How Does Stress Of War Affect Military Families?
Wednesday, September 23, 2009
How are repeated deployments and the psychological impact of war affecting local military families? We speak to a social worker and an expert on PTSD, both from the VA San Diego Healthcare System, about the effects of PTSD and the challenges troops face when they return to civilian society. We also speak to a psychologist about his research on military families.
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. When the tour of duty is over, some veterans find the battle to regain their normal lives has just begun. This morning, the KPBS series “War Comes Home,” focuses on the challenges that face veterans and their families as these former warriors transition into civilian life. Some vets are dealing with invisible wounds. Traumatic brain injury has been called the signature combat injury of the wars in Iraq and Afghanistan. And, post traumatic stress disorder, if not treated, can last for years and tear relationships apart. The good news is there is a lot of help available for returning veterans and their families. And, we're about to speak to several guests who know both the challenges and the support that exists for military families. I’d like to welcome my guests. Benjamin Karney is associate professor of psychology at UCLA, and an adjunct behavioral scientist at the Rand Corporation. Ben, welcome to These Days.
BENJAMIN KARNEY (Associate Professor of Psychology, UCLA): Thanks for having me.
CAVANAUGH: Dr. Jeffrey Matloff is senior post traumatic stress disorder psychologist at the Department of Veteran Affairs San Diego Healthcare System. Dr. Matloff, welcome.
DR. JEFFREY MATLOFF (Senior PTSD Psychologist, Department of Veteran Affairs San Diego Healthcare System): Thank you very much.
CAVANAUGH: And Laura Owen is licensed clinical social worker and the program manager of the VA San Diego’s OEF/OIF Care Management Team. Laura, good morning.
LAURA OWEN (Program Manager, VA San Diego’s OEF/OIF Care Management Team): Good morning. Thanks for having me.
CAVANAUGH: I’d like to invite our listeners to join the conversation. If you have a story you’d like to share as a veteran making the transition to civilian life, we welcome your call. If you have questions or comments about the challenges of veterans coming home, give us a call. Here’s the number, it’s 1-888-895-5727, that’s 1-888-895-KPBS. Laura, I’d like to start with you, if I may, and, as I say, you’re the program manager of the VA San Diego’s Care Management Team here. And I wonder what the most common problems or challenges there are that veterans face when they return home from deployment?
OWEN: Well, there – I don’t know that there’s any common set of problems. There are certainly a set that we see more frequently than others but every veteran is unique. For our reservists, we see a lot of confusion about whether another tour is coming up. You know, we are doing multiple deployments and reservists often have to leave their families for uncertain amount of times (sic) and with uncertain return dates and they never know if they might get called up again, so there’s – they strike a tenuous balance between civilian life and active duty, and that never really goes away until they get out of active – out of the reserves and even then that doesn’t guarantee that they won’t get called back to duty, of course, because we now have stop loss and we now have recalls where people who thought that they had been discharged from active duty are recalled because they happen to have a specialty that we still need. So we see some of those in our reservists and our national guard populations. With our younger veterans, we see difficulty reintegrating into civilian life. Many of their peers have had very different experiences from what our twenty-something warriors go through. I like to say that our warriors know what it’s like to take a life, to save a life, and to put their lives on the line, and that’s not something that the typical GenYer who stayed home and went to college has any concept of.
OWEN: And, of course, our veterans tend to marry younger so that would put a strain on the relationship with a spouse and maybe the young children. And, you know, anybody who’s been married any length of time knows that all marriages have their times of difficulty but it’s particularly difficult when you are young and when you’re coming home from war and your spouse has had a very, very different experience.
CAVANAUGH: Yeah. Now, Ben, that brings me to you. You study families and how forms of stress affect families. So what kinds of stress are our military personnel and their families dealing with at the end of a tour of duty?
KARNEY: Well, as you can imagine, the stress that comes out of deployments actually begins prior to the deployments. So when military families are told that there’s an upcoming deployment, the pre-deployment phase is described as stressful in itself, even before there’s been any separation or any deployment because arrangements have to be made, people have to start talking about child care. There’s all sorts of demands that are placed on military families even before the deployment begins.
CAVANAUGH: And when, indeed, the soldier, sailor, Marine comes home, what kind of stresses do families face then?
