PTSD and Scuba Diving
*This is an article from the Summer 2021 issue of Combat Stress
By Kevin James, Master Scuba Diver Trainer, Navy Diving Supervisor
This article has been written to inform readers about Therapeutic Scuba Diving and how this has provided significant benefits to 3 Servicemen suffering from varying levels of Post-Traumatic Stress Disorder (PTSD). It focuses mainly on Diver C, who had no previous diving experience and who had been suffering from complex PTSD symptoms. This had required a 6-week stay in a psychiatric facility.
Nothing in this piece is claimed to be conclusive, other than the 3 divers’ accounts regarding their arrival on Long Island in The Bahamas while suffering from PTSD symptoms and thus, claiming to leave symptom-free after a completion of 8 to 10 days of diving operations. The author believes that this work could be of interest to others who may be more able to move this emerging work forward scientifically and/or clinically, using these single case studies as a starting point or baseline.
The dive report concerning Diver C’s PTSD Therapeutic Scuba Diving plan is documented in his own words as the first part of each sub-section below.
Disclaimer: The author does not have a medical or psychological background, but does have a profound experience of 40 years as a scuba diving professional (instructor, dive master, expeditions and salvage etc.) This also includes a full military career in the British Army. As a Veteran, the author’s interest in helping PTSD sufferers has become his dominant force where scuba diving is concerned for the last decade.
Introduction
This project began when the author reviewed a Johns Hopkins University Hospital study by Adam Kaplin, MD, PhD (2011)1, regarding an improvement in sensation due to the utilization of scuba diving with paralyzed Veterans by as much as 15 percent. The study suggested that 10 of the candidates realized an improvement on average of 80 percent as this applies to PTSD symptoms, while diving at an average depth of 60 feet (18 meters). This was immediately considered worthy of further investigation by the author.
The Project Begins
The PTSD diving project actually began following 7 years of attempting to interest wounded warrior and PTSD organizations worldwide through the author’s offer to help sufferers based on the Johns Hopkins study. These messages included the offer of location, (Long Island in the Bahamas), a boat, a full range of modern scuba diving equipment, together with the author’s expertise and experience in taking disabled individuals scuba diving. This was all offered gratis in the hope of further investigating the validity of the initial study. None of the agencies contacted showed any interest in gaining more knowledge and most did not even reply. With this negativity in mind, a decision to go it alone was made and the author posted a message on a Veterans’ social media page. This is when Diver A decided to pay his own expenses for a trip to the Bahamas, accompanied by his wife, to discover if perhaps scuba diving might help to reduce his symptoms. This is a quote from his wife in 2018:
“He seemed to have a wall up with everyone apart from the guys that had been over in Iraq with him. Then the night tremors and mood swings came, which had no effect on his day to day life, so he just got on with things. Last year he started to get short flashbacks during the days, which were pretty graphic and then he started to have what he described as little ‘daydreams’ where he would be brutally killing someone/thing. It was clear to me that his symptoms were worsening year on year and he needed some form of help quickly.”
Diver A had completed 12 scuba dives prior to his arrival through a British Sub Aqua Club (BSAC) Sports Diver Course. It was ascertained that he was medically fit to dive. At the time, he was taking no medications that would disallow scuba diving. Following his scuba diving trip, Diver A claimed to leave the island PTSD symptom-free.
Diver B was selected to attend the course, also having scuba dived before (10 dives). He had also completed a BSAC sports diver course. The same medical and health checks were made for this diver as for Diver A. His selection was based on a previously failed attempt with a United Kingdom-based scuba diving charity, with which he had labored to find a way to deal with his symptoms. This is a quote from Diver B’s wife, also in 2018:
“His main symptoms were, night terrors, night sweats, lashing out in his sleep, nightmares reliving Afghan times. Depression, suicidal thoughts, often angry, he regressed into his own bubble. He also had daytime flashbacks. fireworks or gunshots made him hit the floor as if he was being attacked. He threw himself into his work as a police officer to the detriment of his own mental health.”
