koffman earlier this year about about his career and approaches, from his first deployment to Kuwait in 1991 to the value of breathing techniques and acupuncture in treating TBI and PTSD. Questions and answers have been edited for brevity.
Q. When did you first notice how widespread PTSD and TBI were becoming?
A. I realized there was a lot of hidden burden. I deployed to Afghanistan from 2009 to 2010. I was with a mobile care team to deliver field mental health services to individual augmentees. I think my job at [the Navy’s Bureau of Medicine and Surgery] was to support the mental health needs of operational forces and I think throughout that period, that’s really when the Red Cell, which was the forerunner to the Defense Centers of Excellence, stood up to respond to congressionally-directed mandates to improve mental health resources.
Q. How did holistic medicine become a cornerstone for you?
A. Well, I’ve always been interested in Chinese medicine. I think it’s one of the reasons I’m a psychiatrist, because looking at things in different ways appeals to me. I’ve always known that patient engagement, getting patient buy-in was absolutely the most critical aspect of care. Not all patients want or will take medication — psychotropics — and so I did some mind-body classes and I learned how to provide difference aspects of holistic, or now what we call integrative medicine. Acupuncture, Reiki, meditation.
Acupuncture is recommended as a secondary modality, largely to help with pain, to aid sleep and most importantly, to decrease some of the autonomic excitability — to down-regulate the autonomic nervous system. That’s largely what I use acupuncture for, to help relax people and lessen anxiety. That in and of itself helps the symptoms of PTSD.
Q. Why has NICOE been so successful with special operators?
A. I was once told by an operator that NICOE’s the kind of facility SEALs would build if they were in the brain injury recovery business. Our four-week model is like a pit stop in the middle of the Indy 500 for operators, who are always on the go. It really enables them to undergo an unprecedented amount of diagnostic evaluation and treatment.
I think one of the reasons why so many operators have expressed interest in our model is because of the fact that it is empowering. A lot of what they do, they can’t take medicines even if they need medicines, so to be able to find new, emerging techniques is helpful for them.
Q. Are there any challenges in working with that community?
A. Nobody likes to take time out from their command, from their busy life, from the job that they signed up to do. One of the huge challenges is convincing people that they need to take a knee for four weeks and get their studies done and get looked at and figure out how to engage in a treatment plan that is going to provide them the longevity they need to finish their career.
We’re a tertiary care facility, so it’s really the primary care docs out there on the front line, whether that’s the SEAL community or [explosive ordnance disposal],it’s those primary care providers that actually are the ones who identify the need to send folks here. I’m fortunate enough to be able to care for individuals once they come here.
Q. What can NICOE offer that on-base care might not?
A. We are so skill-based here. We have the time in those four weeks to really reinforce all of these skills that will help with cognitive retraining and, more importantly, take advantage of teaching people how to operate on their own autonomic nervous systems.
That’s particularly where the mind-body medicine, or the “Eastern medicine,” is able to help people lessen their hypervigilance: by showing them how to meditate, by giving them the tools of breathing. Breathing is perhaps one of the most simple techniques to managing anxiety, but it’s almost so simple that it’s not highly touted as a first-line treatment for PTSD. But it’s one of the most important skills.
Q. How can troops advocate for themselves if they feel their on-base providers aren’t enough?
A. Beneficiaries ...need to realize that they have choices. Providers should always make that clear — that there are options. It’s hard to be one’s own advocate, especially when you’re hurting and when you’re not sleeping and you’re cognitively impaired because of the number of TBIs that you have, but I would say that it’s critical to realize that at all levels that patients want choices — need choices — and underscoring those choices is accurate and helpful information.