KARNEY: Well, reports from military families suggest that the – what’s called the integration phase, the reintegration phase, carries with it its own set of demands, partly because the expectations of that phase tend to be really high. So, you know, soldiers are dreaming of coming home to their families, families are dreaming of having the soldier home, and there’s a lot of high expectations that that’s going to be just this wonderful time, and there’s certainly wonderful things about it but the problem is that because these deployments, especially for the Army, have been really long, the family that’s left behind when a soldier is deployed makes adjustments. New rituals are established, new responsibilities are allocated to different family members in the soldier’s absence. And when the soldier returns, the soldier returns to a different family than the one that is left, not an entirely different one but a different one. And adjusting, readjusting, making room again for the soldier where there’s been sort of efforts to compensate for that soldier’s absence, that takes adjustments on everyone’s part. And so that’s a stressor at a time when people aren’t expecting it to be stressful.
CAVANAUGH: Right. So, Laura, in the face of what Ben is telling us, what kinds of services does the VA San Diego’s Care Management Team offer?
OWEN: Well, we sponsor what’s called a welcome home event for soldiers, sailors, airmen and Marine who come home, and it’s a chance for us to do a host of post-deployment screens for PTSD, for traumatic brain injury, for any kind of medical or psychological problems that might have come up as a result of the deployment. It’s also a time for us to recognize the tremendous sacrifice of our families who sent their loved ones to war. And it’s also a time of celebration, it’s a celebration of the family and of the return together. So and it’s also a good opportunity for the veterans or soon-to-be veterans and their spouses and children to be introduced to the vet – to the VA for the first time, and so we try to make it fun. We have food, we have balloons, we have things for the kids to do, and that’s the first opportunity that the spouses also get to hear the benefits available to the active duty member or the veteran. And that’s important because when a veteran or an active duty member comes home from deployment, they are inundated with information. But I am an OEF vet myself and I remember getting off the plane and I had more to do when I got off the plane than I ever did when I was in country, and that’s because you have to check all your gear, you have to check in with your commanding officer, you have to be briefed, you have to medically evaluated, and it’s hard to remember to – the self-care portion of your responsibilities and all the things that you’re going to need to do later on down the line when you have a chance to breathe. So it’s a good opportunity at these welcome home events for us to talk to the spouse and say, hey, when your loved one is ready to hear this, remind them of their benefits and here they are.
OWEN: We have counseling, we have substance abuse counseling, we have – we had explanation of benefits, the GI Bill, you know, all of the benefits that the VA provides materially and financially as well as the healthcare benefits that we offer as well.
CAVANAUGH: And that is Laura Owen. She works with the program – she’s program manager of the VA San Diego’s Care Management Team. I’m also speaking with Benjamin Karney, and I’m going to bring Dr. Jeffrey Matloff into the conversation. This morning, we’re continuing our series, “War Comes Home.” We’re talking about returning veterans and their families and the challenges and the support that is available to them. And we’re taking your calls at 1-888-895-5727, that’s 1-888-895-KPBS. And, Dr. Jeffrey Matloff, as I said, welcome again. And I want to know – we – I began this conversation by also mentioning the fact that there are some veterans returning who have these invisible wounds, brain injuries and the symptoms of post traumatic stress disorder. I’m wondering, do we see a lot of veterans who have these problems?
DR. MATLOFF: We actually see quite a great number of veterans now that present with both problems. And by the way, there is a lot of overlap between both PTSD and TBI because we know from studies that have been done that the chances of developing PTSD are twice as great when somebody is wounded, as in the case of somebody may get a TBI, let’s say, from an IED.
CAVANAUGH: Well, let’s clear our definitions, just going into the conversation here. If you could tell us what is post traumatic stress disorder, what are some of the symptoms of that disorder?
