Conclusion and Offer: Combat PTSD, Pools of Emotion, and Putting the Truth Into Words

Dear Sir,

Let me finish today by turning to journaling–and an offer I’m glad to make to you and all your fellow combat veterans. (I’ve decided to discuss the clergy and spiritually-oriented groups later, in separate posts.) I’ll present these ideas in a FAQ-like format.

3. Decontamination and “Putting the Truth Into Words”: Loved Ones, Psychotherapy, Journaling (C)

The Truth and Journaling

So what do you mean–journaling?

I mean: anything you want it to be if it involves, in some way, putting your thoughts and feelings into words. You can write your words down on paper of any kind, whether looseleaf or bound, whether bound in a spiral notebook or in a special journal with formal binding. You can write your words down on a computer, storing them on your hard drive or in cyberspace somewhere. It’s up to you.

Is this supposed to be in some particular form? Formal or informal? Do I worry about spelling, grammar, complete sentences, things like that?

Not at all. You write what’s on your heart. If you feel like cursing, you curse. If you feel as if only random words can come out, not even sentences, then write random words. Any particular entry could be as short as one word or as long as it takes until the words run out for that entry (or exhaustion sets in).

Are you talking a one-time thing or something that I do over and over?

Either one. Maybe you write something one day and then never write again. Maybe you write again in a day, a month, years or more. Maybe you write again in fifteen minutes. You’ll know when it’s time to stop. You’ll know when it’s time to start up again, if ever.

Am I supposed to write this to share with someone?

That’s up to you. Maybe you want to write a letter to someone who’s alive, but first you want to “try out” what you want to say. Maybe you want to write to God. Maybe you want to write to a buddy or a loved one who’s no longer with us. Maybe you want to write to a Head of State, a legislator, the “brass.” Maybe you want to write to your kids or grandkids you have or might one day have, the kids of a friend–or the kids your friend will never have. Maybe you want to write an op-ed piece. Maybe you just want to scream, at anybody, at War, at Death, at Life.

Should I actually share this with someone?

That’s also up to you, but reserve the right that you may, at any time, write something that you would not want anyone to read. If the latter, though, remember: words, even in cyberspace, can sometimes end up in hands you’d not planned on. Take extra precautions to make sure that you lock such words away, e.g., with passwords, or literally under combination lock. Maybe write in a “code” that only you will understand.

If you have a therapist or counselor, however, I do hope that your relationship with that person will be such that you could share as much of your journaling as is possible.

What if I don’t have a therapist or counselor? Should I do it anyway?

Absolutely. Some of you may not be ready yet to consider talking to a professional. Some of you may have become disillusioned with any professional who claims to be a “helper.” Some of you may be too far away from any professional help to allow any type of meaningful contact. Some of you may be working with a counselor who can only see you every once in a while or who seems uncomfortable discussing material that’s too “tough” or “raw.”

So what good’s this going to do for me? Am I not just torturing myself even more by writing down what I already can’t get out of my head?

In fact, “getting it out of your head” is precisely the point. “Putting the Truth into Words” is precisely the point. Will the Truth leave your head as a result? Of course not. But now the Truth will be something physical in addition to mental. It will be written down on paper, on a hard drive. Your hand will write it or type it. The words will not melt away, as they can in your head. You can go back to them. Reflect on them. Change them. Erase them–but you’ll have to decide to erase them. They can’t “run away from you” any more. You can leave them on the paper and never go back to them, but know that somewhere in this world, whether in a locked drawer or in a computer file, those words will still be there. You will have options that you didn’t have before. You can “forget” because you know that paper and data files never will. Sometimes memories and feelings become more real when you see them in handwriting or type. Sometimes they become less so.

Should I do this instead of therapy or counseling?

No. If you have the chance to work with a therapist, a counselor, a trusted clergy person, I would strongly urge you to do that as well, even if you don’t share what’s in your writings (although, believe me, the writings, when shared with the right person, will only help to improve your work with that person). For most people, recovery from combat trauma/PTSD is a two-part process.

First, you put your memories and feelings into words. As above, that makes them more “real.”’

Second, though, you will fully heal when you share those words with someone and know that your words are being taken seriously, that you are being taken seriously, that your words will not destroy that person, that the person will still be glad to know about you, know you, care about what happens to you.

That’s how you detoxify the contaminated memories and feelings. That’s how you know that neither you nor your therapist/counselor/listener will be poisoned by the Truth forever, even though both of you will have to live knowing the Truth forever.

If, however, you don’t have access to counselor, or if you are not quite yet ready to take that risk that a counselor or therapist or clergy will understand or have the courage to bear what needs to be borne, or if you are too disillusioned to go back to one, one of the above out of two is better than none out of two. The very act of putting the Truth into words will help you some–and maybe a lot.

I’m a kinetic-energy/extroverted type. I rejuvenate through movement, literal and figurative. So what’s in it for me?

You and I both know that simply because you’re kinetic-energy/extroverted, you cannot say that you don’t have memories and feelings that you need to “get out there.” In general, I have found that kinetic-energy/extroverted combat veterans usually have fewer words to share in writing (in the grand scheme of things, in therapy as well). You probably, in other words, won’t be spending hours a night in journaling. Yet writing, typing is indeed movement: getting something done in the real world, making appear what was not there before, making a change from thoughts that never stop to thoughts that at least stop long enough to have the decency to stay put in a sentence.

I’m a potential-energy/introverted type. How am I not just “wallowing in self-pity”? How won’t I be just stuck in the same rut I already am, thinking and feeling the same things over and over?

Good news, that is less likely to happen precisely because you’re writing things down, precisely because you’re moving all those thoughts and feelings out of the “inner spa” (where they’re going to stay anyway) and into a sort of “outer spa” that can be observed more easily, maybe without quite the “stench” of the War Within.

If you’re writing the same thing over and over again, you’re going to see that. Remember, you’re military! In other words, you’ve been taught from the first moments of boot camp to think mission! You’re not like many folks who have never done anything with their lives, who go over the same, go over the same and do nothing, year after year. Maybe The War Within is telling you that you are now such a person–but you’re not!! The day will come when you will look at those words and say, “What the . . . ? Wake up, friend, wake up!!” Trust me. It may be today, tomorrow, next month, next year. You may have to write the same word, the same memories, the same feelings once or ten thousand times. But the “what the . . .?”day will come.

Remember, as a potential-energy/introverted type, words are what rejuvenate you. Your job is to get those words to a spot that can help you, not torture you. Write those words down. Give them a “permanence” that you’re going to have to come to grips with. Those words may finally be the force that drives you into therapy. They may be the force that finally allows you to say “OK, enough of that.”

So, what is it again I’m supposed to write about?

