Quite the Handful

June 30, 2012 By Paving the Road Back in Living Life, Personality and Identity, Professional Relationships Tags: cluster b traits, combat, hyperactivity, military, OEF, OIF, Posttraumatic stress disorder, veteran Leave a comment

I’d first heard about him several months ago. His has been a complex story, and truth be told, he shouldn’t be alive. He has had several near-misses, although there has apparently been much-heated disagreement among him and some of his treaters as to where “accidental” ended and “purposeful” began. Still, he’s pretty much the straight-shooter: he readily admits that sometimes the latter is the only adjective worthy of at least a few of his tête-à-têtes, shall we call them, with the Great Specter from Beyond.

He came to me for Suboxone, the new opiate substitution regimen that has proven so helpful for many combat veterans who have struggled with addictions to painkillers and heroin since their return from The War. Like many of his fellow veterans, he has endured chronic pain both of a physical variety and of an emotional one. He has also long complained of very marked, almost continuous anxiety, an anxiety that, true, sometimes has had the quality of the hypervigilance so characteristic of the combat veteran who just can’t seem to get off guard duty, but at most times has simply seemed to be (to me, at least) a dramatic, post-combat upsizing of the chronic tension and energy that has been his hallmark since toddlerhood.

He has not been, what, particularly enamored with us at our VA. He’s willing to admit, though, that he’s not always been, what, particularly enamoring himself. When so much pain is ricocheting through a room as a combat veteran struggles with the acute emotional challenges of posttraumatic stress injury, both veteran and treaters can sometimes get caught up in the tornado-esque swirls of suffering. We treaters do our best not to get so caught up, but indeed, we’re human, and humans catch emotions from each other, especially powerful ones, and since most of us went into the field precisely because we are good at experiencing the emotions of others, even the most calm and patient of clinicians can, at times, feel a bit unhinged in the midst of tense situations.

We had no such experiences together when we met, though. He was pleasant, though (appropriately) wary. I had no doubts whatsoever as to the sincerity of his desire to find a more satisfying solution to all his pains, for his relationships have suffered tremendously because of them. I also had no doubts whatsoever that he can get quite ugly quite quickly, and both he and his wife had no problems whatsoever acknowledging that very fact. He knew he needed help. His wife knew it. I knew it. We came to a “meeting of the minds” quickly as to the medication.

But I will remember my encounter today with him not because of Suboxone.

Several months ago I wrote a post entitled Cluster B Traits. Only one other post, The Killing Floor, has received more hits. As of today, that post has been visited a total of 557 times. In fact my new claim to fame is that if you Google “cluster B traits,” my post comes up fourth (some days, third) on the list after Wikipedia, Answers.Yahoo.Com, and another blog post!

I’m kind of impressed with myself, if do so say.

All these months later, I still have my reservations using that label (“cluster B traits”) with combat veterans. My patient today, for example, has been the recipient of that label more than once. He has, in fact, read page after page of his medical record, and he has more than noticed how frequently he has been given the honor of that quasi-diagnosis.

He has not been impressed.

Quite the contrary: he told me that he now finally understands why so many treaters at our VA have been, in his words, “less than supportive,” especially of his medical concerns. “If you have a ‘personality problem,’” he said, “people just assume you’re trying to get something over on them. I mean, that’s what I would think if I read that, you know what I mean?”

And . . . well . . . while I might say that he may be being a bit harsh and overgeneralizing with that claim . . . well . . .

I wouldn’t say that too vociferously.

Instead, I had him consider an alternative interpretation.

“But isn’t it a fact that you’ve felt this inner tension ever since you were a boy?” I asked.

“Yeah. So?”

“So wouldn’t it make much more sense to call it for what it feels like, that is, lik too much adrenaline flowing through you all the time?”

That stopped him cold. Apparently he’d not been expecting that from me.

“I’ve seen it with a lot of you guys in the military,” I continued. “Ever since you were kids, you’ve had a motor running. People usually called you ‘hyperactive,’ but that wasn’t quite right, was it? It wasn’t so much that you couldn’t focus as it was that you couldn’t focus on the routine or the trivial. If you found something that really interested you and allowed you to work out your energy, live it, love it, you could actually be quite focused. True?”

He just stared at me.

Then I saw it. His eyes began to well up.

He turned away from me slightly, looked down. He brushed the edge of his right hand against the edge of the corresponding eye, swallowed. Still he still looked down.

“Isn’t that true, though?” I asked again, though a bit more genly this time. “That it’s always just been so much to handle on the inside of you, that the military took care of that, gave you something meaningful to do with all that, rewarded it?”

He looked up. Whether he was fighting the tears or just not caring what happened anywhere north of his lips, I couldn’t quite tell.

“I wish other people understood that,” he whispered.

“Not even your wife does?” I asked.

He was still looking right at me, every microfiber of muscle still.

“I don’t know,” he finally said. “I think she tries, but I don’t know. Nobody else does. You don’t know how I fought to stay in the military. They tried so hard to med board me out, and I fought it and I fought it and fought it, until finally I had to go. You don’t know what I’d give to get back over there.”

“Because it all fit over there, didn’t it?”

“God, yes. I loved what I did. I was good at it. I didn’t want to kill people, hurt people, destroy things. I didn’t try to do it. But I protected myself, protected my men. We did what we had to do. We saved a lot of lives over there. Now I’m just here.”

“And inside you, the motor keeps running, on and on and on,” I said, myself whispering now. “And it’s eating you alive.”

He just nodded. What else could the guy have done.

He’s quite the handful. Always has been. Yet character-disordered? Cluster B traits? Oh, sure, I could make the argument as well as colleagues could: the veteran’s longstanding difficulties, his interpersonal challenges, his “persistent unwillingness” to look inward and “fix” it, whatever that it might be, “tame” it, “reflect” on it, “soothe” it.

Unwilling? Or unable?

Yes, he loves his energy, his adrenaline, his push, push, push into the world, now, again, again, harder. He feels alive with it. He feels real.

But he’s no fool.

He knows that we don’t cotton too much to such energy back here in the civilian world, even if we say that we like our boys or girls to be “Army tough”, Semper Fi. You leave that out on the playground, child, you hear? Run that out of you and then get back in here and get to work.

You go do your military thing, man, woman. Run that out of you. “Thank you for your service,” we’ll say. Shoot, we’ll even give you a parade or two (the Fourth’s coming up, you know).

Then get back in here and get to work.

And we wonder why he turns to pain pills to ease the pain. All that energy, we say, if he would just use it right, ‘tis a pity .

Use it? Really? Where?

You gonna put up with his constant edginess, Mr./Ms. Civilian? You gonna give him that opportunity to punch that bag, run that ten miles, pump that iron–even if maybe you might lose an hour of work out of him to let him do so?

You gonna tell him he’s a good man, that even when he’s a handful, yes, even when you’ll exhale quite the sigh of relief whenever he’s bounces out to do whatever it is he needs to do “get that out of you, boy, go on, go, go, go!, you’ll tell him that you’re so glad that he’s here, that you wouldn’t want him any other way? (Well, all right, most times . . .)

They just want to be understood, you know, these men and women with that Army-tough, Semper-Fi drive, energy, passion. They know they’re a handful. They know they’ve got too many hormones and neurotransmitters hurtling through their arteries and veins, banging on the doors of their neurons as if there were no tomorrow, ordering every cell within the vicinity to “move this sucker, baby, and I mean now!”

They know they’re not “normal,” i.e., not like most of us on the remainder of the bell curve. You think you’re gracing them with some eye-popping epiphany when you label them “hyper” or “emotionally dysregulated”?

Actually, I’ve found them to be quite a forgiving bunch, if you want to know the truth. You can label them whatever, from my experience–just as long as you can smile and like them, give them the space they need, the passionate direction they need to allow them to burn up a few of them inner chemicals so that, maybe, tonight? We could just chill a bit, you know? Be friends? Talk?

“Now, true,” he or she might then say, “I’ll do most of the talking, but . . .”

Please don’t blame them for their bodies’ chemical composition. Please don’t abandon them to some poor spouse or some few kids who cannot deal with this all on their own, who are are just going to need a break every once in a while–and not just talking every few weeks here.

It takes a village, a village that’s willing to adjust its work schedules, willing to say up front “We understand. We’ll work with you.” Willing then to do just that. I can’t help but wonder what would happen to those veterans’ “Cluster B Traits” if that were to happen.

Well, actually, I don’t wonder, but then . . . I’m one of those types, you know, unwilling to call pathology when I see it, unwilling to set limits that must be set in order for an individual to learn to function in society, after all.

Yes, indeed. I am.

Relationship, Relationship . . . Mission

June 24, 2012 By Paving the Road Back in Culture at War, Personality and Identity, Professional Relationships, Respect, Honor, Duty Tags: combat, Craig Bryan, Suicide prevention, United States Armed Forces, veteran, Veterans Health Administration 1 Comment

To date, I have said nothing about the current crisis of suicide both within the military and within the veteran population. With this post I enter the discussion , but with some trepidation, and I do hope that I enter it with the respect that the many dedicated clinicians and researchers across the country deserve as they grapple with this epidemic. I simply want to add my take as of today.

As many of you probably know, this week the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury sponsored a major conference in Washington DC, bringing together the Department of Defense and the Veterans Health Administration for a Suicide Prevention Conference entitled, Back to Basics: Enhancing the Well-Being of Our Service Members, Veterans, and Their Families.

It was a big deal, and rightly so.

Today I only want to reflect on one presentation given at the conference, as brought to my attention by the ever-vigilant, ever-informative Bobbie O’Brien in her blog Off the Base: remarks made by Dr. Craig Bryan and his co-presenter, Dr. David Rudd, in a breakout session entitled Reasons for Attempting Suicide Among Active Duty Soldiers: Clinical Implications. The substance of the presentation was reported by Karen Parrish of the Armed Forces Press Service.