DR. MATLOFF: Sure. Post traumatic stress disorder is a diagnosis that was established by the American Psychiatric Association in 1980. And there are basically four major criteria to the diagnosis. Number one is, a person has to have suffered what we define as a trauma and a trauma is something that either causes oneself to feel one’s life is in danger, generating feelings of fear, horror and dread, or actually witnessing it in someone else. Now people may argue what exactly is traumatic for one person may be traumatic for another (sic) but, on the other hand, we agree that generally it’s something that is really outside, at least the traditional definition, outside the realm of normal human experience and, certainly, combat would qualify. We also have then symptoms being generated from that trauma. Now in order to qualify for a diagnosis of PTSD, these symptoms have to have been ongoing for at least a month, and they are intrusive recollections like we would see in the form of flashbacks, which are like daymares, intrusive reexperiencing memories of the event itself, physiologic reactivities such as heart racing being triggered by stimuli that previously didn’t have any kind of negative stigma to them. The other thing we will also see are what are called avoidance symptoms and that’s a third criterion. And avoidance symptoms typically are things like a person will have very little emotional reactivity to things, have an inability to express warm, loving feelings, maybe experience a loss of – or of their normal interests, and let’s say in living. They may have a sense of what’s known as a foreshortened future, really not see themselves as being able to have a long, fulfilling, good life. The final set are what we call hyper-arousal symptoms and hyper-arousal symptoms constitute things like irritability, inability to, let’s say, sleep. And, by the way, that’s probably one of the most common ones…
DR. MATLOFF: …we see, is people who have problems sleeping. Interrupted sleep, anxiety and, again, maybe having problems modulating anger. So if it goes on beyond three months then we enter what’s called a chronic phase of PTSD. Now chronic doesn’t mean it’s a death sentence, that you’re stuck with this all through your life but it means that you’ve definitely got a bug or, as I like to call it, and we definitely need to try to see if we can help that person.
CAVANAUGH: Now, in the beginning of – In introducing this topic, I said that traumatic brain injury was one of the major injuries that people who have fought in Iraq and Afghanistan have suffered. Tell us what that is and why that’s so.
DR. MATLOFF: Well, I think in the nature of this particular form of combat, as you alluded to in your introduction, traumatic brain injury is a very common injury with the use of things like IEDs. Now we’ve seen traumatic brain injuries in other kinds of conflicts as well as peacetime events. Motor vehicle accidents, for instance, people can get head injuries. But the nature of this conflict is such that with, you know, the use of armored vehicles, with people of course, you know, getting in contact with things like mines and other things, this is a huge, huge problem. Now, fortunately, the majority of the injuries we see from IEDs are what we call mild traumatic brain injuries, and mild traumatic brain injury is very amenable to treatment, rehab, even in its most extreme forms. On the other hand, of course, there is a gamut, a range, from mild, which is really the vast majority, all the way down to moderate, which is a person may have some life impairments, all the way down to severe in which a person will need help all through the remainder of their lives kind of coping with, you know, activities of daily living and other things. Fortunately, that’s the extreme and the rarer of the end of the continuum.
CAVANAUGH: We are continuing our series, the KPBS series “War Comes Home.” We have to take a short break. When we return, we will continue with our discussion about returning veterans and some of the invisible wounds of war. Our number, if you would like to join the conversation, is 1-888-895-5727. And we will return in just a few moments.
# # #
CAVANAUGH: Welcome back. I'm Maureen Cavanaugh. You're listening to These Days on KPBS, and we’re continuing our conversation on returning veterans and their families and the challenges that face them. My guests are Laura Owen, she is program manager of the VA San Diego's Care Management Team. Dr. Jeffrey Matloff is senior post traumatic stress disorder psychologist at the VA here in San Diego. And Benjamin Karney, is associate professor of psychology at UCLA, and adjunct behavioral scientist at the Rand Corporation. We are taking your calls at 1-888-895-5727, if you’d like to join our conversation here. And, Ben, you know, I wanted to pick up on what we left off before the break because I know you recently worked on a study for the Rand Corporation called “Invisible Wounds” and it studies the consequences and effects of post traumatic stress disorder and traumatic brain injury. What did that study conclude? What did you learn?
KARNEY: What we learned from that study is that the prevalence rates, just as Dr. Matloff was saying, of traumatic brain injuries and PTSD are pretty high, higher than in comparable conflicts. And in some ways, that’s good news because one of the reasons they’re high is that people are surviving now wounds that would’ve killed them in prior conflicts. Battlefield technology has advance so people are now able to come home. Also battlefield-like protective technology and protective gear have advanced in such a way that people are coming home from wounds that would’ve killed them before. The problem is that now we have people coming home with a variety of ailments and disorders, the long term consequences of which are kind of unknown. We know that – but what we – Another lesson from this study that we did at Rand is that more people are coming home with symptoms than are getting treatment.