Air miles were donated by a friend of the authors to fly Diver B round trip to the Bahamas. It was decided by the donor that because Diver B was flying home alone, a first-class flight should fortify any success achieved by the PTSD therapeutic scuba diving. All other expenses for this visit were paid for by the author. Following the scuba diving experience Diver B also claimed to leave the island PTSD symptom-free.
Foreword by Diver C
“Initially when I was first asked if I wanted to go scuba diving in the Bahamas, I grunted ‘no thanks.’ I couldn’t think of anything worse than leaving the safety of my couch or the security of my house. I couldn’t begin to think about anything more adventurous than attending my mandated medical appointments or making the occasional trip to the local shop for milk.”
Diver C was selected for two reasons. Firstly, he was extremely ill, according to his wife and his psychiatrist (he had participated in a very recent 6-week inpatient admission to a psychiatric facility). Secondly, he had never scuba dived before, even though he is a strong swimmer. By choosing a non-diving and very ill candidate, it was believed by the author that having any kind of success with this individual was both worthwhile and desirable for the emerging track record and the planned future possibility of helping non-diving PTSD sufferers. Most importantly was the wellbeing and potential symptom relief for Diver C himself. After making contact with the candidate’s wife, it became clear that he was not well enough to travel alone to the Bahamas. Funds for travel and accommodations for their visit were not available in the initial stages of their prospective trip.
A crowdfunding page was set up for the prospective diver’s flights and accommodations. It was, however, considered inappropriate for a non-PTSD sufferer’s flight expenses (diver’s wife) to be paid for by the fledgling PTSD scuba charity (presently attempting to become registered), which is set up only to only actual PTSD diving candidates themselves. Therefore, a friends and family message was sent out by the author in order to successfully raise enough money for Diver C’s wife’s flights.
One Step at a Time
“So, before I knew it, I was on a ‘try dive’ in a swimming pool in Bristol, UK. If I’m honest, I still wasn’t that enthusiastic about doing it, but it definitely beat staying in my house feeling bad about myself, I did agree that giving it a try was a fair request of me. Wetsuit on, Buoyancy Control Device (BCD jacket) on, mask on, fins on, I was then asked to take that first breath underwater; it felt strange and alien, I was told to breathe long and deep and relax as much as I could, I followed this advice on my next attempt, and all of a sudden I was under! I was staying under; it felt good, really good, it felt like I was cheating nature!”
It was decided that because Diver C had never scuba dived before, it was necessary to determine whether he could function and make progress underwater before raising the funds and therefore paying for his trip. This is why a ‘try dive’ is always needed before travel for all non-scuba divers. A full diving medical examination was also required, together with an agreement from his psychiatrist that none of his medications were going to be a problem where scuba diving was concerned. His psychiatrist did, however, indicate that he was never to become dehydrated because of the medications he was prescribed. This was followed scrupulously morning, afternoon and evening. Mandated drinks of water or juice were both available and consumed while actually on the island. It was decided that 3 liters spread out over the periods mentioned was appropriate.
Be in the Moment
“We carried out some skills and I felt calm and relaxed doing them, I tried to stay underwater as much as I could for the duration of the try dive; for some reason it just felt right. When the hour was up, my head felt a little bit clearer, all of the worries and the other ‘stuff’ were still there in my head, but it felt diluted somehow. I approached the dive school and asked how do I keep doing this? The only way was to sign up for the PADI Open Water course, with the plan to do the confined water swimming pool sessions and the classroom requirements in the U.K. and then completed the 4 qualifying ocean dives with Kevin (PTSD scuba diving) in the Bahamas.”