Dr. Bryan is a big deal in these circles: the guy has an eye-popping CV (even more impressive for somebody only six years out of the engraving of his doctoral sheepskin!), and currently is in the well-deserved position as the Associate Director of the National Center for Veterans Studies at the University of Utah in Salt Lake City. I get worn out just reading the man’s accomplishments, let alone imagining how I could attempt even a third of them and not collapse in sheer ignominy.

Drs. Bryan and Rudd worked with active-duty service members who had been hospitalized for suicidal ideation/behavior. In a study designed both to gather data and to institute prevention/treatment strategies, they tried to understand the reasons why active duty military desire to take their lives. Using a classification system apparently well-known within suicidology circles, they came up with the following data:

1. One hundred percent (100%) of those interviewed stated that they were seeking emotional relief, or the “desire to stop bad feelings”;

2. Over eighty percent (82.4%) stated they were seeking avoidance and escape, with the primary goal of “get[ting] away and escap[ing] from other people”;

3. Just over eighty percent (80.1%) stated they were seeking interpersonal influence, especially “to communicate or let others know how desperate [they] were”; and

4. Over seventy percent (72.1%) stated that they were seeking the generation of feeling, especially to “feel something, even it was pain.”

Quite the list.

In his CV, Dr. Bryan notes that he is especially interested in developing evidence-based treatments to reduce suicide, and as presented by Ms. Parrish, he hopes that his work may be useful to “teach patients ‘how to suffer in a way that doesn’t require you to die.’”

On Teaching, Relating, and Suffering Together . . .On a Mission

Clearly Dr. Bryan and his colleagues throughout the suicide prevention community are deeply passionate about their work and deeply committed to improving the lives of all active-duty military and veterans. I applaud them in their persistence and in their efforts to clarify what needs to be clarified and to treat what can be treated.

Today as I sit on my porch in the relative coolness of a June Sunday, far away from Lake Huron, less than twenty-four hours away from my return to the world of combat veterans desperately seeking hope somewhere, soon, I merely think again about language. And about hierarchy.

And about mission.

As most of you know, I was not a military man. Yet I am a man, one who grew up in the America of the Sixties and Seventies, who established himself both personally and professionally in the Eighties and Nineties, and who now looks to the twenty-first century as the place to pull all that together, offer what I can, and then leave the rest to my children’s generation and beyond. It is true that the concept of “man” and “masculinity” has undergone, shall we say, some re-examination over my lifetime. I acknowledge that, and I do hope that, in many ways, I am embodying the best of those re-examinations.

Still, the key word there for me is embody: I experience the world as a man whose biology has emerged within the interpersonal context of American culture, its “boy culture” and its “male culture.” No matter whether I have wanted to or not–quite frankly, often in spite of my best, conscious efforts–the interpersonal and the physical have united to create a pattern of thought and feeling that sets the stage for my every thought and feeling long before I even realize that I’ve had either.

And I must say: as time is moving on and I am meeting men much younger than I, both in military/veteran contexts and in far different contexts, I am not finding that “twenty-first century men” experience their world much differently from how I do.

So let’s call it like it is: many of us men–maybe even most of us–are obsessed with hierarchy.

Every single thought, every single feeling we have has already come to us through a filter of “who’s first, who’s second?”; “who’s winning, who’s losing?”; “who’s up, who’s down?”; “who’s front, who’s back?” Who else but a group of Western men, even a group of very good friends-Western-men, can turn a Domino’s pizza order into high drama over who will prevail: the pepperoni-only guys, the sausage-only guys, or the two-toppings-even-though-it’ll-cost-extra guys?

Ah, ‘tis the age-old question, is it not? How much of a “relationship” is hierarchical and how much is mutual, the traditional-male approach to the elephant and the traditional-female approach to said creature? As individuals, no matter what our chromosomal patterns, which is our primary experience? How much of the alternative experience will we allow into our consciousness?

Is teaching, is therapy hierarchical or mutual? The answer, of course, is C, i.e., both A and B. Great, fill in the circle on the scan sheet, next question.

But really . . . really . . .

Maybe it’s because I’m a guy and a traditional one at that. Yes, maybe that’s it.

But I’m going to have to confess in public: I don’t experience teaching as mutual.

And honestly? I don’t naturally experience therapy as mutual.

I don’t experience it as mutual when I hear other therapists talk about it, especially in the context of psychoeducation, task performance, and review/rehearse. And I’m constantly–constantly–having to remind myself when I’m with a patient that I’m just a guy who once hurt a great deal and who still can hurt, sitting with a man or woman who continues to hurt a great deal, still. I ain’t above, I ain’t below. Sometimes, I’m barely holding on with.

Or maybe it’s because I’m an old guy as well. Yes, maybe that’s it, too.

Not only are my students (undergraduate, graduate medical) younger than I, not only are most of my combat vet patients younger than I, most are now the age of my peers’ children or, horrors, of my very own children. I had always calmed myself by the fact that I started this parenting deal later than did most of my peers. Good Lord, I can’t even fall back on that now.

This is not necessarily a bad thing, however, not by a long shot, this age stuff. As I’ve noted in previous posts, I have a certain paternal relationship with many of my patients (and even many of my students) that both of us, patient/student and I, seem to enjoy a great deal. When hierarchy is suffused with warmth, especially for us guys, it’s usually a win-win, big time.

For never forget: not only do many of us guys first experience the world as hierarchy, many of us are consequently more comfortable within hierarchy. As long as we’re being respected (and not humiliated) in the number-two position, the latter ain’t a bad place to be in life, let me tell you. Let the big guy take the heat, you know what I mean? The rest of us can just shrug our shoulders, then, with one of those classic “what’s-a-peon-like-me-to-do” looks plastered on our mugs.

From what I glean, a whole lot of military men (and women) have lived that latter life to the fullest.

What’s hard, of course, is for “Dad” to admit to “child” that he both does know a thing or two and that he doesn’t really have that much of a clue as to which way is up, at least much of the time. It’s hard to hold on both to a position of authority, often a necessary position desired both by the one in authority and the one under authority, and a position of “I’m just a guy wanting the best for you” position of mutuality.

Which takes me back to language, and specifically to the language emotional relief, avoidance and escape, interpersonal influence, and feeling generation.

How easy it is for us as teachers and/or therapists, man or woman, to look at our students, our patients/clients, to observe them, always with the underlying desire to learn from them and to give back to them what we’ve learned so that they too can learn one, do one, and then hopefully teach one themselves.

How much harder it is for us to look at them and feel them, as one sufferer with another, as one who may have no clue as to the depth of the suffering of the other, who can therefore never suffer as (my daily experience), yet as one who is willing to sit in the presence of that other and his or her depth, who can–and will–again and again suffer with.

I have to confess: I have no way of conceptualizing emotional relief except as the most profound of interpersonal experiences, of finding relief from someone for the pain that one is enduring. I have no way of conceptualizing avoidance and escape except as a desperate attempt on the suicidal person’s part to run away from his/her suffering precisely because there is no one, at least in his/her mind, to run to with that suffering. I have no way of conceptualizing interpersonal influence except as a desperate attempt to find someone–dear God, anyone–to influence, please, maybe just for a few minutes of your time? I have no way of conceptualizing feeling generation except as a desperate attempt to get something ignited within the person, given that no one seems to be able to ignite anything of any significant for him/her.

I wish in my mind’s eye I could easily conceive of a general, a colonel, an admiral, a captain looking the soldier, the Marine, the sailor, the airman, the guardsman eye to eye, a superior to an inferior, yes, but also a human being to a human being, saying with all his/her heart, “I want you to live, soldier. I want you to live” . . .

. . .and then not have to conceive the questions that inferior, that fellow human being might ask in response:

“Really, Sir/Ma’am? Me?

“At the expense of the mission, even?

“Oh, yes, Sir/Ma’am, I do understand: I am the mission, an indispensable part of it, the one united with others who will make the mission succeed, bring peace, bring us all home safely.

“But, Sir/Ma’am, you and I both know: I might end up having to be an “expectable loss” of this mission, won’t I? Yes, I know that I will die with honor. I know that you will honor me. I know you will bestow honor upon my family. I thank you for that.

“And, yes: I know that if I die by my own hand, I will die with tragedy. I know you will feel my tragedy. I know I will bestow tragedy upon my family. No, Sir/Ma’am, I don’t want that.

“But, permission to speak, Sir/Ma’am: either way, I’ll be dead, won’t I?

“True, you’ll feel better, my family will feel better if I die with honor and not tragedy. Yes, that is important to me.

“But either way, Sir/Ma’am, I’ll be dead.

“Correct?

“And you’ll still have your mission.

” . . .Correct?”

I don’t know what to say, really, what to think, what to feel. I’m a civilian, after all. My only comparison is a weak one: if one of my patients kills himself or herself, my life will go on. I will be sadder, less whole, but I will continue.

Without the soldier, the mission will be sadder, less whole, but it will continue.

It all comes back to hierarchy, doesn’t it. Guys get that. In the twenty-first century, women get that too. At least it’s an even playing field.

So there you have it . . .

If it’s between you and me, patient, yes, I’ll choose me, but I’ll wonder why it had to get to this point.

If it’s between you and the mission, soldier, though: well, you signed up for this. That always was the point.

Dear God, I thank you, truly, that I never had to live the latter encounter.

Dear God, be with those who do.

On Grossman, On Combat, On Lake Huron: An Introvert’s Manifesto

June 21, 2012 By Paving the Road Back in Culture at War, Personality and Identity, Professional Relationships Tags: Dave Grossman, extrovert, introvert, longform, Myers-Briggs Type Indicator, On Combat, On Killing, PTSD, veteran, WPLongform Leave a comment

The family is up in Oscoda, Michigan, on Lake Huron this week, enjoying a quiet beach and a quiet time (even if the flies have been insufferable). Yet yesterday I also found myself back in high school, nearly forty years ago.