CAVANAUGH: I see. We are taking your calls at 1-888-895-5727. Right now, David is on the line from San Diego. And good morning, David, welcome to These Days.
DAVID (Caller, San Diego): Good morning. Thanks for taking my call.
DAVID: I had a question about, well, when gay service members are discharged because of being gay, I assume that they lose most of their benefits. But I’m wondering when gay sailors and Marines return from deployment and then become veterans, do they lose their VA benefits? And if they get to keep them, I mean, will the VA extend benefits to their gay service members? And if so, you were talking earlier about the effects of reintegration into the family, does the VA offer services to same sex couples where at least one of them is a veteran?
CAVANAUGH: Well, Laura, I’m going to field this question to you. I don’t – do you – are you qualified to answer it?
OWEN: Well, I don’t know if I’m qualified to but I’ve got a good answer.
CAVANAUGH: Okay, great.
OWEN: Thank you for your question. The VA does not have a “don’t ask, don’t tell” policy. That – Sometimes people and, in fact, sometimes – some members of congress have difficulty distinguishing between the Department of Defense and the VA because our missions are similar; we take care of the same people but the DOD takes care of people during service and we take care of people after service. And as long as a service member has an honorable discharge or a discharge even at general discharge under honorable circumstances—and you can get that from a discharge under the “don’t ask, don’t tell” policy—you are eligible for care under the VA’s system. So we don’t make any distinctions between gay or straight or any sexual preference at all. And as far as the service members’ domestic partners or, excuse me, the veteran’s domestic partners or anybody in their life that’s important to them, I also want to make the distinction that the VA takes care of veterans and not spouses or…
OWEN: …children. So, again, we don’t make that distinction, we take care of any veteran who is eligible for care and sexual preference is not a criteria for eligibility.
CAVANAUGH: Thank you for that. And thank you for that question, David. There’s another caller, David in San Diego now on the line. Good morning, David, and welcome to These Days.
DAVID (Caller, San Diego): Good morning. Thank you for taking my call.
DAVID: I’m a Vietnam veteran. I was in the First 16th Rangers, First Infantry Division, and we saw quite a bit of combat. And I’ve come to the conclusion that everybody that has been in combat like that—I was also wounded—does have PTSD. And the survivors of my platoon have recently got in touch with me, and all of them have been diagnosed with, you know, PTSD. And when we returned, there was very little outreach, very little understood and one of the main things that returning veterans have to cope with is that the general population is not aware and cannot empathize with what has occurred. And that feeling leads to isolation. I think that is one of the more dangerous aspects of PTSD, is the isolation and inability to find a, you know, a common sounding board for it. And that’s my observation and I’ll take your reply off the air. Thank you.
CAVANAUGH: Thank you, David. Thank you very much for the call. And Dr. Jeffrey Matloff is here shaking his head and you agree with the assessment that David has.
DR. MATLOFF: Oh, absolutely. In terms of combat exposure and the development of PTSD, we know that the more combat one is exposed to, probably the more likely one is to develop PTSD. Now David also pointed out and I want to validate this, that isolation is a feeling that many combat veterans who have PTSD experience, the feeling that other people outside of other combat veterans don’t understand what they’ve been through. And, again, what I want to reiterate, though, is that there is help. And one thing I wanted to also share with David is it’s actually because of the actions of Vietnam veterans that the diagnosis of PTSD was developed in 1980. It was like a class action of hundreds of thousands of veterans who said basically, you know, the old way of treatment, the old way of diagnosis, doesn’t fit me. And as a result of studies that were done, we now have a diagnosis. And, David, you’re right, back in the days of Vietnam there was virtually no outreach. You know, unfortunately we’ve learned from the experience of the Vietnam veteran how to do it better. Now we still may not be doing it perfectly but we are certainly 30 years now ahead of where we were back in 1979, 1980, when the diagnosis was first put on the books.
CAVANAUGH: Now, Dr. Matloff and Ben, I’d like you both to address this question. One of the ideas that David’s phone call brings up, though, is how long is it going to take before we truly know the scope and the – of the PTSD in the veterans that are coming home now from Iraq and Afghanistan? First, Dr. Matloff.