Anything. Memories of specific events. Memories of how you felt back then, about what happened, about that person. Impressions of how you feel now. Regrets. Sorrows. Guilt. Shame. Disappointment. Rage. Forgiveness. Fear. Hope. Events that happened today, yesterday, ten years ago that bring a smile, that make the next day worth facing. Goodbye. Hello.

So what’s this “offer” you’re talking about?

I am glad to offer you my reading eye and reading heart. In other words, if you don’t have anyone to “listen,” I am glad to do that. I will provide an e-mail address below, and you can send me what’s on your mind, your heart, your soul.

Are you talking about you becoming my therapist?

No. Therapy, counseling is about two real people interacting over time. I will not be able to respond to your writing. If you have questions, whether general or specific, I will not be able to discuss them with you or answer them for you.

Please know that it is not that I wouldn’t want to do that. It is simply that I cannot. It’s not just that it would be unethical, in a professional sense, to make such an offer. It would be inhumane to make such an offer. It would be unfair, just another so-called “helper” making a promise that he has no intent to keep. Enough people have done that to you already. You don’t need one more.

I am one person. I have a family I value and to whom I have committed myself. I have patients with whom I do interact regularly through my professional duties (and I add, privilege). I cannot shortchange them. I will not do so.

So why should I waste my time sending you anything?

That’s the question you’ll have to answer for yourself.

Here is what I can offer: I am a man, a fellow human being, who does have a talent for understanding the heart. I’m not bragging about that. It’s just who I am. I like to read. I am not afraid to hurt. I have a good life with a good family who have as good a future as anyone of us can hope from this world. Your story, your memories, your feelings will affect me, but they will not destroy me. Yet as you can see from all my blog entries under the heading Living Life, you will have an impact on me. I’m not a passive, lazy reader.

I am no fool, you see. Given the right circumstances, I too would kill. I know that.  I too would make decisions about life and death that I would never forget. I too could experience unspeakable rage. I too could experience grief that rips the heart open by hand.

But also, I have not killed. I have not seen body parts on the ground. I have not watched the life ebb out of my best friend or seen him or her disintegrate in front of me. Therefore, such memories, such feelings will not overwhelm me, precisely because they have never overwhelmed me to date. I can only imagine them. But I am willing to take the risk of knowing in my heart that such things could happen to me even today and thus let myself take the risk of letting what has actually happened to you infiltrate my heart enough so that I’ll be disturbed enough to make it as real for me as I can.

How will I know that you actually read what I write?

You won’t. You’ll have to trust me. I will send you a very brief reply e-mail with a simple message: “Got what you wrote and will read it when I can. My best to you, always.” That will be it.

Is this a one-time offer?

You can send me as many writings as you wish. You can know that one day I will read each of them.

Will you keep track of who I am?

No. I will not keep emails. Therefore, I ask that you send your thoughts as an attachment, either in Word or Wordperfect format. Once I run the document through a malware protection protocol, I will then store it on a hard drive to which only I have access, labeling it only by date and time of receipt. Once the document is stored and I have sent you back your two-sentence reply, I will permanently delete your original email message.

What if I want you to keep track of me?

That’s up to you, but again, I will not be writing you back. If you wish to use a pen name, once I have read the document, I will then store it in a file with your pen name. If you want to use your real name, I will store it by your real name.

Will you write about what I write you about?

Only if you tell me that I can. I will assume that you do not want me to write about anything that you write about. Even if you give me permission to write about what you write about, however, do not assume that I will do so. The future will bring what the future will bring.

If you use some of my thoughts in any of your writings, will you let me know?

If you would like me to. If you wish to allow me to write one day about your experiences, but would prefer to know first about it, then leave me your e-mail address in the body of the document. I do promise that in such circumstances, I will never make any reference to what you write without sending you a copy of the essay and then getting your explicit approval to publish it. You would also be free then to have the essay retracted (if possible) at any later time, although obviously I will have no control over any previous disseminations in any form.

Will what I write you be confidential?

No. It will be anonymous (unless you give me information within the document), but  it will not be confidential.

So what’s the difference?

As I said, I will separate your document from your e-mail at the time of storage, and I will make no effort on my part to link the two, deleting the e-mail upon storage. (Therefore, if you write anything of substance in the body of the e-mail, it too will be deleted immediately upon storage.) I, in other words, will have no way to link you to your document at the time of my reading it unless you give me explicit, identifying information.

I will not, however, be taking any steps to erase all “footprints” of the e-mail. I don’t know how to do that. I have no plans on learning on how to do that. We will not, nor ever will be in a psychotherapeutic relationship, and therefore you have zero protections offered by such a relationship. I have no clue whether any government official would ever take an interest in my documents. If they do, though, I will have no legal grounds upon which to refuse handing them over. If they have the cyberknowledge to link documents to their originals senders, then  they will what  they want. I can take no responsibility for that.

THEREFORE, if you are afraid of anyone “official” ever possibly reading what you write, then you should be accordingly careful. Remember: specific dates, names, places, often they are not that important as to the feeling of what happened or the haunting memory of what happened. Look through my entries under the category Living Life. I specifically avoid as much detail as I can–location, branch of service, specific dates, easily identifiable details of persons and events–and focus instead on the feelings engendered by the memories, which usually only require minimal “backstory” to make them meaningful.

Will you ever actively divulge information without my permission?

Obviously, that will only be possible if you identify yourself in the body of the document. If you make any threat against an individual and you have identified yourself, I will send a copy of the document, with the identifying information, to the United States Federal Bureau of Investigation (it’s federal because you’ll be using the Internet to transmit the threat), and they will do with it as they will. Similarly, if you make claims to be considering committing future crimes of any kind, I will do the same immediately.

If you threaten to harm yourself and you have identified yourself, I will forward a copy of the e-mail to the Veteran’s Crisis Line, and they will do with it as they will. IF YOU ARE HAVING THOUGHTS OF SELF-HARM OR HARM TO OTHERS AND DO NOT WISH TO ACT ON THEM, DO NOT COUNT ON YOUR TELLING ME, EVEN WITH IDENTIFYING INFORMATION, AS BEING SUFFICIENT TO GET YOU HELP IN TIME. As I have said, I cannot promise you when I will read your document, although I promise that eventually I will read the document.

If you need help, GET HELP NOW. IT’S AVAILABLE, AND IT’S THE REAL DEAL. Call the Veterans Crisis Line at 1-800-273-6255, ext.1.  Alternatively, you can have a confidential chat at VeteransCrisisLine.net or you can text to 838255.

Also know that I am obligated under the laws of the state of Indiana and of the United States to report matters such as abuse and neglect of children, of the elderly and disable, etc. If you tell me of such matters and if you identify yourself in your document, I will need to forward that information to the appropriate authorities.

Also, if you do write me more than once and use a pen name and do any of the above, I will not guarantee that I will not attempt to  link your e-mail to your pen name. If I do do so, then if any of these above events occur, I will forward your email information to the authorities, along with the documents in which the threats or allegations are made.