Proof does not yet exist that embarking on any activity while underwater in a swimming pool helps PTSD sufferers in any way. However, Diver C clearly felt that he did gain some benefit from the try dive in the swimming pool. The need to take care of himself safely while being under the water (his focus) may be the reason he felt some gains, but his comment was that the pure serenity of the experience did, in fact, help. Diver C’s view was that in the shallow end, there was no challenge or gain, as he felt completely safe and not at any risk. Therefore, there was no reason to focus his attention on anything important. In his mind, this was not particularly useful. However, while in the deep end with a need to either “do it right, or die”, using his words, he noticed an improvement in how he felt while underwater. On the way home, he said there had been some benefit. He described achieving something of use (new skills perhaps) for the first time in a while or maybe he was simply able to focus on something interesting to him for the first time in a long while.
Keeping the Wheels on the Bus
“The PTSD scuba charity started ramping up the fundraising with just a giving page to get me out there. Now that they had a ‘green light’ and I could actually do the physical aspects of diving they checked in with my doctor and psychiatrist, ensuring that I also passed a dive medical. From before the try dive and during the training in the UK, Kevin and the PTSD scuba diving set up were there for me every single step of the way, from Kev giving advice and help at any hour of the day or night, together with a serious amount of banter, which I had missed. There were regular phone calls checking in with me, making sure that ‘the wheels were still on the bus’ and I felt that lots of people were rooting for me.”
It was very apparent from the beginning of the journey for Diver C, that being gentle was the way to go with him. There was not a large amount of interaction with him by the author initially, apart from regular check-ins. Most of the discussions and the required pre-visit preparations were completed with his wife. He was too ill to react to anything, other than lighthearted (not too heavy at this stage) banter, which is military jargon for joking with each other. The author felt it was very important to keep Diver C’s hope of getting better; a big part of every conversation. Also, to be considered in the pre-travel preparations was the winter weather in the UK at that time, Christmas, the New Year, and 6 children between husband and wife. These potentially stressful issues were a huge added burden to Diver C’s PTSD symptoms. As Diver C was accompanied by his wife for the flights and an overnight transit stay, it was felt that no help was required from a PTSD scuba diving charity point of view for their travel from the UK through Nassau and onward to Long Island, Bahamas the next day.
The Process Begins
“The first dive in the Bahamas was a ‘shake down’ dive, a shallow one to about 15 feet (5 meters) initially, to get used to the equipment and to get my weights right. This also involved becoming familiarized again with scuba diving following a few weeks’ break. After all, it is the ocean and salt water now instead of a swimming pool in Bristol. So the gear was on; I felt good, I felt so lucky to be there, Kev asked me to put the dive regulator in my mouth, put my face in the water and have a swim about in about 3 feet (1 meter) of water, I couldn’t do it! I had forgotten everything… I was panicking, couldn’t breathe, I was hyperventilating and getting frustrated with myself, to the point of extreme anger. ‘I’ve wasted everyone’s time and money,’ I thought to myself over and over again, the PTSD fog creeping into my mind and brain. ‘I’m not capable anymore,’ I used to be ‘on the ball’ before I admitted to everyone that I had PTSD. I was a great Soldier. Now look at me, scared of 3 feet of water!”
Diver C was required to complete his 4 Open Water Qualifying Dives, demonstrating what he had been taught in the swimming pool, but now in the ocean. This is required in order to embark on the therapeutic PTSD dives. As can be seen from his text above, a serious challenge was immediately being faced. Therefore, dive number 1, in the author’s mind, naturally became a PTSD therapeutic opportunity, as well as a PADI qualifying dive. If the author pressured too hard or created any negativity in Diver C’s mind, the pathway to overcoming Diver C’s PTSD symptoms could easily become an impossible one to follow, culminating in a lack of any achievements being made by this diver.
