The War Within

Over the next several days, I wish to publish a series of essays on the page The War Within, accessible either via the menu above or via the individual links below.

Over the past two years, I have thought long about a truth I have faced daily in my work as a psychiatrist treating combat veterans: while no one ever “Recovers” in some capitalized, all-encompassing, get-over-it way from combat experiences, some do “recover” in the small-R way much more readily–or better put, much more day-to-day reliably–than do others.

Here I am not talking about the well-documented phenomenon of “post-deployment adjustment,” the weeks, even the few months following deployment in which combat veterans must learn to readjust to life back in the “real world,” with their families, friends, colleagues, whether that be on a military installation or, even more challengingly, in the community. Instead, I am talking about those combat veterans whose challenges persist well “longer than they should” (whatever that’s supposed to mean), who are haunted by their experiences long enough and hard enough so that they know–whether or not they seek treatment–that “this” is no longer a “phase” that they are going through.

Many quite thoughtful individuals are trying to understand the “whys” of combat trauma/PTSD. I make no claim whatsoever that I have found the answer to any one of these “whys.” I do, though, wish to put forward a hypothesis, or better, a narrative that some veterans with whom I have worked have found helpful as they consider their own struggles with life after combat.

I have come to believe that extroverts, i.e., those who get psychologically “fed” or “recharged” through interactions with others, might experience the challenges of recovering from combat trauma differently from those who are introverts, i.e., those who get psychologically “fed” or “recharged” through individual reflection, through “alone time.”

The terms extrovert and introvert are not about sociability, as they are often colloquially considered to be. Both types of individuals can be quite social. Extroverts, however, get their energy from social experiences themselves, the more, the merrier. Introverts, in contrast, live out their energy in more intense one-on-one experiences, whether that “one-on-one” is with another person or with a “cause” or a “mission,” always after they have had at least some time to themselves to “pull themselves together” and “recharge.” Social interactions, in their broader sense, increase the emotional energy of the extrovert. In contrast, they use up–and therefore decrease the total, at-hand supply of–the emotional energy of the introvert, even when the introvert is participating in those interactions quite willingly and quite genuinely.

While I share these ideas, as always, for the benefit of professionals who are working with combat veterans, I am also sharing these ideas (even primarily so) for combat veterans themselves and for those who love them. Many of the individuals with whom I have shared these thoughts have found them quite helpful. I am curious to know if a broader audience might find them helpful as well, and I am eager to learn how I might improve (or even totally recast) these ideas in light of the experiences of others who are trying to make meaningful lives after combat.

In that light, I welcome all comments, and I look forward to my growth.

1.  Introduction

2.  Intensity ≠ Extroversion

3.  Extroverts and Escaping the Tractor Beam Within

4.  Introverts and Battling the Guerrilla War Within

5.  Introverts and the Long Haul Within

6.  Afterword:  Broken Vases, Mending Lives

Inside, Outside, Anywhere

Last Sunday, the New York Times Sunday Magazine ran an article entitled “Post-Traumatic Stress’s Surprisingly Positive Flip-Side.”   It was an interesting piece describing what’s called “post-traumatic growth,” a concept exploring how one can grow more resilient out of an experience of life-changing trauma.   The piece described a program that the Army is implementing that encourages troops to approach difficult situations with an eye toward viewing the situations as neither good nor bad, but rather as opportunities for change and positive outcome.

In addition, this past week I met a veteran who had survived significant combat trauma and who, as a result of physical injuries he had sustained, developed an addiction to painkillers.  It does appear that with the use of Suboxone, a modern opioid substitution agent, he will gain a new chance at living life without resorting to the illicit use of substances.

The veteran had already undergone standard treatments for PTSD, including the “prolonged exposure” therapy that many practitioners are now using to help combat veterans process the emotions they are experiencing as a result of their combat experiences and, at least to some extent, to help them integrate those emotions and their associated memories back into a coherent-enough narrative of the veterans’ lives.  He had found the treatment to be helpful, and he told me that he felt that he was “doing fine” vis-a-vis his war experiences.