So what’s in it for you, Doc?

Honestly, I offer it because that’s just who I am and what I do. I promise you that I will not interfere with my family’s life because of anything you write. You don’t have to worry about that.

Given that I’m psychoanalytically trained, I of course believe that there is more than just “who I am and what I do” behind my offer. Certainly I have known, as I write in About Me, the impact of combat upon a family through generations. I suspect a part of this is a gift to my paternal grandparents for their suffering, a remembrance for my uncle, a gift to both my father for the impact of my uncle’s deaths on his life (and even on the lives my mother and her parents, given that my mother’s family and father’s family had been quite close). I know what I need to know, it is what it is, and I do what I do.

I also do enjoy reading and writing about lives, and I am glad that some have found help in what I write, especially in my ability to let combat veterans know, through my writing, that a). they are not alone in what they experience and struggle with, and b). their sufferings and struggles can have an impact on at least one other human being, no matter how horrible those experiences have been, and c). that I’m not only willing to experience in my limited way those sufferings, but am willing to try to “convince” words, language to “capture and hold” as much of that suffering as “they” can.

The email address is rodneydeatonmd@gmail.com. It’s available any time, only for this purpose. As I said, I will not be making any personal responses except to acknowledge receipt.

There you have it.

So, Sir, a simple comment engendered all these words in all these posts. Such is who I am, as you now know. I again thank you for your bravery, and I thank you for giving me the opportunity to put these thoughts into words. I hope at least one or two of these words have been helpful for you. All my best to you and yours, at this time of year celebrated by many traditions as ones of Holiday and throughout the rest of the year–and the rest of your life.

Best,

Rod

Combat PTSD, Pools of Emotion, and Putting the Truth Into Words (III)

Dear Sir,

Let’s now talk about the persons who should–sadly, I must italicize that word–be available to bear with you as much of the truth as can be spoken: your counselor or psychotherapist.

3. Decontamination and “Putting the Truth Into Words”: Loved Ones, Psychotherapy, Journaling (B)

As I said earlier, if medications are detoxifying agents of the pool, then psychotherapy (or its equivalent) is the decontaminating agent of the pool. I stressed “of the pool” because, as I said in the last post, the “contaminants,” i.e., the memories of the experiences of the War, still need to be detoxified. Psychotherapy, however, detoxifies outside the pool, on the observation deck. In Real World terms, that means that psychotherapy relieves the pain of the War by bringing it into the therapeutic relationship, feeling it, talking about it, and dealing with it there.

The Truth and Psychotherapy

First, let me say up front what every combat veteran already knows: not every therapist in the VA system (or for those of you in other countries, your national treatment system) is worthy of the name. I know that. In fact, one of my colleagues put it most colorfully when she described a VA clinician (fortunately) not at our facility as someone who “has all the empathy skills of a lower amphibian.”

Sad to say, I know the clinician whereof she speaks, and sadder to say, my colleague is spot-on.

I would ask you to consider, however, that sometimes the problem is more a mismatch between therapist and veteran. Just as combat veterans differ in how they rejuvenate, so do therapists. Perhaps through understanding this, you and/or some of your fellow veterans might be able to salvage some therapeutic relationships. At the very least, you might have a better understanding of why a particular relationship might not work, no matter how hard either party might try.

a. Psychotherapy, Kinetic-Energy/Extroversion, and Potential-Energy/Introversion

Generally speaking, psychotherapies geared toward helping veterans with combat trauma/PTSD are ultimately neutral as to whether they can be effective for kinetic-energy/extroverts or potential-energy/introverts. It is less about the therapy itself and more about how that psychotherapy can most effectively be used with any particular veteran.

That being said, therapists trained in most modern mental health training programs, i.e., psychiatrists, psychologists, social workers, mental health counselors, tend to have been schooled in a “world view”that is much more congruent with the kinetic-energy/extroverted style of rejuvenation rather than that of the potential-energy/introverted. As I have stated in earlier posts such as Treatment Plans and Is It Something I Said? (all right, I admit it: as I lamented), the ethos of much modern psychotherapy practice is get-‘er-done, get-‘er-done efficiently, and get-‘er-done fast. Even when particular therapists resist this type of practice mind-set, they often still have to justify to the powers-that-be why they in fact are resisting. “Expedient effectiveness” is the name of the game.

It is, of course, ridiculous for anyone (starting with myself) to argue that psychotherapy should not be expediently effective. All of us want suffering to end as quickly as possible, after all.

That’s not the point.

The point to remember in the following discussions is this one: kinetic-energy/extroverted veterans rejuvenate far away from the inner emotional pool. Potential-energy/introverts, in contrast, must rejuvenate right next to the emotional pool. Any particular decontamination technique (i.e., psychotherapy, especially an “evidence-based” one) might work equally as quickly for a kinetic-energy/extrovert as a potential-energy/introvert in terms of rate of pool decontamination. However, the former can escape the stench in order to rejuvenate, while the latter cannot.

To understand the ramifications of this, let us look at how the psychotherapies fit into our metaphoric system and then look at how the kinetic-energy/extroverted and potential-energy/introverted “environments” influence how these therapies may be most effectively used.

The Evidence-Based Psychotherapies

Two officially-sanctioned therapies for combat trauma/PTSD in the United States’ VA system are prolonged exposure therapy (PE) and cognitive processing therapy (CPT). (I would have also liked to have included in this list for my discussion eye-movement desensitization and reprocessing therapy, or EMDR, but given the time it would take to explain it, I’ll save that discussion for another day.)

Let’s go back to our pool analogy. Metaphorically, in PE the veteran dives right into the contaminated pool, with the therapist (hopefully) right there on the observation deck, gently pushing the veteran each time to swim a little longer, gather a few more contaminants, throw them out on the deck, and then get out of the water to sit with the therapist long enough to allow the toxins to seep out. In the Real World, that means that the therapist encourages the veteran to remember in detail the most traumatic experiences, usually recording them (e.g., cassette tape or digital recording) for later playback, so that with each episode of listening to the recording and remembering (i.e., jumping into the contaminated pool), at first in the therapist’s presence and then later on his/her own, the veteran can be less and less emotionally devastated by the memories and thus can be freer to experience a variety of emotions, both good and not-so-good, in that very same Real World.

In contrast, CPT is a bit more like both veteran and therapist sitting on the observation deck throughout the treatment, with the therapist giving the veterans lessons and guidance in how to use a net to fish out the contaminants and then bring them out to allow the toxins to seep away. In Real World terms, the therapist asks the veteran to observe the patterns of emotional responses, the thoughts and actions that trigger them and relieve them, all for the purpose of the veteran’s learning more effective ways to “think through” painful emotions before they get out of hand.