I was (I’ll admit it) a bright guy in high school–and well-known, I guess you could say, for that. I ended up one of two valedictorians in my class, and even to this day, at reunions people associate me with being “The Brain” who had a proclivity for language learning.

I guess you could say I was a “mid-level” nerd; I wasn’t one of the pocket protector types, in other words. Ultimately what saved me were two talents which have come in quite handy through the years: musical ability and an ease with public speaking. Consequently I don’t remember my high school years badly at all, even if I wasn’t one of the athletic ones. I was never bullied. I had plenty of friends to hang out with, some of whom I still correspond with. I was even Ben Franklin in our senior year production of 1776. (I graduated the year before the Bicentennial.) All in all, not bad, if I do so say.

One “event,” however, changed me forever, and it precisely had to do with my cognitive abilities.

Back then, there was a certain senior-year course that was one of the “test your mettle” courses for the college-bound: Biology 3 & 4 (second-year biology). It was taught by the boys’ athletic trainer, a boisterous, quite exacting guy who loved his athletes (and they loved him), yet who was not going to take second-rate as an answer from a-n-y-body. All the athletes (especially the men) who planned on going to college were sans doute expected to take “Doc’s” class–and every one of them knew that he could not count on football or basketball prowess to get him extra favor. Don’t even try, pal, don’t even try.

Well, OK, you see, then there was this Rodney kid, and he happened along and, for some darn reason, he decided to take Bio 3 & 4 as a junior.

So here’s the scoop: in Biology 3 & 4, “Doc” made up these Byzantine tests with humongous numbers of points (even he didn’t know how many there were until he counted them up after the test was over!), and he had this, shall we say, idiosyncratic grading system: the person who missed the least points got a perfect score, with everyone else adding that person’s number of “missed points” to his or her score, with the final, adjusted scores subsequently being curved. The tests were very publicly graded, and grading days were always a drama down to the very last question graded in the very last class of the day. This was high school, after all, and this was a big deal. I mean, this was Doc’s class, come on.

So . . .

I had class sixth period, with earlier classes in second, third, and fourth period (amazing what one remembers after forty years). And, well, I was, oh, what can I say–the one whose score came to matter, test after test after test? After test?

I got a lot of perfect scores, in other words. And I mean, a lot.

If I were to get all military on you, I guess I could say that I mowed everybody down. It would probably be more accurate, however, if I were to compare the whole situation to a standard-sized nuclear crater in the Mojave.

The seniors noticed. All of them.

I had never–and I mean, never–had athletes envy me. Never, never, never. To their credit, they actually treated me with a fair amount of respect, which sort of shocks me even to this day. But back then, in the Dark Ages, we used to call smart kids “pencilheads”? Well, my nickname was–the Typewriter (yes, my children, such thingamabobs once did grace our fair, American landscape, manual ones, even, believe it or not). To this day, I meet high school classmates who remember me first as Rodney Typewriter, or, in Doc’s inimitable, endearing fashion: R.T.

So, you ask: what does that have to do with Paving the Road Back?

All right, first: my three children would probably dispute my eschewing the “pocket protector” title, as they (albeit lovingly) consider their father to be a hopeless geek. And I must say, dear reader, they have a point, for there I was this week, lounging on the banks of a Great Lake, lightly perusing Lt. Colonel Dave Grossman’s two, modern-day classics on the psychology of war, On Killing and On Combat.

Light beach fare, in other words, you know what I’m saying?

OK, fine, but why R.T. and why now?

Second, that junior year of high school was the very first time I realized, down to my bones, that I was quite good–aggressively good, one might even say–at something that cool ones (or at least the serious cool ones) desired. I wasn’t exactly a quiet kid, but I had always kept a low profile in my classes, a habit I continue to this day. Back then I took it all in, ran it through my little “typewriter”–and then let ‘er rip. I got people’s attention.

That too is a habit I continue to this day.

So (third) back to Colonel Grossman. On Killing is an amazing book dedicated to providing an understanding as to what happens when humans kill one another. I had dipped in and out of the book many times before, but never had I read it cover to cover. I found his insights quite useful and quite thought-provoking. It’s a great book. I recommend it to anyone who is interested in understanding combat and how men and women respond in and to war.

Its companion book, On Combat, however?

Well, in a nutshell, it is a book in praise of warriors, both military and civil (i.e. police). His thesis is that someone must face the Universal Human Phobia, i.e., human aggression/combat, and those someones are the warriors, the ones who run toward dangerous evil, not away from it. It is an extended meditation on the joys and challenges of being a, as he puts it, “sheep dog”: someone who protects the “sheep” (those, such as the overwhelming majority of humanity, who run from said Universal Human Phobia) from the “wolves” (the predators who use the UHP for their personal gain). To give the man credit, he endeavors his utmost to carve the pejorative out of the word “sheep,” but as one who has experienced such creatures at the Indiana State Fair, I do say that the good colonel has his work cut out for himself.

Where do I begin . . .

Every once in a while I read a book that hurls my limbic system (or as Colonel Grossman puts it, my “puppy brain,” i.e., the part of the brain most like the little dog who barks first and then thinks later, if ever) right straight back to Ben Davis High. It’s remarkable, really, how the brain works, how after forty years (the length of time most Viet Nam vets have had to remember their little forays) reading a book, an essay with a certain tone, a certain set of assumptions can put me smack dab back in the middle of junior high, remind me of the frightened kid I once was who felt he needed to apologize for his very existence to those who really knew how to make things of import happen in the world. . .

. . .and how quickly I can then put on that combat gear of sixth-period Biology and reconnect with my very adolescent, very “OK, Mr. Hot Shot, sure, you could beat me to a pulp, you know it, I know it, no question, but in the Game of Life, where the smart and the clever are now the cheetahs running after the gazelles? You think you’re up to it? You want a piece of me? OK, you go right ahead, pal: come and get me. Let’s talk.

“I mean, after all, I ain’t been to the Mojave for a while, and I’ll admit it: I’ve been itching to catch me a gander of the landscape again.”

It all gave me an up-close-and-personal appreciation of one of the Colonel’s main theses: combat ain’t no fun, and it ain’t for amateurs, but when the time comes, sombody’s got to do it. Period

Some of you who have followed the blog for a while might remember an earlier post, Inside, Outisde, Anywhere. There I mused on “post-traumatic growth” and the conundrum of PTSD/combat trauma and the “extrovert” versus the “introvert.” Just to review: in the technical, Myers-Briggs meanings of those words, one is not talking about sociability, but rather about one’s preference for how to make sense of the world. The extrovert “metabolizes” the world preferentially “in the world,” “out there,” in action and in the play of concepts and experiences as they are lived out in the external world. In contrast, the introvert “metabolizes” the world preferentially “in the mind and soul,” “in here,” in thought and in the play of concepts and experiences as they are lived out in the internal world. Each of us has a major. Each of us has a minor.

My major is introversion, my minor, extroversion.

I can’t help but suspect that Colonel Grossman’s are the opposite.

I may be wrong about that, I do know. For an introvert like me, though, I can’t imagine an “extrovert,” “get it taken care of in the world” message coming off any more loudly and clearly, O, Thou Soldier/Civilian, than in On Combat.

Please understand: clearly Colonel Grossman is a passionate, dedicated man, committed to inspiring warriors everywhere to live well, love well, defend well, and–only when necessary, but then without hesitation–kill well. He radiates his desire to encourage warriors to acknowledge, grieve, and move on, primarily by encouraging them to prepare themselves ahead to face the horrors that they are built to take on, built to endure, built to overcome, whether in life or in death. He stresses the power of debriefing methods, punctuated by genuine, but appropriately restrained emotion, for warrior and non-warrior alike, as well as the power of understanding the physiology of stress, both in order to subjugate it as much as possible, as well as to tame it, primarily through interpersonal support and deep breathing methods (in his words, “tactical breathing”).

And, God bless him: the man does his utmost best to try to avoid coming right out and saying that if only a warrior would get things off his/her chest soon enough, with adequate tears, but not unnecessary ones, using tactical breathing repeatedly whenever more virulent emotion threatens to erupt from the “puppy brain,” then (well, of course, there are some who might still develop PTSD, but . . .) most warriors will escape that most horrendous–but, thankfully, most avoidable–of outcomes.

In fact, if I do say: the man skirts, skirts, skirts the very edge of the assertion that indeed it is mental health professionals (such as I?) and, shades of Spiro and Sarah P, the media who do our best to convince warriors who would otherwise be able to transcend the pains of their past instead to stay stuck in the (now, did he use the word “whiney”? shoot, I can’t remember, but I do remember something about “pity party”) morass of never-ending, self-imposed and/or professionally-endorsed misery.

He must know some of my colleagues at the VA, remember them? The ones who claimed that in my need to feel important I was helping to create a generation of disabled veterans who would have otherwise been free to live a life of purpose and action?

Thus, this introvert heard a message loud and clear from the good colonel: either follow the extrovert way, put the emotions “out there” and corral them with a “leash” (i.e., tactical breathing) on that “puppy brain,” thus returning the sheep dog back to his rightful place as the guardian of the flock–or just devolve into a sheep yourself, no different from the rest of the poor, huddled masses, and pray like the dickens that someone in this world actually rises to the occasion that is his or hers to rise to, lest you and those you love end up on the receiving end of some thug’s bullet smack dab in the middle of your forehead and/or blood-pump.

Hmm, this is beginning to sound familiar. Evidence-based treatments, anyone? “Paging General McCaffrey, STAT, paging General McCaffrey, STAT . . .”

So, on Lake Huron, what is this introvert’s manifesto?

To My Fellow Introverts, Especially Those of You Who Have, At One Point, Suffered from Combat Trauma:

1. Extroverts will never understand us, and we will never understand them–but in America and much of the Western world, they win (as if this were a surprise to you).