He was a burly, friendly chap, although understandably embarrassed by the extent to which the opiates had become the center of his life.  He had gone into sales and had been successful, although he had found the whole rigamarole boring, truth be told.  He certainly had a saleman’s air about him:  focused on the pragmatic, with a certain bottom-line no-nonsense.  He has his demons, to be sure:  his addiction did not arise from nowhere.  Yet I had a sense that his usage stemmed more from boredom–as well as from the desire to avoid withdrawal symptoms–than it did from terror.  We’ll see what the future brings.

It is an intriguing question, though, one that is even now confounding, yet captivating researchers:  why do some veterans leave combat with extensive, long-standing psychological sequelae, even after the “best” of “best-practice treatments” (essentially everyone has challenges in the short-run), while others do not?  Is “resilience” and ease of “post-traumatic growth” a state to be learned or a trait to be appreciated?  Do “some got it and some don’t?”

Certainly I don’t have the answer, and I cannot be too bold generalizing from my experiences, given that mine are clinical experiences, i.e., the people whom I meet are already suffering.  I do find myself wondering, though, what might be the relevance of an old Jungian concept that became popularized through the Meyers-Briggs, a common measure of personality typing: extroversion versus introversion.

Colloquially, these terms are about sociality, the life-of-the-party versus the wall-flower.  In this sense I’m describing, though, the words deal more with the cognitive than the interpersonal.  Extroverts “think,” if you will, from the outside-in, while introverts do so from the inside-out.  Extroverts make sense of the world initially (and preferentially) via looking outward, making things happen, seeing how matters fit or do not fit together.  Introverts, in contrast, make sense of the world intially (and preferentially) via looking inward, contemplating, rehearsing.  Extroverts are capable of inner contemplation, and introverts are capable of external focus.  Yet each has his or her major and minor.

When trauma hits extroverts, it hits them in their minor.  The memories, the emotions:  they haunt and they demand.  Yet they reside in “foreign territory,” if you will.  The extrovert keeps being drawn back inward to a place that never did feel that comfortable.  When they work in therapy, they seek to be freed from all the inner focus of trauma so that they can return more reliably to the familiar world of their major:  the world out-there.   Extroverts find hope in escaping the War’s clutches and going back “home.”

For introverts, however, trauma bores right into their major, colonizes an inner world that had always been their home, making what had once felt so comfortable (or at least familiar) so very, very uncomfortable and unfamiliar.  Focus on action, even on internal action (e.g., “stepping back” and re-examining emotional and cognitive responses), is fine as far as that goes, but it always seems somehow beside the point.   Introverts find that the War has taken up residence in their “home” and that therapeutic “escape” takes them away from where they had once felt most real.

Extroverts have a point:  the world “out there” has far more options for freedom from War’s memories and pains.  Yet for us introverts, “out there” just isn’t home.  We can live there–and even live there rather successfully.  But we are always expatriates.

In my role as a Suboxone provider, I see many combat veterans who have completed “standard” PTSD therapy and who have benefitted greatly from it, usually with far less emotional upheaval and far more insight into their pain.  Yet in a real way, the thoughtful, internal ones, the ones who always prided themselves in their capacity for looking inward, not as navel-gazing (these are military folks, after all), but rather as preparation for action:  they still struggle.  “Home” has been invaded by an interloper who has taken these veterans’ most prized possessions–their memories, their emotions, their linkages between the two–and forever altered them, not only distorting them, but also robbing them of the healing, restorative power they had once had.   Looking outward may help, may even help greatly.  But sorry, extroverts:  ultimately your restorative, out-there “home” feels more to us introverts like a consolation prize than like a gift.

Perhaps because my style is the introverted one, I find myself so much more “captured” by the combat veterans who struggle with their inner demons within their beloved, internal home.  In a very profound way, I feel the adage:  there, but for the grace of God, go I.

It may not  be the most resilient of options, but it’s what I have.  May both introverted combat veteran and I “grow” all the same.

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