Kinetic-Energy/Extroverted Combat Veterans

In an earlier post, I wrote:

For kinetic-energy/extrovert veterans, [the “observation deck”] is not a particularly large one. It is an “area” that is large enough to allow them to take the time necessary to reflect adequately on their emotions–but that’s it. Again, they want to be back out in The Real World, using their knowledge of their changing emotional states to get “moving” into activities and relationships for the purpose of rejuvenation, of getting the energy/intensity they need to live out those emotions in the ways they most desire.

PE and CPT are more than just techniques, even though there is a “technique” aspect to how each therapy encourages the veteran to “decontaminate the pool” (“diving” for PE versus “net fishing” for CPT). Both rely heavily on the therapist’s and veteran’s having a good relationship within which to detoxify the contaminants once they are “out of the pool,” i.e., identified and discussed in the therapy.

Both therapies adapt quite nicely, however, to the kinetic-energy/extroverted veteran’s rejuvenation style. These veterans want to “get the job done” so that they can take back to The Real World better emotional states with which to live, interact–and thus rejuvenate. Being, in their classic form, very “goal-focused,” these therapies serve well the kinetic-energy/extroverted veteran’s goals by giving the veterans “something to do.”

The more trauma a kinetic-energy/extroverted combat veteran has endured (whether before deployment or during), the more contaminants there will be in the emotional pool and the longer the duration of the process will be. As the psychotherapy continues, however, there will be fewer and fewer contaminants to be removed and detoxified. Combine this with the fact that the kinetic-energy/extroverted combat veteran will always come “back” to the pool having rejuvenated “far away” from the pool, the veteran will almost certainly be able to take over the decontamination-detoxification process from the therapist more quickly than would have been the case if the veterans could not have rejuvenated in that way (i.e., if the veteran had been potential-energy/introverted).

Remember: it is not that kinetic-energy/extroverted veterans are not reflective, for many of them are. It is not that they do not ponder the existential and spiritual issues of War, for many of them do. It usually is the case, though, that they do not regularly seek to reflect and ponder, for (usually) they are much more focused on motion and interpersonal connection day-to-day. It’s not that they couldn’t discuss such “inner” issues in psychotherapy. It’s just that more often than not, they would prefer not to do that too much at all–and certainly not by having to take a couple hours out of their week to do so with a relative stranger.

Potential-Energy/Introverted Combat Veterans

In that same earlier post, I then wrote:

[For potential-energy/introverts,] the emotional pool sits in the middle of a figurative “inner spa” that is not solely about emotions. Like kinetic-energy/extroverts, we too need a space near the pool to reflect adequately on our emotions. However, [they] then need to move to an “adjacent” area in order to sit quietly within [themselves] and reflect not only on what [they] feel, but also on what [they] know, whom [they] know, what [they] might wish to do with such knowledge, all for the purpose of rejuvenation, of getting the energy/intensity [they] need to live out that knowledge in The Real World in the ways [they] most desire. In other words, for potential-energy/introverted combat veterans, their pool of emotions is an integral part of that rejuvenation spa, but it is not the only part of the spa.

Like their kinetic-energy/extroverted counterparts, the more trauma a potential-energy/introverted combat veteran has endured (whether before deployment or during), the more contaminants there will be in the emotional pool and the longer the duration of the process will be. Similarly, as the psychotherapy continues, there will be fewer and fewer contaminants to be removed and detoxified. The stench of the toxic pool will lessen over time.

But the potential-energy/introverted veteran must rejuvenate in the midst of the stench, no matter how long it takes for that toxic stench, through therapy, to lessen.

Here is the essence of the potential-energy/introverted veteran’s dilemma with the evidence-based psychotherapies as they are often presented by some practitioners: just as the emotional pool is only one part of the spa, so is the decontamination/detoxification of that pool only one part of the veteran’s recovering his or her ability to rejuvenate in any meaningful way.

In other words, once potential-energy/introverted combat veterans have decided to open themselves up to trying psychotherapy, they are usually expecting their therapists to help them out with rehabilitation of the whole spa, not just the decontamination/detoxification of the pool.

For the potential-energy/introverted veteran, the therapist who relies solely (or essentially solely) on evidence-based psychotherapy techniques and interactions is like a specialized subcontractor for the spa rehabilitation, rather than the general contractor  that the veteran is so desperately seeking. It’s as if such a therapist is saying to the veteran, “Sorry, I just clean pools. If you need someone to freshen up the air while I’m getting the job done or help you renovate spiritual aspect of the place, you’ll need to call somebody else.”

In other words, veteran and therapist never had, as we say in Law-land, a “meeting of the minds.”

I am absolutely convinced that this is why many combat veterans, usually the potential-energy/introverted types, can “successfully”leave an evidence-based therapy, whether individual or programmatic, and yet still wonder aloud, “I’m supposed to be fine now? So why do I still feel so bad?”

The answer is simple: the veterans “still feel so bad” because the toxicity of The War Within not only poisoned their pool, but also poisoned their entire spa. It’s as if the toxic fumes have rotted the walls, destroyed all the furniture, made the whole place inhabitable, with no place to be fed, no place to be revived, no place to be treasured. They had thought that if they were going to be opening themselves up to the pain of psychotherapy, they were going to be getting a full renovation–not a partial job (though a competent one) with options for referral to other providers.

So how can such a mismatch/misunderstanding happen? I have three hypotheses.

Different Veterans, Different Therapists, Different Systems

Hypothesis One: Potential-Energy/Introverted Veteran + Kinetic-Energy/Extroverted Therapist (with standard, modern training)

Even if a therapist is kinetic-energy/extroverted, one should not assume that she or he cannot understand the rejuvenation strategy and needs of a potential-energy/introverted veteran. My longstanding consultant/supervisor, for example, is as kinetic-energy/extroverted as they come (you ought to see her do West Coast Swing dancing), yet she is a well-known, well-respected psychoanalyst who specializes in understanding the inner world of trauma victims.

Similarly, one should not assume that just because a kinetic-energy/extroverted therapist has been trained in more contemporary training programs, the therapist cannot sit for longer periods of time with veterans and do more generalized, “inner” work that is not solely focused on symptom management and emotional regulation.

Still . . .

I do think that many kinetic-energy/extroverted therapists from contemporary training programs have little to no understanding of the potential-energy/introverted veteran’s (or any other patient’s) need for more extended inner reflection in order to feel that anything of value is being accomplished. In fact, many such therapists, from my experience, do seem to believe–quite sincerely–that focused, goal-oriented, shorter-term treatment is not only something valuable, it is something superior in value.

Some of them–and I do mean only some–even seem to believe with all their hearts that if a veteran is not responding with reasonable enthusiasm to a more standard, evidence-based approach, then the veteran is either a). suffering from longstanding trauma that must have predated the employment, or b). resisting treatment because of personality disorder issues or a conscious desire to seek the sick-role in order to maintain an illness that will allow disability benefits to be paid.