I absolutely have no doubt whatsoever that Colonel Grossman is a very good man whom I would find to be charming, forthright, and deeply desirous of the best for me. I can imagine liking him very much, although I can’t even begin to imagine leaning on him, something which I can only imagine to be one of the more masochistic tasks I could set out for myself.

I can also easily imagine his being deeply disappointed in my profound misunderstanding of his message, although probably his not being surprised as well, given how there indeed are people in this world who cannot seem to take advantage of the most basic tools available to them to promote their own healing and not to prolong their own unnecessary pain.

But remember, my fellow introverts, we cannot understand our extrovert sisters and brothers as well, even though, admittedly, we cannot escape being enveloped by their worldview 24/7/52. Take, for example, deep breathing or, for Colonel Grossman, tactical breathing. We, of course, understand how such methods can indeed decrease autonomic (automatic) body functioning, allow us to calm tension and focus more clearly. We too are thankful for those very outcomes.

However, it does appear to me, fellow introverts, that extroverts find such methods to be healing in a profound, totalizing sense that we cannot even begin to fathom. For years, for example, I have known that many fellow mental health professionals, especially clinical psychologists, have found something really, really important in deep breathing exercises. Although to us introverts such techniques seem genuinely useful (but, truth be told, often a bit beside the point), to our extrovert brothers and sisters, the ones who control the discourse of human behavior, these techniques apparently mean something, and I mean, something big. They can’t stop talking about them, have you noticed?

This is not going to change, my friends. They run the show. We are the odd ones. We may be nice odd ones, but we’re odd nonetheless. Therefore,

2. It is crucial beyond crucial that we remind each other that we are not crazy, no matter what we experience radiating from them in tone and in body language. Given the primacy of extroversion in America–and certainly in the military and most modern mental health professions–we will usually experience our extrovert sisters and brothers as, at best, sad and concerned for us–or, far more often, as dismissive of and irritable with us.

We must continually remind each other, though, that we can both feel better and still feel a wound whose depths cannot be breathed away or trained away. The extroverts will never fathom this. Never, never, never. They are not being mean. They simply cannot do it–and given that theirs is the “baseline” state, they do not even have to try to empathize with us if they are not so inclined. Never, never forget (as if you could): just as victors write history, extroverts write normalcy. Our pointing this out will not enlighten them; it will only annoy them (again, as if you didn’t know that already).

3. Most extroverts are decent people who not only want the best for us, but who truly believe that their best is our best. In other words, if we would just . . .

Grossman, for example, strongly stresses the importance of “delinking” memory and emotion after a trauma, primarily through the strategies of extended, well-organized, well-led debriefings, replete with, as noted above, appropriate, yet genuine amounts of emotional expression, all coupled with tactical breathing. He assures us all that this is the high road for avoiding PTSD for future generations, and he has lots and lots of data, letters, interviews, endorsements by warriors famous and not-so to support his point . . .

. . .all, I suspect, from extroverts, but, hey, I could be wrong.

So here we are again, my fellow introverts, with our usual dilemma: we too agree with the good colonel that the delinking of certain memories from certain painful emotions is a vital, desirable task for the traumatized person to pursue. Yet for us, at our core we are memory and emotion. We actually like that about us. We don’t like to suffer, yet at the same time, we feel most human when we are aware, at least in attenuated form, of the experiences that have the formed us, that still call to us from our bodies. We need the following affirmation from somebody, for God’s sake: linked memories and emotions matter, and matter big time. Not linked memories and overly painful emotions. But linked memories and emotions period.

Folks, we’re going to have to affirm ourselves. At one level, we’ve all known that all along. At another level, though, I know, many of us have hoped against hope that “somebody” important to us would affirm that in us. If that “someone” is a fellow introvert, then we must follow through with that affirmation for each other, lest we mistake each other for the sheep that we are categorized as being.

If that “someone” is an extrovert, though, it’s time to delink that thought from that hope and, in the most extrovert of advice, move on.

4. Because extroverts define normalcy both in the military and in the vast majority of mental health practice that “matters,” i.e., gets touted, funded and/or reimbursed, we need to practice doing what military men and women (as well as bureaucrats) have done for centuries: smile at those who have the power that we don’t have, thank them endlessly for their insights–and then go off and take care of ourselves.

And here’s the manifesto part:

5. For some of us, that will involve both affirming the hurt of our own fellow introverts, while also entering into a recurring combat ( of sorts) with our well-meaning, extrovert friends and colleagues so that at least a few of them might–and I mean, might–understand that some sheep dogs will protect their own even against other sheep dogs who are convinced beyond convinced that they have come to save us sheep and pseudo-sheepdogs from the wolves, instead of, as we see it, allowing such “real” sheepdogs as they deem themselves to be to shame us introverts into submission to the rightful order of “real, un-romanticized” humanity.

My fellow introverts: it is up to us. We have to help each other understand that even after all the debriefings, all the exposure therapy, the cognitive reprocessing, the EMDR, some of us so-called sheep–even those of us sheep who were once willing to die alongside our extrovert brothers and sisters–some of us may need over and over again to, in the psychoanalyst Robert Stolorow’s words, “reach out to our brothers in the darkness,” even long after we have found sufficient light to allow us to move forward. That’s a confluence that we feel so deeply–and one that our extrovert siblings will never, never, never fathom.

So let’s stop asking them to. For our sakes.

Oh, and by the way: if you ever need a fellow introvert who’s come to enjoy his occasional engagements with our extroverted siblings who always win in the end, yet who may periodically benefit from a bit of re-education on what it can sometimes mean to be “one of those quiet, thinking types”?

Give me a holler.

The Long Haul

June 14, 2012 By Paving the Road Back in Living Life, Professional Relationships Tags: American Psychoanalytic Association, combat, long-term therapy, longform, Posttraumatic stress disorder, psychoanalysis, PTSD, veteran, WPLongform Leave a comment

Hang in here with me: I will pull all the following together. I promise.

Part One

A back-forth day trip up I-65 to Chicago yesterday. The interesting aspect of it is–why.

The following is a semi-insiders’ joke that will make sense only to a). certain mental health professionals who b). have read the Harry Potter series.

So, you ask: where was I yesterday?

Dining with Death Eaters at Malfoy Mansion, my arm burning the whole time.

In other words, I was at the Palmer House in Chicago at . . . the annual convention of the American Psychoanalytic Association.

That was the punch line.

I will not bore you, dear reader, with the ins and outs of the joke. Just suffice it to say: some of you may still think that psychoanalysis is synonymous with psychiatry, psychology, and other mental health disciplines.

How charming of you.

Instead, think of it this way: at the mere mention of the word psychoanalysis these days, what, eighty per cent, ninety per cent of mental health professionals flop around on the floor either in:

a. paroxysms of hysterical laughter that anyone worthy of having an IQ would ever take that nonsense seriously any more, or

b. paroxysms of righteous indignation that such oppressive pseudoscience is still allowed to exist on the planet any more.

Take your pick.

I will also not bore you with the squabbles of my profession. Let me say only this: after my experiences at the meeting, I thought of a patient.

Part Two

I have known him for quite a few months. He travels a ways to get to our hospital. He is a combat veteran from the current conflict. He once struggled with opiate dependence. He is now doing quite well on Suboxone.

He also once struggled with severe PTSD symptoms, especially marked, reactive emotional lability. He participated actively in the PTSD-treatment programs at his local VA facility. He worked with an individual therapist using current, evidence-based treatment methods, and he has long been part of an ongoing support group run by a mental health professional.

He has found his treatment to be helpful. He feels better about himself and his world.

Last week, however, after I asked him how he was doing, he reported that he’d had a difficult several weeks with a recurrence of some symptoms, although thankfully in no way to the extent he had previously endured them. I knew that he’d taken a break from his group at one point, but he told me he was now going back. He had also told me that he’d wished that he could have had access more regularly to individual sessions with a therapist.

That, however, has not been possible in his case, as he has completed the PTSD treatment course offered at his facility. Certainly no one was saying that he could not come back to speak with anyone, but the veteran did report that, at least in his view, the treaters implied that there was little else they could do for him unless he had a very specific problem to be addressed and solved in a focused manner.

Understand, my patient was not complaining. That’s not his M.O. Yet he also made it clear that it would have been nice to have had someone he could have visited briefly without having to enter the door with a focused, well-articulated answer to the question “So, why are you here?” so that clearly-defined short-term goals could then be formulated. Granted, he didn’t put it quite like that–but he did wish he could have “just been able to talk to someone and leave it at that.”

We live in challenging times, at DoD, at the VA, in the community, in the nation. A lot of men and women are suffering, and there are not enough qualified individuals available in many parts of the country to meet even the most pressing, short-term emotional needs of combat veterans. If you’ve had any contact with the news, no matter the time of day, over the past few weeks, you are more than well-aware of the suicide epidemic being faced by both active military and by veterans. We’ve got problems right now.

So why this talk of long-haul?

Part Three

You should understand: many, many modern mental health professionals feel quite strongly that long-term, regular contact with patients disempowers them, promotes an unhealthy dependency, prevents patients from growing up and facing the need–and the privilege–of finding their own solutions to their problems. Mutual aid in self-help groups? That’s OK, for that is mutual empowerment. But professionals must stay focused, focused, focused on the well-defined and the self-limited.

In fact, everyone seems to have his or her own favorite Woody Allen-esque story to tell about the patient in therapy for thirty years, only finally to meet a therapist who speaks the clear truth of the well-defined task and thus who finally helps usher in for the patient the relief that the patient had never thought could be available for the claiming. I sometimes find myself wondering whether some therapist training programs require their graduates to have at least three such stories to be trotted out at will in order for the trainee to get his or her sheepskin.

Weirdest thing, though: my eldest just finished her freshman year of college. She had a great year on her own, and believe you me, girlfriend was empowered! So, you know, I had never thought that her mother’s and my willingness to provide her as many opportunities as she would desire to come speak to us merely from her heart was somehow disempowering her.