Solving the First Challenge to Any Symptom Relief
“Then Kevin appeared in front of me. ‘Marc, look at me. All we have to do is train your brain, and we’ll do that together.’ Now I had no idea what this meant but thought that this bloke is supposed to know his stuff, so I went with it. So, we added a bit more weight to my belt, had a swim on the surface with the regulator in my mouth and my face in the water, 15 feet (5 meters) then 30 feet (10 meters), up and down the beach in 3 feet of water (1 meter) and that was as much as I could manage. I was trying really hard to suppress the brain that was telling me, ‘You can’t do this; PTSD has made you who you are now; useless, and it’s how you’re going to stay.’”
Clearly being empathic and coaxing Diver C to go underwater was going to garner so much more success than going into drill sergeant mode. This does, in fact, often work with regular divers who just need a nudge to convince them they can in fact do it. A firmer route was believed by the author to be very dangerous in this instance and should be avoided where a diver suffering from PTSD is concerned. What appeared to be guilt and worry could physically be seen on Diver C’s face during the early stages of dive 1, so, it was very much a wait and see approach. There was still lots of time, as Diver C was going to be on the island for very close to 2 weeks; so, there was no need to rush anything at this point.
Training the Brain
“We’d been in the water about 30 minutes and by this point, Kevin asked me to let out a big breath and exhale with my face in the water and regulator in. I did this and descended to the seabed about 5 feet (1.5 meters) below me. I was under at least and breathing and not panicking. After coming back up, Kevin then asked me to do the same again, but to swim to the edge of the slope down to the seabed where the dive would take place, and stare down to the bottom, which was 15 feet (5 meters) below me. I did this, swam to the top of the ledge and looked down to the seabed. Something was stopping me; nothing physical, just the very loud PTSD noise in my head, my own voice telling me that it couldn’t be done, not by me anyhow. I surfaced to speak to Kevin, who was standing next to me, I told him ‘I want to go, I really do,’ before I admitted I needed help. I would have pushed through and gone straight down. Kev looked at me. He listened, told me not to worry, ‘We’re just training your brain. We can do as much or as little of this as you feel you want to do today. Oh, and by the way we have 2 weeks to get you down there,’ he said with a chuckle.”
With continuous talking, encouraging, and support of Diver C, the author believed that this would help solve his minor mental reservations of submerging below the surface to the planned depth. It appeared he was likening the situation to being in the shallow end of the swimming pool in Bristol, where he felt ultra-safe. Once this was identified as being the probable issue he was facing, it was assumed by the author that the pathway to completing the dive became clearer in the diver’s mind.
Down We Go
“I said I’d like to try again. I descended to the seabed at about 6 feet (2 meters), got to the edge and stared down. My head was screaming at me, the self-doubt creeping in again. It was getting louder and louder and louder; I was still staring down into the deeper sea where I desperately wanted to go. I remember it vividly now in my head. I screamed in my mind ‘F$&# OFF, JUST F#$& OFF’ and the noises suddenly went silent. All I could hear was the sound of my regulator; all I could see was an underwater playground in front of me. I looked to my right and Kevin was there. He signaled if I was ok, I signaled back ‘yes, ok.’ I then gave him the descend thumbs down sign, he gave an underwater ‘YES!’ shake of his fists, I then went over the edge and completed the majority of that dive to a maximum depth of 20 feet. (6 meters) and the next one on the PADI referral course to 30 feet (10 meters).”
During this period, Diver C continuously said, “I’ll just push through my fear and do it.” Whereas the author is not a psychologist or medical professional, it felt right to tell him that he should not do this and risk any progression beyond his absolute comfort zone until he felt it was right and proper to do so. The author knows that handling scuba skills, if not feeling 100 percent relaxed, is neither safe nor desirable. It was very gratifying to see Diver C achieve the level of comfort needed to progress from the shallows, without using anything other than his calm decision to do so. Hand signals in scuba diving, ok, down, up, are always questions such as, “Are you ok?” “Would you like to go down?” “Shall we go up?”. Clearly, if given vigorously, they command or convey a decision made or a pressing desire. Once the diver gave a relaxed, “shall we go down” signal, the author realized all was well and progress could be made accordingly.