I wish I could say that I have never heard a VA therapist say such things. Even sadder, though: it’s not only the occasional kinetic-energy/extroverted therapist who does.

Hypothesis Two: Same Veteran + Potential-Energy/Introverted Therapist who cannot tolerate strong emotion for extended periods of time

I wish this were not as common a scenario as it apparently is.

I am going to make a boldfaced, general statement: most modern mental health training programs do an atrocious job in teaching their trainees how to work with individuals who have been severely traumatized.

I cannot fault a relatively-new therapist for struggling to deal with the emotions brought on by sitting with any traumatized individual, let alone a combat veteran. Classroom education cannot adequately prepare anyone for those challenges.

Too many recently-trained therapists, however, have zero conceptual inkling of even how to understand such challenges. They don’t even know what they don’t know, and too many of them think they do. These are often the therapists who reduce PE and CPT to mere technique, almost as a way to assure themselves that they are a). competent and b). accomplishing something.

At one time, you could assume that therapists had undergone some type of more extended therapy themselves. You can no longer assume that. In fact, I’d say you’d be more often right if you were to assume that any particular therapist has not. That is not to say that the therapist has maybe not done a counseling session or two or three at some point in his or her life. But it is doubtful that he or she has done much extended work. The modern ethos of psychotherapy is “keep it focused, keep it quick.” You don’t need to have that much such self-understanding to do that relatively successfully and graduate from a decent program.

In fact, after a session or two of instruction, you could probably do all the rest of the therapy with an app on a good iPad, right?

Admittedly, kinetic-energy/extroverted therapists usually can get away with minimal therapy of their own. Usually they do work that is focused, and they prefer to work with people who are able to stay focused. As I often say, no harm, no foul.

The ones I worry about are the potential-energy/introverted therapists who, by their very nature, spend a lot of time in their inner spa, yet who are not that particularly aware of what’s going on in there. My experience is that many of them do evidence-based therapies particularly badly with potential-energy/introvert veterans: at their core, the therapists know that a lot more than the emotional pool is at stake, but they can’t even keep their own inner world in order, let alone another person’s.

One can get away with such semi-blind-leading-the-blind therapy (sort of) with standard issues such as depression or anxiety. But with the horror of combat trauma? Usually bad news, all around.

Hypothesis Three: Same Veteran + Potential-Energy/Introverted Therapist who is caught up in a “do more with less” System

The majority of potential-energy/introverted therapists whom I know fall into this third category. I am not going to rail against my employer here. I work for the largest healthcare system in the United States, and it’s a very public-faced one within a highly political context. Everyone is doing what they can with what little they have–oh, yes, and we’re going to have to cut back, you know, spending beyond our means, so the wise ones of Congress and the think tanks say, and all that . . .

There are no surprises here: a (massively) underfunded War with no clear strategy for providing afterwards for the large number of combat veterans in general, let alone a strategy for differentiating treatments based on underlying personality dynamics (although there are those that hope against hope one day to find a blood test to figure it all out). Combine that with a challenging economy without a lot of leeway for those with interpersonal challenges or mild cognitive challenges, within a group of young men and women who have families that need to be not only provided for, but watched after, requiring packed schedules with little room for play in them, and what do you get?

Why, eight visits within fourteen weeks of focused, evidence-based therapy, with supplemental support through veteran-run groups, right?

Don’t get me started.

There are a lot of excellent, overwhelmed, and semi-demoralized potential-energy/introverted therapists out there in the public sector, trying to help potential-energy/introverted combat veterans who are looking for more than a few well-run individual sessions followed by groups of “veterans helping veterans” (only a kinetic-energy/extrovert could have come up with that line and felt it to be the self-evident goal so many want to make it out to be). Many such therapists  love their work and the veterans whom they serve, yet they are finding every day of work to be so very, very frustrating.

Well, dear Sir, even if all that does supply some valuable background information, it does not help you much with your challenge, does it?

At this point, I’m going to go out on a limb, speaking as an individual and not as an employee of the federal government: if you are a potential-energy/introverted combat veteran who, because of your emotional intensity, is looking for an opportunity to meet more regularly with a therapist to try to reconstruct your “inner spa” in as many ways as is feasible so as to maximize your meaningfulness in life?

Look outside the VA.

I wish that weren’t the case. But as of today, I believe I can say: it just is.

The following three national organizations might be able to help you in this search:

1. The Soldiers Project is an excellent organization that is continually trying to recruit experienced therapists to provide free, ongoing therapy for combat veterans who are looking for longer-term solutions to their inner turmoil. As of this point, they are primarily hindered by the relatively-limited geographic availability of therapists, but they are working to increase their supply of referrals daily. I cannot recommend them highly enough.

2. Give an Hour is a larger organization that provides similar services, i.e., referrals for free care in the community for veterans with a wide variety of needs. This organization tends, from my understanding, to draw on a variety of therapists using a variety of modalities, so it is not solely about therapists seeking to provide longer-term services for veterans who feel a need for them. Yet they remain ready to consult with veterans  to try to find a therapist who will best meet a veteran’s personality style and goals.

3. The Pathway Home is a superior, residential facility located in the Napa Valley of California that provides intensive, four-month-long, twenty-four-hour-a-day programming in an unlocked, residential setting to help combat veterans deal more intensely with their emotional struggles. It is a nonprofit organization using a variety of funding sources to provide care for veterans without requiring insurance or private pay, and they have access to a variety of national programs that help veterans with transportation to California, as well as to a nationwide network of alumni who provide 24-hour support to each other through texting, social networking, and other avenues.

I wish, dear Sir, that I could offer you more in the way of longer-term treatment options, but they remain limited at this time. I am thus fully aware that none of these options may turn out to be viable ones for you.

Therefore, in the spirit of the military’s “change course and keep going,” let me conclude with the next post on alternatives, including “spiritual”or “ritual” retreats, work with clergy, and, when all else fails, journaling.

Combat PTSD, Pools of Emotion, and Putting the Truth Into Words (I)

Recently I received the following comment to one of the posts of The War Within (TWW) series, in the Thoughts section, above.

Doc,

I can’t thank you enough for putting this website together, it may have just saved my life. You have really got something here. I find this article a very accurate narrative of my personal existence. After reading this I’m an introvert for sure, and I feel like I’m losing it again.

I was doing very well for a while. I went from being homeless to completing a program at the Chillicothe VA hospital (during which time my wife divorced me) and getting a great job. I did so well there I got picked up by another company and now I have a bright future. From the day that I left I the VA hospital I felt great but TWW, as you call, was always right there.

I went to counseling and met with my doc for a few months after until I got my job and then I focused on that and the counseling went by the wayside. The echo of my past was always right there but I was able to focus on my job. It was very fast paced and revolved around helping others and working with highly motivated people. I recently ended a relationship and switched to a new job.