Her mother and I have good lives. We have established ourselves well, and we do not need her to fill holes in our psyches. We enjoy her successes without any minimal-contact requirements on her part. More and more we are speaking with her as equals, sharing of our lives with the sole goal of her choosing what of our thoughts she wishes to consider, what of our alternatives she wishes to take. Our door is always open to her whenever she wishes to enter it. She needn’t appear weak to speak with us, nor does she need to hide her competence and her successes. Neither does she have to hide her weaknesses from us, just as we do not need to claim that we are without weaknesses of our own.

In other words, we’re in it for the long haul, and we’re in it for the long haul for her. She can come to us confident. She can come to us confused. She can come to us invigorated. She can come to us exhausted. She can not come to us at all if/when she does not wish.

Whatever it is, we’ll make it work.

I don’t know, maybe I’m a naive dreamer, but . . . isn’t that precisely where a good therapist would hope to end up with a patient, in a relationship that can be open over time, in which the challenges of life can be discussed safely, even if just periodically, even if there is not a particular behavioral objective to achieve? That disempowers the patient how?

And just as my wife and I don’t demand that our daughter justify her desire to connect with us both as a peer and as one-who-needs, I need to require my patient to justify his or her desire to connect with me why?

And just as my wife and/or I can at times loom larger than life in our daughter’s experience, while at other times seem nothing more than fellow travelers with her on this earth, I harm my patient when he or she feels the same about me because . . .?

That’s where the Death Eaters come in.

Part Four

People freak out these days when they hear the word psychoanalysis, imagining the worried, upper-class victim of ennui, carrying out years of whining and complaining on a leather couch with some old dude fast asleep in the chair behind.

But that’s not what I think of when I hear the word.

When I hear the word I think of a complicated set of ideas, always controversial, yet also always embedded in a basic notion that connections over time matter, that the words we use are important and telling in and of themselves, that we cannot hide from our aggressiveness, while we also cannot hide from our capacity to love.

I think of two presentations I attended yesterday, one honoring Dr. Elvin Semrad, a psychiatrist and psychoanalyst from Boston in the mid-twentieth century who taught my teachers that our jobs as therapists is to help our patients “acknowledge, bear, and put their feelings into perspective,” an ideal that my teachers taught me, an ideal that I try to live daily with the men and women who bravely come into my office.

Or I think of a presentation by Dr. Russell B. Carr, a Navy psychiatrist who has deployed to the Middle East and who struggled to find a way to help the men and women there cope with the demons that were haunting even in the combat theater, a medical officer who turned to a psychoanalytic theory called intersubjectivity that allowed him to understand what it means to bear trauma in one’s body, allowed him to understand what it means for he himself to bear his own wounds of explosions and death, permitted him to feel that by simply taking seriously the development of his relationships with a particular a soldier or a Marine, he was able to connect in a deep way with these men and women, not after ten-some odd years of psychoanalysis, but after only a few meetings, offered genuinely in the spirit of one person trying to aid another and thus, in a way, aid himself.

I think of how something can happen between two people who are taking one person’s pain as seriously as both can: that the very fact of trying to make sense and “acknowledge, bear, and put in perspective together,” whether that time is short or long, can make the difference that will interject the human and the humane into the manualized and the efficient.

The End?

I don’t know what to say: I’m hearing veterans over and over and over again, in my office, in the blogosphere, on social media, asking the same question: “Are you, mental health professional, going to stick with me for as long as it takes? If life becomes more complex than your treatment manual can bear, are you going to be there, just to remind me that someone outside my immediate circle can actually care about whether I not only live or breathe, but whether I live or breathe well?

“Does anyone understand that what I’m struggling to do after I’ve seen all this death, after, perhaps, I’ve helped cause all this death, is simply try to connect to life again, try to decide to live even when I doubt the wisdom of that? Does anyone understand that while I am glad that some, maybe many of my brothers and sisters find the way to “move on,” I might not be able to so easily? Do I have to justify my pain to justify your presence, therapist?

“Didn’t I already do that back in that godforsaken desert?”

I wish I could say that many are ready to hear those questions and answer “present, accounted for, and in for the duration.”

I’m not so sure. I’m sorry, men and women who have been willing to give so much because you believe in honor and duty and faithfulness. I’m so sorry. I’m just not so sure.

A Love Remembered

June 10, 2012 By Paving the Road Back in Living Life, Personality and Identity, Professional Relationships Tags: combat, First Love, longform, Marriage, Posttraumatic stress disorder, PTSD, Relationship counseling, veteran, WPLongform Leave a comment

This post will not be an easy one. And it’ll be a long one. I’ve got too much to get out of me.

For starters, I am not a couples therapist. Let’s get that on the table right off the bat.

Next, I was (I’ll confess it) well-trained as a youngster shrink, so it’s like: I know what I could be doing if only I were to have the fortitude to do it. For those in the know, I have the basics down for the Milan School of family therapy (everything sounds better in Italian, and it was all the rage, baby, all the rage back in the eighties) and for Bowen systems theory (one of the old warhorses of the industry). I’ve done my Generation Whatever part: I’ve read Harville Hendrix’ Getting the Love You Want, which is holy writ in my neck of the words (and, yes, for good reason).

On the bright side, I have recently (through the VA) been trained in a couples communication method called PAIRS (which stands for Practical Application of Intimate Relations Skills). It is, without a doubt, the most sane method of skills training for couples that I have ever found, hands down. It is not a couples therapy method. Instead, it is a highly-structured way of communication-skills building that is quite dramatic in its impact. Through the Chaplaincy departments of many VA’s nationwide, it is increasingly becoming a must-do program for couples struggling to find their way back from deployment(s). I can’t recommend it highly enough.

Still, I ain’t the guy for marriage counseling.

For starters (second round), I’m not good at dealing with more than two psyches in a room. Because of the way I’m made, I absorb too much of a couple’s conflicting emotional lives at the same time, and my talent that is usually my strong point–an ability to experience quickly the nuances of a person’s interpersonal style–becomes my absolute point of weakness. Honestly, I can listen to a combat veteran go on indefinitely about the horrors of war, but to have a couple bring before me the nitty-gritty of the horrors of their daily life–and then live it out right there in front of me, in stunning, surround-sound technicolor, no less?

I’m toast, period.

Even when I have a technique at hand which can bypass that immediate emotional turmoil (e.g., the PAIRS method), I still find myself afterwards, in my own head and soul, embroiled in the complexities of a couple’s relationship. Perhaps because I’m a man, I do find it relatively easy to see the perspective of even the greatest jerk of a male partner. But sorry, guys: even with that said, I can more than easily understand why the female partner is often two micrometers shy of kicking your sorry-butt out into the street, partner, and don’t even bother looking back with that hang-dog look of yours! But then I can understand why the man might be so sick of the “you never even try to understand my feelings,” but then the woman might be so sick of the “I just need some time to myself,” but then . . . you’ve got the picture.

But you know why I really don’t like working with couples?

Frequently, all too frequently, it can just be so painful, so God-awful, soul-wrenching painful.

The couples who already started out on shaky ground? Not easy, but tolerable. You made a mistake. You move on.

But the couples who once truly loved each other, who truly, truly handed over to each other their hearts, their souls in a way that only the young can, those first “real loves” of high school or college? To watch such a couple truly, truly have to face each other, hackles down, guns holstered, and ask each other truly, truly: can we go back there after all this? Or are we going to have to release each other into the future, hand back to its original owner the heart that we had once treasured so deeply, that we now know, if we give it back, we will almost certainly never have again, no matter how many children we might have together, no matter how many years it’s been, no matter where the present might take us? To remember, down to our deepest beings, what once had been, what had not been fake, no matter how much we wish it might have been so as to make our current lives that much easier, to grieve, to mourn in front of each other a death of something we had once both stitched into our hearts–stitched, what are we saying, more liked wove lovingly into the warp and woof of the thing: the death of our relationship, our future? The death of the us of us? To take back strand after strand every thread of that weaving, destroy a pattern that once truly, truly was there, but which can no longer ever be again and then to say, with tears that we truly, truly don’t want to shed: goodbye?

Just shoot me now.

And, oh, BTW: for those of you who might have forgotten, I signed up for a job in which daily I meet one-half of couples who often had stood before each other with precisely those heartfelt loves of loves, knowing full well that the one before me (usually the man) might never return for Chapter Two of the saga, who practically surgically implanted their hearts into the soul of the other, with the deepest of truly of the deepest of trulies.

And then the terror of what they had done hit them, him in a godforsaken wasteland, her in a might-as-well-be-godforsaken apartment, pregnant, or with one baby, two, each wondering–like every other couple who has ever lived on the planet since, what, the Neolithic Age?–what the heck did I do?

And given that many had never known a parent, a loved one who had ever been able to answer that question in his or her own life, and thus had never known a single soul who, yes, knew that these things can be gotten through, just call me and we’ll figure it out, kid, don’t sweat it–so yes, given all that: bad things then happen. Mad escapes into spicy-hot relationships that promised–what?–anything but the truth of the truth? Silences that bring meanings heretofore never fathomed by humankind to that simple word cold? High dramas of high dramas that put to shame even the most Daytime Emmy-winning performances of the greats of the great soaps–or even better, if you ever got past high-school Spanish, of one of those absolutely insane Argentine or Mexican telenovelas?

Oh, yes, and even if all that can be avoided, there’s this slight problem of . . . the return of a different man than the one who had left.

And so it begins, lights, camera, action!: “You don’t understand my feelings!” “You don’t know what I went through!” “You don’t know what I went through!” “Well, at least she understands me!” “Well, at least he understands me!”

And then the truth truly, truly hits them: when one has truly, truly loved, truly, truly been woven into the soul of another, one does not truly, truly let go of that like some washcloth that’s gotten a little threadbare. So . . .

Then let’s see if we can truly, truly make each other so truly, truly miserable that, truly, truly, we’ll not have to deal with what Life has brought us, what we have done, what we have not done, and . . . and truly . . .truly, truly . . .