Quantifiable Progress Made
“After surfacing from the second qualifying dive, I felt a huge personal victory. I realized that I can be in charge of my thoughts, fears and feelings. My worries of inadequacy and being incapable were also starting to fade; maybe I am a great Soldier after all. I still felt the brain fog but had a considerable amount more hope onboard. The next 2 qualifying dives were in the Deans Blue Hole area, being tested on skills for the PADI Open Water qualification and gaining experience in becoming an open water diver. There was one dive in particular that I remember; just feeling an overwhelming sense of ‘You know what, I reckon everything is going to be ok!’ After completing my initial PADI course we were diving at around 30 feet (10 meters) in Deans Blue Hole and Kev asked me if I was ok to descend, I signaled, ‘Yes, good to go,’ and we descended slowly to a broad sandy ledge within the hole itself. I remember Kevin sitting me down on the sand, at the front of the ledge, showing me where he was and that we weren’t going anywhere, then signaling me to look around, breathe calmly and relax. Now, I sat on that ledge only for a maximum of 4 or 5 minutes, but those minutes were the calmest that I had felt in as long as I could remember. All my negative thoughts were gone as quickly as they appeared, complete medicine for the mind, perhaps I was training my brain after all.”
Once Diver C was able to progress further forward after the initial PADI open water qualifying part of his visit (he completed a further PADI Advanced Open Water course after first gaining some more experience), the author was then able to focus more on the therapeutic side of his trip. This was started with a dive to 60 feet (18 meters), where he could begin mirroring the depths mentioned in the initial study. Diver C said that while completing the dive to 60 feet (18 meters) and afterwards in the vehicle while returning to the hotel, he could feel the ‘brain fog,’ using his words, ‘clearing from behind his eyes’ (which, incidentally, were of a yellow hue in the center when he arrived at the island, instead of normally light blue according to his wife).
It’s just a Helicopter After All
“Over the next two weeks, as my experience progressed and we increased the amount of dives I was doing for me to maybe become a divemaster or instructor one day, which is my long term plan now that I have discovered scuba diving. I also managed to qualify as a PADI Advanced Open Water diver, having completed the 5 required dives for that qualification. This now meant we could dive a little deeper, all the time with Kevin by my side with all of the safety measures and spare air-tanks/regulators/masks/dive watches and computers we could carry…. ha ha! Now this is where, for me, the real magic started to happen. It was on the deeper dives to a maximum depth of 130 feet (40 meters). After being at that depth and then slowly ascending, the same feeling I had experienced on the ledge earlier during the shallower dives came back but was more amplified. No bad thoughts or feelings even entered my head, either during these dives or after on the surface. I felt complete relaxation. For example, one of my PTSD symptom triggers used to be helicopters; my pulse would race, I would start sweating, and generally just want to run away and hide somewhere. I saw a helicopter after the second deeper dive and just logically thought to myself when I saw it, ‘Oh look, a helicopter, it’s just moving parts of machinery,’ when that happened, I knew something had ‘clicked’ back into place, the old Soldier perhaps was coming back?”
The pace of the trip picked up as Diver C was reporting success. Once the PADI Advanced Open Water qualification was finished, Diver C could now enjoy dives up to a depth of 100 feet (30 meters), which he did. After completing a number of dives to that depth, the author felt that accompanying him on dives to a maximum of 130 feet (40 meters) was both safe within a one-on-one scenario and desirable from a PTSD symptom resolution point of view. This was because both Divers A and B claimed the deeper dives were, in their opinion, more beneficial for PTSD symptom relief than the shallower excursions. Diver C continued to claim that deep dive after deep dive, that his PTSD symptoms were becoming less and less evident.