DR. MATLOFF: Well, I think we’re fairly fortunate. With the development of the technologies, with the outreach services that Laura’s described, of what we can do now to do more outreach and actually present services to veterans even prior to their getting out. Now I also want to say that actually I think we’re doing a pretty good job of getting veterans, once they’re discharged, into treatment. But still the problem is that people have to come forward and identify…
DR. MATLOFF: …themselves, and there’s certainly less of a stigma after the military and I think that’s a – with all the efforts at outreach, we’re seeing a lot more. But there’s also a concept in the diagnosis of PTSD known as delayed onset. And I think our last caller, David, pointed out that he thinks he may have post traumatic stress and it’s been probably 40 years since…
DR. MATLOFF: …he was in the combat zone. People can often present with symptoms many years after the fact when they’re going through, let’s say, a life transition such as retirement or when they’re developing medical problems and they have less structure in their lives and they have more time to focus on the past. So I’m hopeful that at least we’ll be able to get this newer generation of warriors into treatment sooner. And that’s our big push, is to get the services to them sooner so, hopefully, they’ll have a better outcome and can go on and function with the rest of their lives and not be too bothered by things.
CAVANAUGH: And Ben Karney, as you did this study for the Rand Corporation, do you agree that it’s going to be many years down the line before we know the full impact of what these – the post traumatic stress disorder and perhaps even traumatic brain injury is going to wrought on the veterans?
KARNEY: Absolutely, Maureen. As Dr. Matloff points out, there is this phenomena of delayed onset and that’s just talking about the individual consequences of these disorders. The social consequences are even harder to measure and may even be yet more delayed. When I say social consequences, I mean the consequences of the service members or the veterans disorder on their relationships, specifically on their marital relationships and their relationships to their children. We know from work on civilian populations with PTSD and traumatic brain injury that the families and the intimate partners of people who are suffering, they get really affected. So marriages suffer and children suffer. Children, years down the line, can suffer academic deficits and their own social deficits as a function of being raised by parents who are struggling with these issues. Again, early treatment is going to be key but one of the challenges is going to, as Dr. Matloff points out and as the Rand study pointed out, is that a lot of people are suffering without getting treatment. So the – so early intervention is going to be crucial.
CAVANAUGH: Let’s take another call. Nicole is calling from Oceanside. Good morning, Nicole. Welcome to These Days.
NICOLE (Caller, Oceanside): Hi. Thanks for taking my call. I actually am responding – my comment is directly related to what was just said. I’m a marriage and family therapist who serves military families and I’m still seeing so many young men coming home with these injuries. And my brother was one of them so I have some personal experience with it as well. But they’re very, very reluctant to get treatment. They’re very reluctant in fear of losing their jobs, which is, you know, their only way of supporting their families. But the marriages and the children are suffering dearly and so often I’m left with the, you know, the job of trying to help the kids and the wives cope without really dealing with the issue at hand, which is that there’s a member in the family who is suffering from sometimes pretty significant PTSD or brain injury. And as far as the stigma getting better, I don’t see it in active duty military at this point, so that’s another big concern.
CAVANAUGH: Thank you…
NICOLE: Oh, I’ll take my response off the air.
CAVANAUGH: Thank you very much for the call, Nicole. Ben, since the study you worked on is called “Families Under Stress,” I also want to maybe broaden this out a little bit to the idea if a veteran’s transitioning to civilian life, does that make more – do people have more divorces in the military? Do – What kind of outcomes do we have because of the strains that are put on military families?
KARNEY: We really have to make a distinction between what’s going on with military families while they’re in the military and what happens to those families after they separate from the military and transfer into veteran status. So the – As Laura pointed out earlier, the military takes care of military families. Military offers services for active duty and reserve and service members and their families. Military offers healthcare and childcare to the families of service members. The VA, and correct me if I’m wrong, the VA focuses on the veterans and doesn’t offer services to anyone else, anyone who hasn’t directly served. That is a crucial distinction, and here is why. While families – service members and their families are in the military, the military is offering benefits to everybody. That helps to compensate for the effects of stress and as a result, while families are in the military, their divorce rates are relatively low given the stress that they’re under. In fact, we did analysis which directly compared the divorce rates of people who are serving in the military and their families, compared to comparable civilians. Civilians were matched on age and on racial composition and level of education. And we found that despite the enormous stress that the military’s been under in the last few years, divorce rates are still lower in the military…
KARNEY: …than for comparable civilians.