The new job is super slow paced corporate job. People, quite transparently, whine and complain at this job and make up excuses to avoid doing work. I feel myself getting lost and falling back inside of myself. My apartment used to be immaculate and now it’s a mess, and I am finding it harder to go to work even though it’s ridiculously easy and pays very well. I feel unworthy of asking for help from anyone, but I feel like you really get what’s going on. What can I do? What should I do?

Thank you,

The veteran who wrote this comment has given me permission to answer it via a regular post. As I have a lot to cover, I will be dividing the posts into two. Here goes:

Dear Sir,

Thank you very much for your courage in sharing with me some of what has been happening in your life and heart. I do hope these thoughts can be of some help.

First, let me share with you an analogy I often use with both patients and trainees. I like to think of the emotions as an indoor pool within each of us. When functioning well, there is a certain temperature variation to the pool’s water, but nothing drastic or too uncomfortable. Like a well-running whirlpool, it also has a certain circulation going on within it all the time, again nothing too drastic or too uncomfortable, yet enough to keep the water from stagnating. Some pools are brightly lit. Some are less so.

Next to the pool is a deck for observation. This is where we “get out of the emotional water” and from where we can “observe” our emotions and take actions vis-a-vis them (e.g., change behavior, alter ideas, consider medical intervention).

Second, let me share a passage from the book that I’m writing, The War Within: Different Veterans With PTSD, Different Missions To Recovery:

I would have you consider the usefulness of thinking of certain combat veterans as kinetic-energy veterans. Like the extroverts that most of them are, kinetic-energy veterans are energized/rejuvenated by movement, literal or figurative, usually via participating in group interactions. Talk = Life for them. If such a veteran feels emotionally empty, depleted, then it’s time to slap a few backs, make a couple calls, gather ‘round ESPN, head down to the local pub.

In contrast, think of other combat veterans as potential-energy veterans. Like the introverts that most of them are, potential-energy veterans are energized/rejuvenated by stillness, literal or figurative, either via solitary or one-on-one activities, or via watching group interactions. Quiet = Life for them. If such a veteran feels emotionally empty, depleted, then it’s time to sit back, make one call at most to a close friend, open a book or fire up a computer, sip a glass of wine or a nice Pilsner and take a deep breath (even if you find yourself in the middle of the pub!)

With that as background, let me say this:

1. The Role of Medications

Although my “role” at the VA is “prescriber,” I do not see myself as a “pill pusher.” Instead, I believe that my job is to help combat veterans understand what, at least for most individuals, medications can or cannot do.

Medications are about “pool management,” nothing more, nothing less. They can warm up overly-cool water, cool down overly-warm water, add a certain flow to stagnant water, calm down waters that are too stirred. In other words, they manage the physical part of emotions: the muscle tension that will not go away, the emotional heaviness that will not relent, the pit-in-the-stomach sensation that accompanies the loneliness of rejection and despair.

Traumatic experiences–the worst that Reality can offer, whether in combat or in any other of Life’s events–are, in this metaphor, pool contaminants that continually release toxins. The toxins they release can change the emotional water’s flow, temperature, volatility. Thus, as these are physical-like phenomena, the effects of the toxins open up the possibility that medications (also physical “phenomena”) can be of partial (although, hopefully, significant) help.

Genetics and environment–Nature and Nurture, if you will–play their role in setting up the basic “chemical structure” of the emotional pool before any traumatic contaminants have been introduced. Some pools are naturally more “active,” for example, some more “still.” Some have a temperature that always runs on the warmer side, others on the cooler side. Some have already had other Life-contaminants added–abusive homes, assaults, poor educational experiences, drugs and/or alcohol– that have already been releasing toxins into the mix.

In a word, it’s complicated, this emotional-pool “stuff.”

Two important take-home messages, therefore: first, particular emotional states most likely arise from a complex mixture of traumatic toxins with the inherent qualities of any particular individual’s emotional pool. Cleaning up certain toxins with certain medications might or might not help the inherent qualities of the emotional pool, and vice versa. In other words, medications can often help a lot–yet at the same time, paradoxically, can sometimes help only so much with any particular physical manifestation such as tenseness, emotional heaviness, and physical despair.

Second–and for combat veterans, more important–medications are almost always detoxifying agents, not decontaminating agents.

I ask my patients to understand the “emotional pool” as located within their whole bodies, not just their heads. Anger, terror despair, shame, even joy: these are full-body experiences, not just head-ones. Detoxifying agents can often help relieve the body of the consequences of those contaminants, their “toxins,” by reducing the effects of external triggers and by putting a damper on the emotional volatility and reactivity that can destroy the interpersonal lives of so many combat veterans.

But the contaminants themselves, those actual traumatic memories that either linger or are reignited by a particular scene, sound, smell: rarely, if ever, do medications remove them. That’s where psychotherapy comes in.

The tasks of the different therapies are usually quite distinct, then. Medications, something physical, detoxify. Psychotherapy, something interpersonal, decontaminates.

Bringing this back to your case, Sir, I do wish to say, therefore, that I am concerned that you may be becoming increasingly physically depressed. Depression as a physical illness is much more than simply sadness. It is a physical tenseness, heaviness, interpersonal loss that can be felt in the musculature and the gut. When the body gets involved in that way and does not recover after a few days, one is more often than not in a physical depression–and physical depressions often do respond at least somewhat to medication interventions. Not always, of course, and sometimes the side effects of the medications are not worth what little relief they might provide to the physical aspects of depression.

Yet you wrote that you’re finding it hard to keep up with activities that you once did without much thinking (e.g., maintaining a clean environment), to start activities you once had little trouble starting, whether or not you particularly liked them (e.g., going to work). You find that you’re feeling “unworthy” in a deep, physical sort of way. These sound, to me, like indications that you might benefit from speaking with a prescriber–a psychiatrist, a clinical nurse specialist, a physician assistant, a primary care provider–about either a medication trial or a re-examination of your current medications, if you are already on some. I’d recommend that you check back with your former counselor to see to whom she or he refers–or if your former counselor is prescriber, to see what that person would recommend vis-a-vis more physical (i.e., medical) responses to your challenges that might be available.

2. Potential-Energy/Introvert Veterans and the Contaminated “Inner Spa of Rejuvenation”

As to issues particular to your being a potential-energy/introverted combat veteran, let’s get back to the metaphor of the “observation deck” surrounding the emotional pool.

For kinetic-energy/extrovert veterans, this “area” is not a particularly large one. It is an “area” that is large enough to allow them to take the time necessary to reflect adequately on their emotions–but that’s it. Again, they want to be back out in The Real World, using their knowledge of their changing emotional states to get “moving” into activities and relationships for the purpose of rejuvenation, of getting the energy/intensity they need to live out those emotions in the ways they most desire.

