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.

Thanksgiving and the Grammar of Hope

At this time of the year, the American holiday of Thanksgiving, I am indeed thankful for so much: for my wife and children, my extended family, my friends and colleagues, the men and women whom I’m privileged to serve, both at the Indianapolis VA or in my private practice.

I am also very much thankful that for veterans who have suffered from combat trauma/PTSD, it is possible for life to get so “better enough,” they can finally just deal with the problems they would have had to have dealt with had they never been on a deployment.

The veteran I write about today is older than many I have written about, smart, handsome and debonair, well-educated and well-spoken, quite the combo, in other words. And for many years, he has suffered the effects of his combat experiences: a shortened military career, a loss of life direction, in the end a loss (in a manner of speaking) of his family.

But only in a manner of speaking.

He and his wife have known each other since childhood. He was to be the golden boy, she, his gal Friday. Because both are so talented–and so committed–each did his or her best to keep that story line going in the years after his combat experiences. They were reasonably successful, if you want to call the well-staged, day-to-day trickle of misery that was their lives reasonable. It was a trickle, though, no need to overstate it. There were many good times. Great (albeit challenging) kids came into their lives. But trickle, the misery did.

The following had been their original script: he was to make it big; she was to raise the kids and then, once they were raised, “find herself” and go on to make it big in her way. His bigness would have led to the bigger (and earlier) retirement, possibly with consulting jobs afterwards, so all was to have worked out evenly enough in the cosmic sense–and big.

But War happened.

He was fine, of course, after The War–or at least so he assured himself and the world. And indeed, as long as he kept himself within certain military/professional parameters, he was fine enough. Still, he was “not the same” after the War, as his wife and everyone else told him through the years, so a brittle, unspoken (though sometimes loudly-spoken) tension settled between the two of them.

But both were (and are ) good people, so she tried to adjust as long as she could, until finally she made a demand on him that could not be ignored, so he adjusted his career path in a way that finally could not be repaired, leading to a loss of all those tenuous parameters, to a deterioration on his part that forced her to “find herself” much sooner than had been called for in the script, that then caused him to question the cosmic order, that then caused The War to take on even more salience, that then eventually caused a . . .

. . . well, let’s call it a complicated situation. Yes, they are divorced, officially, that is. But, really, what’s a piece of paper between friends?

As he and I have worked together over the past year or so, he and she have spoken regularly. She made an excellent career move that took her far away from Indianapolis. He settled some matters in his life that needed to be settled. His nightmares have decreased. He has begun the process of forgiving himself for what he did, what he did not do, what he saw and did nothing about during The War. He has begun to imagine a future, even if he has no clue what that future might look like.

But still, for both of them, there’s that piece of paper . . .

She flew into town earlier this week. The two of them and their kids lunched together, then she and the kids headed out of the town for a few days. When she gets back in town, the two of them will have some time together to speak.

“You know, Doc,” he said to me earlier this week, “I have been thinking: maybe she and I are finally ready to move on with our lives.”

Hmm.  Come to think of it: no, I didn’t know that.

“What do you mean?”

“Neither one of us wants to go back to the way things were. We can’t. She’s changed too much. I’ve changed too much. But at least we no longer have to hold onto what’s probably never been there.”

I did pause. After thirty years, I at least know when I’m walking in very dangerous territory.

“I would agree that neither of you wishes to return to the past. But I’m still struggling to see what that has to do with the future, i.e., whether you walk toward the future in parallel (whether or not you’re a couple) or whether you walk in different directions.”

Now he paused.

“I guess that’s true.”

I have learned that with bright combat veterans, whether of the extrovert/kinetic-energy type or the introvert/potential-energy type, I, as a therapist, have a little wiggle room vis-à-vis boldness. I was certainly well-trained, so I also know that I have to be careful that I don’t inject too much of my own worldview into a therapeutic conversation. Yet sometimes time is of the essence: an important get-together of this couple is about to take place, after all, and neither he nor I have the luxury of piddling away at platitudes that both of us know have zero to do with how he’s really feeling.