CAVANAUGH: That’s interesting. Did you expect to find that?
KARNEY: Well, we – we’re open to any finding.
CAVANAUGH: Yeah, exactly.
KARNEY: But there was an explanation with the explanation being that even though military families are under tremendous stress, they – there are compensations. They get paid to be under stress and they have access to tremendous healthcare and childcare that’s comparable to civilians where civilians under stress aren’t exposed – aren’t – don’t have access to.
CAVANAUGH: I’d like to ask you, Dr. Matloff, what do your patients who are suffering from PTSD tell you about the effects on their families?
DR. MATLOFF: Well, I think the families, I like to think of as a perimeter of safety for the vet. Most vets, when they have PTSD, they feel very isolated. And often when they come home and they have PTSD or TBI or both, let’s say, often it’s the family that really brings it to their attention that they have a problem and, therefore, gets them actually into treatment earlier than they would otherwise. And I think that’s part of the reason we’re seeing greater numbers of veterans coming in from the results of this conflict in terms of get – you know, coming in earlier than in other conflicts. The other thing I wanted to point out was that actually the VA does offer marital and family counseling to veterans and their families and we do have a very active program locally at this VA which actually does work with the families around these issues as well as communication issues and education issues. One other thing I also wanted to make a point is, actually our local veterans hospital here is one of three National Centers of Excellence that deals specifically with post traumatic stress, stress disorders in general, as well as TBIs, so we’re really at the forefront here in San Diego of working on how these disorders interact and what we can do to not only diagnose them but what we can do to treat them. And we’re currently involved in a number of studies that all veterans of this conflict are eligible for as well as from other conflicts, concerning how we can really best bring the research into clinical practice.
CAVANAUGH: And in our remaining minutes, Laura, I’d like to give you the last word. I wonder, you know, in consideration of all that we’ve been talking about and the fact that we’re going to see more and more people come in presenting symptoms and more veterans needing help, I wonder, what are some of the programs that are in the works, ideas that perhaps you’d like to see adopted by San Diego’s VA healthcare system in the next few years.
OWEN: Thank you for this opportunity. There’s something that I’ve been wanting to say and…
OWEN: …today’s topic is family issues and I think something that’s hard for civilians to understand and sometimes confusing for families of origin or marriage families or blood families to understand is that when a service member goes overseas, they form a new family and that is particularly true for our Marine Corps vets. You know, the expression once a Marine, always a Marine is absolutely true. And so it can sometimes seem as if a veteran comes home more loyal to the soldiers, sailors, airmen and Marines that they deployed with, and in some cases that might be – they might find more support and more comfort in the company of people with similar experiences, people who went to war with them. And so that is a tremendous resource that we can use and, as a result, there are many, many vet service organizations that can help a veteran deal with confusing emotions and PTSD and TBI in a way that a civilian’s family members just aren’t equipped to deal with. And I mentioned the Disabled American Vets, we have Vets for Vets, Amvets, the American Legion. There are also a number of veterans associations on college campuses. I remember in my own experience as a war vet, when I came home, well, let me back up. When I was in war, all I wanted to do was go home. And the second I got home, I felt a tremendous level of guilt for the people – the – my comrades who I had left behind. And it was very difficult for my husband to understand how I had only wanted to come home and then the second I got home, all I wanted to do was go back to war. But that’s not an uncommon feeling.
OWEN: So if we can help our civilian family members and our vets access people who have had similar experiences, I think that’s a very, very powerful tool. And, fortunately, in the San Diego region, we are very rich with veteran service organizations.
CAVANAUGH: We certainly are. I want to thank my guests so much. Laura Owen, Dr. Jeffrey Matloff, Benjamin Karney, thank you all for being guests this morning. And I wanted to let our audience know that the KPBS series “War Comes Home” continues, not only on the air but on our website, KPBS.org. There you’ll find our “War Comes Home” page, which also offers resources for veterans and active duty families. Now stay with us because These Days will continue in just a few minutes and, coming up, the trouble with ACORN. This is These Days on KPBS.
To view PDF documents, Download Acrobat Reader.
Please stay on topic and be as concise as possible. Leaving a comment means you agree to our Community Discussion Rules. We like civilized discourse. We don't like spam, lying, profanity, harassment or personal attacks.