It’s a totally different world for potential-energy/introverted combat veterans.

For those of us who are potential-energy/introverts, the emotional pool sits in the middle of a figurative “inner spa” that is not solely about emotions. Like kinetic-energy/extroverts, we too need a space near the pool to reflect adequately on our emotions. However, we then need to move to an “adjacent” area in order to sit quietly within ourselves and reflect not only on what we feel, but also on what we know, whom we know, what we might wish to do with such knowledge, all for the purpose of rejuvenation, of getting the energy/intensity we need to live out that knowledge in The Real World in the ways we most desire. In other words, for potential-energy/introverted combat veterans, their pool of emotions is an integral part of that rejuvenation spa, but it is not the only part of the spa.

Kinetic-energy/extroverted veterans go inside primarily for reflection on the emotional pool in order to focus on rejuvenation efforts out there in The Real World. Potential-energy/introverted veterans go inside primarily for rejuvenation efforts, stopping by the emotional pool as a first step in those efforts, in order to live more effectively and meaningfully in The Real World.

So what do you, as a potential-energy/introverted combat veteran, do when a dump truck called The War unloads a few tons of painful experiences–some of which may be inhumanly horrifying–into your emotional pool, creating a toxic quasi-cesspool called TWW, or The War Within?

Rule Number One:

NEVER, ever forget, no matter what or how you feel: your emotional pool has not turned into a cesspool. It may look like one. It may smell like one. It may feel like one. But it is not one. In other words, it has changed its state (i.e., how it is now), not its trait (i.e., it has not turned into something different permanently).

As I said in an earlier post, many veterans feel that The War Within was all that returned from the combat theater. That is never the case. Always two “people” return: the troop/veteran and The War Within. Nothing has changed inside the troop/veteran in function, even though a lot has changed in form.

Rule Number Two:

NEVER forget that you are military; that once you are military, you are military; that those lessons you learned in boot camp about focused energy are no less true today than they were on the day of your graduation ceremony. While TWW smells so bad that it is hard to remember anything, your not remembering your capacities for focused energy does not mean they are no longer so. Yes, you have a very hard mission ahead. Yes, The War Within is contaminating not only your emotional pool, but your whole place of rejuvenation. Yes, you’re going to have to find a way–temporarily, but likely a long temporarily–to rejuvenate the best you can in the midst of stench.

But think of it this way: you survived those God-awful latrines (if you were lucky enough to have even them) in the middle of Hell-temperatured nowhere without showering for days. You’ve been there. You’ve done that. True, this one’s inside you now, so in some ways it’s a totally different ball game. I know that. You know that. But in many ways, it ain’t different at all. It’s just another fun-time day in Paradise. You had what it takes to make it through the first ones. You have the same to make it through this one.

Rule Number Three:

Accept that this day, i.e., this day in which you have to reduce your activity in The Real World and face The War Within, is going to arrive one day, whether you want it to or not. Ask many of the Viet Nam vets: sooner or later, Life catches up with you. If the day is here, take it. It ain’t ever gonna be fun. See Rule Number Two: you’ve got what it takes, whether or not you feel like it.

Therefore, Sir, for you: although this job is hard for you, in that the relative quietness has brought you to this point, my advice is to stick with it for now, get started on your road toward recovery, and then play it by ear day-by-day. No, you won’t like that. But remember: that’s often how missions go. You’re military. You know that. You keep focused on your goal–and you adjust. Granted, this is the longest mission you’ve ever had to or will ever have to go on.

Again, see Rule Number Two.

I cannot strongly enough recommend that you read and follow the blog of Max Harris, Combat Veterans with PTSD. Max is an Army veteran from early in the current conflict, an Arabic linguist who saw more than his fare share of what War can bring. Max is as intense a potential-energy/introverted combat veteran as you can get, and he’s been brave enough to share his life and struggles in all their ups and downs in his blog, both for his own sake and for the sake of his fellow combat veterans. Recently Max has begun his own personal psychotherapy with a private therapist who volunteers for The Soldiers Project, as well as has been participating in a Cognitive Processing Therapy (CPT) group at his local VA clinic. Max has been struggling these past six to nine months quite honestly with his emotional intensity and symptoms, and he has demonstrated how looking honestly at his employment–and dealing honestly with his employers–have made a difference in his life. I know that he’d be more than happy to share privately with you about his challenges and about how he is learning–day-by-day–to meet them.

In the next post, then, I want to talk about what it means to take all this and then apply it to the problem of how kinetic-energy/extroverts and potential-energy/introverts approach differently the combat veteran’s task of “putting The Truth into words.”

An Update, A Remembrance

Again,  the past few weeks have been busy ones, although this time with presentations as well as patient care issues–oh, yes, and Life.  In addition, though, I have been working on plans  to publish an e-book edition of the series The War Within, to be entitled  The War Within:  Different Veterans with PTSD, Different Missions to Recovery.  At this point, I am considering  publishing it on Kindle, and  I hope to have it available by  November 15.

I plan to keep the original series available here on the website for all who might be interested.  However,  some persons have  expressed  interest in having access to the material outside of the website as well.  Therefore, I am editing and streamlining the essays  a great deal, with a focus on  helping readers frame the challenges of recovery from combat trauma/PTSD as ones of redefining a veteran’s “mission.”   In doing so, the veteran’s  intensity and strength can then be re-channeled into endeavors that can be more worthwhile and rewarding.  I will be arguing again that extroverts, i.e., those who “recharge” themselves in the world “out there,” have very different missions–and therefore very different recovery paths–from those of introverts, i.e., those who “recharge” themselves in the world “inside.”

Still, both “missions” can still lead to the same endpoint:  a more full, more rewarding life post-combat.  If through these essays  I can help some combat veterans find a way to  reframe their challenges into ones that are more hope-filled and more productive, I will consider my efforts  to be successful.

Today, however, in addition, a remembrance:  for some unfathomable reason, earlier this week I began thinking about my elementary school teachers back in Des Moines, Iowa, where I spent my early years.  Given that over forty years have come and gone since those halcyon days of yore, I figured that some of them had passed away, so I went to the website of the Des Moines Register to see if I could find any of their obituaries–

–only to find that one of the most influential teachers of my life, Doris Elinora Stukenberg,  just passed away two weeks ago today, on October 18, 2012, at the age of 91. Her picture accompanied her obituary–and though older, I saw the woman I still remember.

It was 1967-69, my fifth and sixth grade years.  I was invited to join a gifted education program at a school across town from mine, and for both years Mrs. Stukenberg was my “basic skills”  teacher, i.e., all academic subjects except math (why the latter was taught separately, I haven’t a clue).  She taught us during tumultuous times:  Viet Nam and the Tet Offensive; the deaths of Martin Luther King and Robert Kennedy; the race riots of the 1968 summer, Detroit, Newark; the fists held high at the Olympics in Mexico City; the 1968 Democratic convention in Chicago; Richard Nixon’s defeat of Hubert Humphrey (and, never forget, George Wallace!); Armstrong and Aldrin on the moon the summer afterwards.