“Look: life hasn’t turned out like either of you had planned,” I continued. “You were supposed to be the one with all his stuff together, and she was to come into her own just in time to give you some more hours on the golf course kibitzing with the generals. But life happened, War happened. So now she’s ready to tee up, and you don’t even know whether you have clubs or not. This isn’t about whether you two are going to move on, pal: it’s about how you’re going to do it.”

He was quiet.

“I can’t hold her back, Doc,” he said softly. “That’s unfair. I’ve put her through too much.”

“Hold her back? Buddy, if she’d been worried about that, she’d have done kicked you to the curb a good three years ago. Has it ever occurred to you that maybe she’s willing to hold back a bit to give you a chance to catch up?”

Further quiet.

“But I don’t know what to do,” he finally replied. “I don’t have a clue. I mean, I feel better. I know that I can get something going, but I don’t know when, I don’t know how.”

“Like she doesn’t know that?”

“But . . . but this could take a long time.”

Now my turn for quiet.

“And your point?” I finally ask.

This time, only a few seconds of quiet. It just rolled out of me.

“You’re not the first, you know: the first man who thought he had at all planned out, only to find out that Life had different plans, who then found out that the partner he’d chosen was able not only to fill in the holes, but even to create a few new openings. You’re not the first man who’s had to decide whether he’s going to accept that being one-down does not make you the one-down-type, that your finally realizing that you’re vulnerable in front of your partner did not make you vulnerable, but that it merely wised you up to the basic human fact that that’s where each one of us has been, is, and will be, whether we like it or not:  vulnerable. You’re not the first man who’s had to get it in his thick skull that it’s actually possible for two people both to be strong and both to be vulnerable at the same time, and the sun will keep rising and setting.”

Again, quiet. Then it apparently was time for it just to roll out of him.

“Doc . . .”

“Yes?”

“Do you mean . . . are you telling me that this is not about PTSD?”

The question surprised me at first, but only because I was being the oblivious one now.  I just shot from the hip.

“Oh, God, no. Not at all. I mean, yes, your combat experiences and your PTSD are what waylaid you in such a spectacular and horrific way. But, heck, it could have been the economic downturn, a culture change in your industry, a life-changing medical illness unrelated to combat–any of that could have done you in. Combat and PTSD just happened to cause your particular pain, your wife’s and your family’s particular pain. Granted, it’s what’s never going to fully go away for any of you. But this isn’t a PTSD problem. This is a life problem.”

There was then more quiet, but on the outside only. I could hear so much in him. He was stirring so much up in me.

“Doc,” he finally whispered, “I . . .” He swallowed. “Thank you.”

“For what?” I swallowed back myself, not quite yet sure what was going on within either of us.

After a few moments, “I never thought that my life would not be about the War, only about the War, that is. I never thought I could ever again just face . . . a problem.” He smiled. “That’s a good thing, isn’t it, just a man and a woman trying to figure out how they’re going to make their lives work, whether they stay together or not?”

Finally realizing what was going on within us, I could only manage to utter myself, “Yes, it is. Yes, it is.”

Combat trauma makes The War Within the subject of every veteran’s sentence, whether explicitly or implicitly. All the rest of life is reduced to adjectives, adverbs, direct objects of verbs that respond to the will of The War Within and it alone.

Hope and growth from combat trauma are not just neurological, not just psychological. They are linguistic as well.

As combat veterans find their way, individually, to situate themselves as flexibly and as comfortably vis-a-vis their War Within, no longer is that War the sole subject of all their independent clauses. Soon it is moved into subordinate clauses, into because clauses, so that clauses, into language that gives background, goals, reasons for the actions that are now taking center stage in the main part of the sentence, the main part of the veterans’ lives.

And then, one day,  War Within is finally reduced to a mere participial summary statement: “Given the War, I must now . . . , I will now . . . ., I no longer must . . ., I can finally . . . .”

Etc., etc., etc.

At this time of year, then, I am so thankful that hope not only has a body and a soul.

I am thankful that it also has a grammar.

In Memory of Ryan

Last Saturday, Nicholas Kristof of the New York Times wrote a powerful  op-ed piece–an indictment, really–about the epidemic of suicides that are occuring among combat veterans., entitled “A Veteran’s Death, the Nation’s Shame.”  With the column, the Times published on its website a short film concerning the death by overdose of Spc. Ryan Yurchison, put together by the filmmaker Timothy Grucza, entitled “Good Night, Ryan.”  I strongly recommend both pieces to you.