Oh, God.

It had been heroin that had finally gotten him. His wife had told him that she’d had it–although, as I read between the lines, it was most likely that she’d had some, what, issues of her own to deal with that, what, had not been? Still, whatever, he was willing to admit it: he’s an addict, through and through, weak, a loser, unable to control himself, just loving the high, living for it, heck with anything else in the world–you only live once, right? She should have left him, yes, that he knew.

Oh, small detail for later: she isn’t his first wife.

He’d tried Suboxone on the street once. It had helped. But he couldn’t afford the price. Then he heard that the VA was making it available to vets.

Enter . . . me.

OK . . . well, now that he’d just divulged that torrid tale of libertine squalor and self-degradation, I did have to, well, ask one question–well, I mean, I didn’t have to, I guess, for he seemed quite happy to leave it at that, but, well, you know me, inquisitive minds just have to know, especially when The Enquirer isn’t there to help me out . . .

“What was your MOS?”

Silence. All appropriately guilt-ridden confessions screech to a halt. He looks down.

Infantry, such-and-such company.

“Where?”

He names off places. As I recall, no four-star accommodations for infantrymen in a single one of them. Pretty good medical facilities, though, from what I’ve heard.

Further silence. Head still down.

“Had you used in high school?”

Throat cleared. Head still–yeah, you got it.

“Uh, no, sir.” Pause. “I was, sort of, you know, a big fish in a small pond.” Eye contact made. “I mean, don’t get me wrong: I wasn’t an angel, but .. .” Head back down. “No. I didn’t.”

OK, I think, might as well go for it.

“Your first wife, she was your high-school sweetheart?”

Still looking down, he begins to rub his forehead.

“Yes,” he whispers.

“How soon before deployment did you get married?”

Still rubbing.

“Not too long. We had a really nice wedding, though. Then we both got scared, knowing I was heading off, so, well, we thought, should we? And then . . .”

“And then what?”

Throat cleared second time, slight chair fidget, not dramatic, head still down.

“The night before I ship out, I tell her, go ahead, might as well check a test, and . . . sure enough, there it was, positive.”

“And you left the next day.”

“Yes.”

“So what happened then?”

“They let me come back a week before her due date and stay until a week after, but . . . she was late.”

Silence.

“Meaning . . .?”

“Meaning my daughter was born the day after I left. They wouldn’t let me stay any longer. She just couldn’t understand that. She thought I didn’t try hard enough. She . . . she never forgave me.”

“How old were you?”

He looks up. The glisten is in the corner of his eye.

“Nineteen.”

Silence.

“So what happened then?”

He looks back down. “It all went to s***. I came back. We had another daughter. I had to go back and then I came back. We’d split up, and then we’d get back together, split up and then back together. We couldn’t stand to be with each other, and we couldn’t stand to be apart, and . . .”

“And what?”

“And I was awful, I mean really awful. I tried to hurt her. She tried to hurt me. Back and forth. God, I was awful, awful. She should hate me. I hate me.”

“So?”

“So eventually we divorced, and I met my current wife, and everything was going to be much better, and then it wasn’t, and . . .”

“And what?”

Throat cleared, round three.

“My first wife and I just couldn’t stop being awful to each other. We live in a small town, see? Everybody knows everything about everybody. We all went to school together. I mean, people would stop me in the grocery store and ask me why I was being so awful to my first wife. And I just wanted to tell them my side of the story, but they didn’t want to hear if if they didn’t believe me already, so I’d just say ‘F*** ‘em,’ and I’d go on, but then I’d have to get back at her, and then she’d get back at me, and she’d follow me around town when I had the kids, and then I’d text her to tell her to go f*** herself, and then–”

“This was all while you’re already married to your second wife?”

“Oh, yeah. And then my second wife and I began having problems, and–”

“Has your first wife remarried?”

Pause. He’s looking right at me now.

“She’s marrying this guy this summer. Or that what she says, at least. She is.”

“So, is that making things calm down a bit?”

Now the boy g0t riled.

“Are you sh**ing me? It’s just gotten worse. I mean, you’ve got to believe me: I know, I brought all this on myself, I’m not innocent, but I have been trying not to be so mean and provocative, really, but then I hear her voice, and I get . . . I don’t know, it’s like I go crazy, and I say things I don’t even really mean, just to hurt her, and then she says things right back to me, and it hurts so much, and I just–”

“You still love her, don’t you?”

All right, brief interlude: that was big-time risk to say that. I knew it. Colleagues, feel free to label it a mistake, an acting-out, whatever. But you see, I couldn’t help but notice this pattern: as things got worse between one of them and his or her new love, the two of them got along better. As the new couple got along better, the old couple got along worse. You don’t need a college degree to figure this one out.

That stopped him cold. I knew it would. That’s why I did it. It took him about thirty seconds or so to compose himself.

“Yes,” he finally whispered, head back. And believe me: it was a whisper.

“And she still loves you, doesn’t she?”

He shakes his head, clearly not wanting to say what he’s about to say.

“She’s hinted at that more than once, yes.”

Now I try to compose myself, not because I’m sad, but because I know what I’m about to say.

“You’re not going to move on in your life and in love until you deal with this. And even if she refuses to deal with it, you’re still going to have to. You’ve got to believe me: stuff like this can last a lifetime. I’ve known couples who’ve remarried, started new families, yet have gone to their graves still holding on to that first one, screaming at the top of their lungs that they’re long over that jerk, that witch, and yet going off like a Roman candle every time the other’s name is mentioned. Ten, twenty, thirty, even forty years–it don’t matter.”

Still looking down, he’s fidgeting more, rubbing his hands together.

“Did you ever talk with her about what happened over there?’ I ask.

Now he starts rubbing his forehead again.

” No, not reall- . . .no. I didn’t know what to say. I . . . I’ve talked a little bit to my current wife, but not even that much with her, I . . . I just don’t know what to say. I don’t even know what to say to myself.”

“You do know, don’t you, that the heroin’s not just about having a good time?”

Still looking down, he nods his head.

“As long as I’m working,” he replies, “I don’t have to think about The War. But the drugs were getting too bad. I was going to lose my job if I didn’t stop. And it’s a really good job.”

“And your current marriage?”

He looks away from me, toward some far-off spot.

“I think that’s pretty much over.”

I couldn’t help but notice–although I at least finally had the decency to keep it to myself–that he was not as emotionally, shall we say, vigorous saying that as he’d been describing another relationship that was, allegedly, long, long “pretty much over.”

“There’s nothing like a first love, you know,” I finally say to him.

He shakes his head, looks back down, finally smiling a bit.

“She was always so strong-willed. That was what I liked about her.”

The pain in his gut was about ready to slice open mine.

“You’re going to have to stop this nonsense, you know,” I finally say. “And you can’t do it with any thought of getting her back. You and I both know that you’re going to be hoping to do just that, but that’ll get you nowhere, and you’ve got to face that, even though you’re going to be feeling otherwise. You’ve got to stop your part even if she never does. Even if she tells you that you’re a fool for thinking she’d ever want you back for even an instant. Even if she stabs you repeatedly in your heart, your soul, your mind. Even if she makes you look like the biggest wimp in the whole town. Don’t matter. You’ve got to stop. You’ve got to let what happens happen. And then you’ve got to deal with it. If you guys do get back together, it cannot be like before. You’ve got to face what happened to you. She’s got to face what happened to you. You can’t run any more. She can’t run any more. You’ve both suffered too much for too long. You both know that this hell each of you has been experiencing these past umpteen years has gotten both of you exactly nowhere. If you do decide to get back together, you’re still going to have to go through hell, but now in a way that’ll actually get the two of you somewhere. And if she moves on, whether she weeps or not, you’re going to have to. This is a death. You’re going to have to stand next to the grave of that first love, even if all by yourself, and you’re going to have to put her heart in that grave with that first love. And even if she refuses to release your heart back to you, you’re going to have to move forward without that part of your heart. And it’ll hurt like hell. And you’ll have no clue how you’ll do it. And it’ll just be like being back in the military: you’re going to have to do it anyway. But you don’t have to be alone. You don’t need to be by yourself any more. I can’t save you from this. But as long as we’re both here? I’m here.”

A few moments of silence. He takes a couple deep breaths.

“I think I’m going to have to go, I . . . Can I see you next week?”

“Of course..” Now I’m whispering.

He looks up at me, eyes far more than glistening.

“OK. I’ll be all right. I just . . . I just need to go.”

“OK.”

We shake hands as he stands up.

“Thank you,” he says quietly, and then he leaves.

Shoot me now. Just shoot me now.

Combat Vet Seeking Outlet, References Available Upon Request

June 9, 2012 By Paving the Road Back in Culture at War, Respect, Honor, Duty Tags: combat, Iraq War, longform, military, Posttraumatic stress disorder, Posttraumatic Stress Injury, PTSD, veteran, WPLongform 4 Comments

Yesterday I had the opportunity to speak again with a combat vet I have come to know, care about, and respect. He was heavily involved in the first wave of Operation Iraqi Freedom, and he was profoundly affected by it, not only by the horrors he witnessed, but also by some of the ways of the military, where, unlike Don Corleone in The Godfather, it’s always personal and just business. In our discussion, he reminded me of two “truths” I often need to remind combat vets of, ones that I frequently discuss in person and periodically discuss in the blog.

First, this man needed to be reminded how strong he was and is. As a combat veteran struggling with Posttraumatic Stress Injury, he, like most of his fellow veterans, often finds himself feeling confused, unsure of himself, and utterly weak. He’s a guy, and he’s a miltary guy, i.e., a traditional guy with those traditional male hang-ups like, you know, having it all under control 24/7, never sweating, always sporting a rakish smile, with a devil-may-care wink, the usual. Therefore if any of the above qualities is not present in spades at all times, he’s a loser, plain and simple.