Only now can I appreciate the freedom she gave us to explore our ideas, to come up with crazy projects, crazy skits.  Dan Rowen and Dick Martin’s Laugh-In was hot back then, and in the sixth grade she let a group of us boys put on Cry-Out, which was so ridiculous, I suspect it was hilarious.  I remember trying to make crêpes suzettes, of all things, when we studied Europe.  During the fifth grade, my  mother was up all hours of the night making some crazy “float” of the state of Iowa, replete with some tower sticking up somewhere in the northern part of the map.  In class we watched this inane Spanish-language show on the local public television stations (which was dedicated to “educational programming” during the day), my very first introduction to ¿Cómo está Usted?, courtesy of this very odd Latina who was always about three beats behind everyone else on the show.  I also did some over-the-top report on Japan, during the sixth grade, as I recall, courtesy of some propaganda supplied by Japan Air Lines through an ad in the National Geographic, entitled Fifty New Views of Japan (or something of that ilk).  

One year Mrs. Stukenberg even called together a noontime  summit of the fifth and sixth grade gifted classes to settle our differences in The Great Foursquare Wars.  Hillary, Madeline, and Condoleezza, eat your hearts out.

Yet what I most remember was her encouraging me to write, no matter how long (yes, even then . . .), no matter how fantastic.  To this day I remember some semi-novella I penned that went on and on about  a flamingo and the Presidency and Ameranada and, well, you get the picture.  I recall  her as having an eternally bemused look, as if she just quite couldn’t believe what was coming out of these kids–and specifically, this kid’s–mouth.

She taught me a bit about tempering  the fine art of the smart-aleck.  She was quite kind and understanding during my father’s illnesses and surgeries.

In so many ways, this blog is an outgrowth of her belief in me all those years ago.  From what I could see in her obituary, she lived well and loved well, leaving behind a family and a legacy not only with elementary kids, but with college kids as well.

She helped me learn how to pave roads back.  May she rest in peace.

The War Within: Afterword

The following  is the text of my last post in the series The War Within (all essays being available via the drop-down menu above).  I do hope that some readers will find it within them to take the time to read all six essays–but even more, that when they do, then may some of them  go on to help me sharpen my ideas, clarify them, drop the ones that don’t fly,  use well the ones that do.

It remains an honor to serve the men and women who have served in combat, to care about them, about those whom they love, about all their futures–and, I hope, in doing so to prove wrong in our generation the words of the prophet Jeremiah in the Hebrew Bible, i.e., that it can indeed become possible in our lifetimes to “say Peace, peace” and, in the hearts of some, to have that in fact be true (or at least, true enough).

Afterword:  Broken Vases, Mending Lives

After our trilogy of “movies,” then, where do we find ourselves vis-a-vis combat veterans’ finding a way to make a life with–and even more importantly, a life beyond–The War Within.

Consider the following “parable,” presented by Dr. Salman Akhtar, a well-known psychoanalyst and poet from Philadelphia. Although he presents the story within a different context, I believe his is a tale that can speak volumes–one filled with both poetry and hope–to those combat veterans who continue to struggle against their Wars Within. In his book Broken Structures (1992), he writes:

The Parable of Two Flower Vases

[L]et us suppose that there are two flower vases made of fine china. Both are intricately carved and of comparable value, elegance, and beauty. Then a wind blows, and one of them falls from its stand and is broken into pieces.

An expert from a distant land is called. Painstakingly, step by step, the expert glues the pieces back together. Soon the broken vase is intact again, can hold water without leaking, is unblemished to all who see it.

Yet this vase is now different from the other one. The lines along which it had broken, a subtle reminder of yesterday, will always remain discernible to an experienced eye.

However, it will have a certain wisdom, since it knows something that the vase that has never been broken does not: it knows what it is to break and what it is to come together again.” (p. 375)

Just as no two combat veterans are alike, neither are their courses of restoration to more meaningful lives. In the previous essays, I have (in a way) portrayed extroversion and introversion with terms and examples that are often quite contrasting.  The Great Escape is a far cry, after all, from The Endless Return through The Well-Hinged Door. Without doubt, Life–and people who live–are for more complex than that.

Yet at the same time, even though many seem to relish to possibility of being “uncategorizable,” seeing their refusal to be pigeonholed as the ultimate expression of their autonomy as a breath-filled human being, we can often see how much energy such individuals expend simply to persuade us pigeonholing-types that they are, indeed, the proud members of the “uncategorizable” category.

None of us wishes to be black/white, yet most of us just feel better when we believe most everybody else is.

As Kurt Vonnegut so effectively put it: so it goes.

No matter whether you are a combat veteran, a loved one of a combat veteran, or a service provider for combat veterans, I would have you consider the utility of at least entertaining the notion that it might not only be helpful, but also hopeful to take seriously the idea that people “re-energize” in radically different “places.” While we all want to have the flexibility to find energy sources wherever we need, whether within or without, I still maintain that for each of us, one of those “places,” i.e., the inside or the outside, simply feels more “natural” in a way that while hard to define precisely, is nevertheless far less hard to experience usefully.

By understanding how differently the world can feel to people who, on the surface, appear to be so similar, one can go a long way toward reducing not only the misunderstanding of others, but also–and perhaps for many combat veterans, even more–the misunderstanding of oneself. Whether extroverted, introverted, or any combo in-between, combat veterans are some of the most self-demanding persons I know. And without self-understanding, self-demanding always ends up self-destructive.

Sadly, sadly, for many combat veterans, I cannot use that latter word solely as a figure of speech.

Different experts use differing techniques. Different vases lend themselves to differing techniques. Painstaking need not be an expression of time, but it is always an expression of intent, of taking on a project worth doing, a goal worth pursuing, a life worth living (and caring about, whether someone else’s or one’s own). By understanding our differences, we all can have patience when others misunderstand us. We can know how we’re strong. We can know how we’re challenged.

But fortunately, for combat veterans everywhere, even more, they can know this: that the right expert and the right vase can come together, can fool some of the people all the time, can fool all of the people some of the time, but ultimately can fool no one that indeed it is possible to know what it means to break apart, to see Chaos ravage the innocent over and over, to whisper goodbye to one’s best friend as one holds him or her in one’s arms, to swear that never again will anyone matter–and yet then, with faith, hard work, and a few A-list companions, to know what it is to come together again, to escape greatly, to return endlessly yet march back out through doors well-hinged, to mend, to keep on mending, to live, to love.

It is a knowledge that none of us wishes for, yet it is a knowledge that some of us, once endowed with it, can eventually find a way to use meaningfully, hopefully–and, lo and behold, without leaks.

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

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