The VA takes its hits in both pieces.  As I say in my “About Me” page, I do not in any way speak for the VA, DoD, or any other branch of the government.  My thoughts–my reactions–are of a man who happens to be trained as a psychiatrist and a psychotherapist, who happens to be a husband and a father and a son, who happens to have the privilege  of working with men and women who have been so willing to give of themselves–and who happens to work for the VA.

That is how I respond to Ryan’s story: as a man, a psychiatrist, a husband, father, son.  Who happens to work for the VA.

Ever since I was a lad, I have often been able not only to sense, but to feel the very hearts of others.  I have learned through the years how many times I have been mistaken in my understanding or interpretation of those hearts.  I can be quite petty and irritable, as those who’ve been following the blog from the beginning well know.

Yet from what people tell me, I’ve many times been accurate as well, even helpful.  When I was younger, I found this more curse than blessing.  Now, it’s the opposite (though I don’t want to overstate that point, believe me).  It’s an amazing opportunity, though, to be my age and to have so much of life come at me, infiltrate me, even–to a certain degree–lodge within me.  Thanks to a very patient therapist who refused to let me do anything but grow, I have managed to construct enough-of-a-self that I can now do for others what he did for me:  take in at least some of their pain, enough to give them a chance to find–and create– enough-of-a-self as well.  For that I am deeply thankful.

Yet I can only be silenced before Ryan’s mother Cherry DeBrow, his brother Michael Yurchison, his best friend Steve Schaeffer.  Though in a sense I can feel their hearts via their voices, their faces, in the deepest sense I haven’t a clue.  It’s precisely because I have my son that I cannot imagine life without him, my life without my daughters.  I don’t “go there” because I can’t go there.  One only goes there when, like Ms. DeBrow, one is there.

For those of us who have the opportunity to work with combat veterans, we have both an advantage and a duty.  Our advantage is an obvious one: unlike the veteran’s family, friends, even the veteran him or herself, our time with the veteran’s  pain is limited, once a week if both of us are lucky, more like once a month–if even that.  The horror of war does not invade us hour by hour as it does the veteran and all those around him or her.  We spend our half hour or so with it, one hour if again we’re lucky.  Then we’re done.

But therein lies our duty.  In that half hour, that hour, we have to open ourselves as much as we can to all the terror, all the rage, all the shame that comes our way–that comes the veteran’s way 24/7.  It is our responsibility to be mature enough to manage those emotions as best we can, and it is our duty–if I might be allowed a more dramatic word, our “call”–to do just that.

Even then, sometimes it’s not enough

When I’m with a veteran in the worst of his or her pain, when the War threatens to engulf us both, right there in the middle of that cubbyhole I call an office, I always go in my head to the same image, the same experience.  I feel a steel rod ram itself right down my middle, implant itself in the ground beneath me, anchor me in some semblance of a here-and-now reality to allow both of us get through the next five minutes–what am I saying, the next five seconds.

And then in my mind, I just have to grab onto the veteran and hold on.  For dear life.

And when he asks me, “Why?  Why do you care?  Why should I care?  Why should anyone care about anything?”, I can only reply something to the effect of “Because I’m here and because you’re here–and because I’m not going to give up.”  Believe me, there has been more than one veteran who has questioned whether that morsel of pithiness should matter one iota to either of us.  Believe me, I’m in no position at that moment to debate the issue.

I can only give the man or woman a choice as to whether he or she is going to even consider whether I mean what I say and whether my being there matters–yes, as a psychiatrist and therapist who’s trained to weather the pushes and pulls of such encounters, but even more as a fellow human.  Nothing more.

Nothing more.

Ms. DeBrow, Mr. Yurchison, Mr. Schaeffer: I can never fully understand what happened, never even begin to understand what you’re going through.  I can only offer you this: I will remember Ryan.  I will keep doing all I can so that other mothers, brothers, buddies need not hurt as you have.  That I can promise you.

May God be with you.

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