What this combat veteran often fails to recall is that the same bravery, the same chutzpah, the same determination to get the job done, no matter, still resides in him now, just as much as it did when he wore a uniform, barreling down those Iraqi roads, wanting to do what’s right, although never quite sure what “right” was at any given moment.

Combat veterans need to understand something: not everybody makes it through traumatic experiences. I’m not talking suicide here, although that risk of course remains high (see the DoD’s recently published data). Some people did not enter their trauma with anything close to the inner drive, the focus that combat veterans absolutely must have if they are to hope to stay alive. Consequently, such individuals leave their trauma almost decimated beyond recognition, barely functioning, if at all, sometimes psychotic, sometimes so dissociative they cannot even begin to experience anything that for a moment could be labeled coherence.

I fully understand that many combat veterans feel that way, but feeling that way does not mean that they are that way. Yes, most feel that their self was shattered somewhere in the middle of the desert, in ungodly heat, surrounded by the epitome of ungodliness. Yes, some even imagine that the man or woman who had had that drive, that spirit perished somewhere outside of Tikrit or Kandahar.

But that strength, that drive is still there, and in the deepest recesses of their heart, they do still feel it. They just fear that it will get them nowhere, that it’s a piece of their shattered soul that they’d have best left languishing in a Middle Eastern alley somewhere.

That’s where we, as civilians, need to come in.

For the second matter the combat veteran and I discussed was what happens when that strength, that drive does not have adequate outlet, when it demands to be experienced even if the veteran is scrambling like the dickens to tell himself or herself that it is no longer there. The physics of the matter is quite simple, really: if strength, drive is thwarted in its attempt to find a place in the world out there, it will simply double bac k on itself and search for a place in the world in here, inside the veteran himself or herself. The thing about strength, about drive, you see? It zooms forward. It attacks. In the real world, that saves lives and, yes, destroys them. In the inner world, however? It only destroys. One life. The veteran’s.

I’ll say it straight out: I am appalled at how we civilians are doing essentially nada to find honor-worthy, respect-worthy outlets for the energies and hopes of our combat veterans. As I’ve more than ranted in the past, some of us even seem to have the crazy notion in our noggins that these young men and women who were so driven, who were so willing to risk their lives to do what they thought was right (whether you, reader, agree that it was right or not)–they actually want to collect disability just to coast through the remaining, what, sixty or so years of their lives? Yes, record numbers are seeking disability from the VA. But don’t you ever for a moment believe that more than one per cent of them are seeking a handout. (And if you believe the number’s higher, you need to reconsider working with combat veterans, for that belief says more about your world view than it does about combat veterans’ reality, end of story.)

Depression is a real physical illness, one with real physical consequences and, thankfully, real possibilities for physical relief through both psychological and pharmacologic methods. However, we cannot expect combat veterans to sit around happy as clams when every day they are feeling that the strength, the drive that had once so defined them, had once made them feel so proud to be alive, is now nothing more than a a recipe for self-immolation, a cruel hoax perpetrated by Nature and the civilian society that is so unwilling to accept that Nature has not given all its human subjects the innate ability to sit in front of a computer all day and type memos.

I often want to ask my civilian colleagues, friends: do you realize that these young men and women, who volunteered their lives in a time of conflict, actually weren’t looking for a good time to shoot me some biiiiig guns and drive around in biiiiiig, hot-shot armored cars? Do you realize that they were looking for something, someone to give them meaning in their lives? Do you realize that they did recognize that not all Muslims are enemy combatants, that they saw men just trying to eke out a living, women who were afraid to speak their hearts needs, let alone their greatest fears, children who just wanted to get a few extra Hershey bars for my two brothers and my sister? Do you think that now that they’re back home in this wonderful place we call Western society, they’re hoping to get a round of golf in every morning before they catch the latest edition of The View? (All right, Sean Hannity, I know, I know . . .)

And we wonder why they’re depressed and can’t think of a good reason to get out of bed in the morning, especially since they’ve already had the pleasure of driving down the streets of Fallujah over and over again in their sweet dreams of the night?

These men and women don’t only need jobs. They need a way–a socially-recognized way–of experiencing their intensity and drive and energy as a source of pride, not as a source for shame-filled apologies. Naturally, I have no thoughts absolutely whatsoever that most of the West is going to take this call anywhere as seriously as they should. But I certainly don’t have to make my civilian colleagues and friends feel good about that.

I have no plans to.

I’ll be more than glad to supply a reference. You know how to get in touch with me.

The Mockingjay, Revisited

June 9, 2012 By Paving the Road Back in Culture at War, Respect, Honor, Duty Tags: Katniss Everdeen, Mockingjay, Peeta Mellark, Posttraumatic stress disorder, PTSD, Suzanne Collins, veteran Leave a comment

Recently I had a very thoughtful–and thought-provoking–comment to my page The End Games, the page in which I shared my thoughts about the role of combat trauma in the Hunger Games trilogy by Suzanne Collins. I felt the comment deserved a more prominent place on the blog, and I wanted to spend some time in response. Kirstin, the author of the comment, caused me to think again of the role of honor, shame, and love in combat–and in its aftermath. I suspect that she and I might end up in different positions about the relationship between the combat veteran and the Nation-State, but I do believe that each of us sees the message of the trilogy similarly: that no matter how painful life may become, meaning–and hope–can one day be made. Be aware, spoilers abound, but for those who have finished the books, or who have read The End Games page notwithstanding, I hope you enjoy Kirstin’s and my conversation in Peace and War, War and Peace, located in the Thoughts section above.

Just a Chasm: Afterword

June 3, 2012 By Paving the Road Back in Culture at War, Personality and Identity, Professional Relationships, Respect, Honor, Duty Tags: combat, Department of Veterans Affairs, Evidence-based practice, Max Harris, Posttraumatic stress disorder, PTSD, veteran 3 Comments

As you can see from the original Just a Chasm post, I have received very thoughtful comments from two men who have made similar thoughtful comments to past posts, Johann Ziska and Max Harris, the author of the blog I highly recommend, Every Day Is a New Day. I would like to address them directly in this post, rather simply respond to the original one.

Dear Johann and Max,

Thank you both for your continued support of my blog, as well as for your continued challenges to my own thinking and writing. Here are a few of my thoughts from your most recent comments:

First, let me assure you both that the post was both quite serious and quite ironic. I do indeed wonder about my interactions with combat veterans–but only because my experience of them and their “therapies” is so profoundly different from the experience I glean from the writings of my colleagues, which does include the official publications of the Department of Veterans Affairs and the Department of Defense. As I said in the original post of this series, Is It Something I Said, I am always under the impression that I should be quite excited to be part of a new generation of therapists, now providing therapies that really have data behind them and that really work.

Now, I almost ended that last sentence with something like “to reduce in a meaningful way debilitating symptoms of Posttraumatic Stress Injury.” But that is sort of my point: in spite of my self-deprecation (which is both true and not true) I at the same time do not consider myself either a fool or a bad therapist. If the rhetorical tone of those writings were such that I could easily add that above addendum, then

a. we wouldn’t be having this discussion, for indeed I am quite supportive of all reduction of painful symptoms, no matter what the method, and

b. I would have more hope that there is somewhere in the bowels of the VA and DoD a realistic, broadly-sketched plan to address the periodic need for services–and perhaps, periodically, quite intense services–over the coming twenty to forty years for combat veterans who have completed the treatment courses that we are so proud to offer.

Unfortunately, instead, when I read writings about the new evidence-based therapies and the official pronouncements about their effectiveness, I often cannot decide whether I want to 1). roll my eyes so far into my head, the latter hurts, or 2). spit contemptuously onto the ground, in a very public fashion, or 3). both.

I do not consider myself an egregious ideologue, no matter what others might conclude (ideologue without the adjective, all right, but not an egregious one). As I said, though, I am also no fool, and I am quite good at picking up on a writing’s tone, whether that tone be subtle or anything-but.

Consequently I’ll go to my grave, whether personal or professional (who knows, this post might hasten the latter), declaring that many, if not most, of these writings say more about the treater’s need for hope and encouragement than they do about many combat veterans’ experiences of those selfsame treatments. For example, I wrote in one correspondence the following:

While I appreciate your various efforts to give me a sense of what (many of) you mean when you use the word recovery, and you’ve convinced me of its value in those senses (and I do mean that, whether you believe it or not), I did not, though, find these definitions particularly helpful for what is my main argument:　 that the word often carries the connotation of “complete cure,” although bravi that some of you experience that word cure as your incentive to keep moving forward in such difficult work and therefore to be able to share your sense of hope with the veteran in front of you. The subsequent, interesting question, of course, from an empirical standpoint, will be how many veterans you will be able to get to see the wisdom and the joy of making ["]cure["] the description of the experiences that they will be allowed to enjoy thanks to having found finally a therapist who truly wants them to get better, even if the therapist decreases his/her profit margin as a result.

(Side bar: Yes, I did have some colleagues directly state that they wondered whether I was more interested in keeping the money flowing into my pocket (as if I were treating veterans in my private practice, for example) than in having combat veterans receive adequate recovery and even cure from such “proven therapies” as prolonged exposure, cognitive processing therapy, and EMDR. It’s quite the world we live in, guys.)

OK, since I’m already one size-10 ½-D foot into my professional grave, let’s keep going, shall we, what the heck . . .