Final Thoughts from Diver C
“The rest of my time in the Bahamas I spent in a relaxed and happy bubble, I felt present, I felt confident and most of all I didn’t feel scared anymore for my future. I’d gotten my excitement and ‘go for it’ attitude back. All that’s left to say is thank you so much to the Progress Through Scuba Diving Team, who work tirelessly and with no pay or remuneration of any kind. Also, a big thank you to all of the kind and wonderful people who donated money for me to have this opportunity. Especially to the people who donated outside of the charity so I could be accompanied, otherwise I would not have been able to travel so far.”
It became very clear that as the scuba diving continued, Diver C’s PTSD symptom resolution improved with each deep dive. Therefore, more of the same was the selected course of action. All three of the divers that visited, but especially Diver C, were encouraged before, during, and after their dives to focus on very positive thoughts. For example, they were encouraged to consider how fortunate they were to have this opportunity, think of their families and friends and about anything else of a positive nature that they could bring to mind. At the end of his stay, Diver C also claimed to leave the island PTSD symptom-free.
Summary of the PTSD Scuba Diving Story So Far
The author makes no claims of curing PTSD regarding the three divers that have visited Long Island so far in an effort to lessen their PTSD symptoms by scuba diving. However, what can be proven (contact details for Divers A, B and C are available from the author) is that the divers stated, with both medical and family confirmation, that they were suffering from varying levels of PTSD symptoms when they arrived on the island before any diving began. They claimed, upon leaving the island (and this was confirmed by their wives, often their barometer), that they felt symptom-free. As of February of 2021, including each of these divers, it has been over 2 years, 18 months, and more than 12 months respectively since Divers A, B, and C completed their diving programs. On the morning of this composition, they confirmed to the author they still remain PTSD symptom-free.
Next Steps and Aims
As a retired British Army Veteran, the author hopes to continue helping PTSD sufferers to seek resolution of their symptoms. As long as funds continue to be raised, the author’s plans remain the same in terms of giving time, energy and expertise free of charge.
At the time of writing this piece, Diver D is presently on Long Island in The Bahamas, attempting to lessen or eliminate her PTSD symptoms arising from domestic violence and sexual assault. If the author can assist her, it is felt that the opportunity to help a much wider audience than just Veterans via scuba diving will be evident.
Diving Information
All of the scuba diving equipment used for this project is serviced and maintained within industry standards. The dives were all completed with 80 cubic foot (12 liter) aluminum tanks. All dives over 100 feet (30 meters) were completed with an extra 40 cubic foot (6 liter) tank clipped to each diver, in addition to an extra regulator and contents gauge to ensure relaxed, enjoyable and safe dives. Dives were ended leaving a minimum of 500 pounds per square inch of air (50 bar) in the scuba tanks. Every dive was completed with regular air 21 percent Oxygen (O2) and 79 percent Nitrogen (N2). At no time were any exotic gasses or other percentage O2 mixtures used. Prior to the commencement of every dive, redundant practices (use of spare tank and regulator) were rehearsed before leaving the shallow water of 6 feet (2 meters). At no time were decompression limit” times (NDL) exceeded. However, completing a lengthy safety stop of 15 to 25 minutes enjoying the coral and fish around the Blue Hole rim at between 10 feet (3 meters) and 25 feet (7 meters), made it safe to leave the deepest depth selected close to some NDL or no stop times. Diver C used environmental clothing protection because the water temperature was cool enough in February to require a thin wetsuit to remain comfortable. Divers A and B did not use any wetsuit protection against the elements.
The author has completed over 3,300 logged scuba dives, with a minimum of 1,500 of them to 100 feet (30 meters) or deeper. An Advanced Diver, who is also a British Sub Aqua Club Instructor and a PADI Dive Master provided surface cover for all ‘PTSD’ dives.
References
- Kaplin, A. (n.d.). Scuba Diving Improves Function of Body, Mind in Vets with Spinal Cord Injury – 09/17/2011. Johns Hopkins Medicine, based in Baltimore, Maryland. https://www.hopkinsmedicine.org/news/media/releases/ scuba_diving_improves_function_of_body_mind_in_vets_with_spinal_cord_injury.