Here’s what I really think: I think it is quite difficult for most therapists (if not all) to be able to sit for any length of time with the true, excruciating dichotomy in the souls of many (oh, heck, I’m in the grave already, let’s go for it–most, if not all) combat veterans, that

a). on the one hand, they believe deeply that they were part of deeply honorable work, surrounded by men and women whom they loved, whom they also found to be decent and honest and honorable, and

b). on the other hand, they are ripped to shreds spiritually that they had to take actions that went against their most deeply-held morals; that they experienced, even briefly, the terrifying exhilaration of war and even of human destruction; and that they must come to live with, down to the last ounce of calcium in their bones, that the world is often a viciously random place, that there can be no meaningful answers to explain some horrors and some survivals, that, no, pal, there’s nothing more you could have done to have saved your buddy who had been your soul mate, and–now let’s really get down to it, full-bodied sepulcher here I come!–that

c. the military’s credo Failure Is Not an Option is ultimately about what general gets to force a pen into whose hand when it comes time for signing the peace treaty, and not for one moment about whether a particular soldier or Marine finally makes it home in anything but a casket landing at Dover Air Force Base. Every combat veteran knows the truth of truths: that the top brass are always thinking in terms of “acceptable casualties” and that means that you, young grunt, need to get over it and need to get over it now. We’re not talking Hollywood here.

So, you see, I’ve got problems with two types of groups:

1. Many of my fellow progressives who are committed to the notion that combat veterans must finally confess the evil of war–and therefore label their participation in war as a deeply misguided participation in that evil, captivated as they had been by the glory-filled lies of unbridled nationalism and the military-industrial complex (remember Hang a Left And Ask for Rachel?), and

2. Many of my colleagues who somehow seem to feel that we can boldly announce, through written word and snazzy multimedia presentations, to entire swaths of men and women who, as Max recently told me, might have had the pleasure of holding the body of a child who had been hanged, for example, that, indeed,

a. we’ve got the tools in place to get you over all that enough so that

b. all you’ll have to do every once in a while is sit down in a self-help group, and you’ll be able to

c. put all this behind you well enough to lead a meaningful life that will be so much better than the lives of combat veterans from previous conflicts who did not have the access to this evidence-based knowledge, and therefore

d. you’re not going to have to sit for years with these boulders in your soul, because you’ll have the tools that will prevent you from enduring that fate, and therefore

e. you certainly aren’t going to be needing us mental health professionals in anything but the most periodic, cursory of ways–maybe for a “tune-up,” you know, or a refresher course and another “go get ‘em, partner” speech at the end of it–because, of course,

f. we do not want to foster any dependency or encourage you to think that you must remain ill in order to continue to receive your service-connected benefits, and any attempts on our part to come up with a semi-coherent plan for multi-year support will only

g. do that.

One of the correspondences I received suggested the following categorizations:

1. Some veterans, who come to us with a diagnosis of PTSD (an accurate diagnosis) and complete a course of treatment (it may or may not be an evidence-based treatment) do in fact RECOVER. That is, they no longer have symptoms of PTSD, they report that they are “back to their old self” and their loved ones agree. There is little ongoing interference of psychiatric symptoms, [and] when asked about the war, they say it was terrible and then move on. So, they had an infection, were treated and the infection is gone (to use that nomenclature from one of the posts).

2. Some veterans participate in the same kind of treatment program, make some progress, may or may not have some more minimal symptoms of PTSD, but are still clearly impacted by their experiences in combat. They do not report that they are their old self, their loved ones [do] not report this and you can still see “adaptations” to current living driven by the war experiences. All would agree that they have improved and are doing better and are living their lives “better.” Thus, they were “treated” and “improved” but are not symptom free. The disease is chronic, the medication did not remove the infection, ongoing care will needed (again , to use the language of one of the posts).

3. Some veterans participate in the same kind of treatment program and get little from it. They are still seriously impaired, their lives are still quite limited, and all those who know them would agree that the treatment had little to no impact.

4. Some veterans come back from the war, often [having] ridden in the same vehicles and seen the same horror as the those in the first three groups, but do not and have not exhibited the symptoms of PTSD. Some would tell you that they were rather profoundly impacted by the war and others markedly less so. They and we typically see no need for treatment, although we still do not understand why such treatment is not needed.

5. Some veterans come back from the war and are dramatically impaired, they want nothing to do with anyone, certainly not with VA and not with any treatment.

I thought this was an very thoughtful and intriguing categorization. Here was my reply:

I guess the question is, again, the empirical one:　how many veterans can we expect to fit into each category? . . . [T]hat would be extremely useful information to know so that we can appropriately qualify our reports not only to the veterans, but also to their families and to the public about [what] a particular veteran’s chances are of a particular outcome.　 If more people are in Groups 1 and 4, then we should by all means boldly proclaim that so that we can assure [combat veterans] that they will be able to move forward relatively free of the past (except for the expected, human sadness of remembering loss).　 If more are in Groups 2 and 3, then we need to be less boldly proclaim about [Groups 1 and 4], lest the majority (under this hypothetical) feel that somehow they are doing something wrong, when in fact they are the “norm.”

Personally I know of no “evidence-based” plans to explore these questions, although, it would seem to me, the answer to those questions would be sort of, well, crucial to know.

You think?

Second, let me briefly address a few matters that, I hope, might be more clear at this point. Johann brings up the interesting issue of the role of my being a therapist and what it does for my sense of “differentness.” Again, I want to stress: my “differentness” is quite mild as compared to the sense of alienation that many, if not most combat veterans experience. I rarely experience it, and usually only in situations in which I have to be, shall we say, kinder to individuals in social situations (not professional ones) than I might be in the mood to be.

I do think, however, that my natural assumption that some chasms do not close does provide me some of my apparent understanding of the emotional lives of some (many?) combat veterans. Their chasms are much wider than mine. Still, I strongly believe that it is possible to live a meaningful, rewarding life even on the edge of a chasm: one gets used to its presence, and one can deeply enjoy trans-chasm relations, as well as pursue meaningful goals. Meaningful, love-filled connections are quite possible.

Also, I in no way believe that if a combat veterans feels satisfied with his or her recovery that the veteran is “delusional.” To use my colleagues categorizations above, I definitely believe in Groups 1 and 4. My only question is: how big are those groups?

Finally, I have no worries about my impact as a therapist. That part of the discussion is definitely ironic. Here is a paragraph from one of my correspondences:

I guess I’m just trying to imagine [the conversation] with my special ops guy [presented in Is It Something I Said?]:　”OK, now understand:　 I have so much power over you (unconsciously, of course, propelled by unseen psycho-sociologic forces, perfectly understandable as a human phenomenon, but unwise as a matter of public policy), you will absorb my misinterpretations and make them your own, thus causing you to take actions and feel feelings that you would not otherwise do, for such actions and feelings arise not out of the biologic and spiritual sequelae of your experiences, but rather out of my lack of faith in your inherent ability to recover as a process.　But be of good cheer, for your redemption draweth nigh: if you get rid of me, you’ll get better!　Well, you may get better, we can’t predict, of course, but clearly you have to believe you’re going to get better if you’re to expect to get better, and if I don’t adequately have the hope, then you will absorb that lack of hope, which is independent of the biologic and spiritual sequelae of your experiences . . .”

I can hardly wait to tell him

Well, tell him, I did. And we had a good laugh over it. In spite of my amazing Rasputin/Svengali-like skills, he does seem to have enough independence of mind that I will look forward to his protecting me–and not my, him–should the time for action ever arise.

Too long a post, as usual. But I thank you both for your continued stimulation for my thought. I have some further thoughts about “planning for the long-haul,” but ‘tis time for all good psychiatrists to come to the aid of their country/party/child’s filthy room.

Be well, as always,

Rod

Just a Chasm

June 2, 2012 By Paving the Road Back in Living Life, Personality and Identity, Professional Relationships Tags: combat, Posttraumatic stress disorder, PTSD, VA, veteran, Veterans Health Administration 4 Comments

As I said in an earlier post, last week I had a fruitful discussion with colleagues from VA Hospitals around the country about what it means to recover and what it means to be treated for combat trauma. Several posts will probably arise from it.

I still, though, have to go back to my original post, Was It Something I Said, now with new questions. In one of my VA correspondences last week, I wrote the following:

I suspect that I simply experience the world and myself in ways that are fundamentally different from the ways that many of you [my colleagues] (and many . . . veterans) experience your (their) world and yourselves.　What I fathom, you may be able to understand, but not fathom, and vice versa.　We use the same words—treatment, evidence, cure, recovery, time, therapy—and yet we have profoundly different experiential understandings. 　　I meet veterans who resonate with my understanding—and I meet veterans who do not.　　Clearly persons such as I are now in the minority of our profession, and perhaps that is good.　Perhaps most experience the world quite differently than I do, and thus my job is to accept that and enjoy their hard work, resilience, and—by anybody’s definition—recovery.　It truly is a cautionary tale for me . . . that I do not try to create what another cannot—and even should not—ultimately fathom.　We do what we can as we live in the times . . . we do.

I’ve thought long and hard about these words.

Quite early in my life, a series of events occurred around me that have had a profound impact on my experience of the world. While most of these events were purposeful, none was malevolent. People simply lived out their lives in the only ways they knew how. Sadly, those ways were not the most propitious ones for me.

That’s the way life goes.

I have spent many hours in therapy discussing these matters, many hours in intimate, personal conversation, many hours in theological reflection doing the same. These hours have paid off: I find myself feeling much more invigorated in life, much less reactive, much calmer, much more hopeful. I know for certain that growth, change, and significant recovery are quite possible–and quite rewarding.

Yet after all these hours in all these endeavors, something quite deep inside me remains not right. Even though I rarely have to confront that fact outright, I cannot say that I never have to. Certain triggers still bring an intense jolt in my gut that can wipe out (now usually only for a few moments, thankfully) any useful, couterbalancing thought in my forebrain, a jolt that demands–no, screams for–emotional expression.

Previously that expression was usually sadness, often mixed with a certain anxiety. Now it is almost exclusively anger. Fortunately I have become far better able to squelch the latter when it is not a useful response, although that often means that I may have to abandon a conversation, even if only simply by turning quite taciturn quite rapidly.

Moreover I will not deny that there are times when I’m more than willing to let that response sashay right into the open light and skewer some of the people who happen to be in proximity (verbally only, of course). Given that I love words, and given that I was well-trained as a lawyer, I frequently have no problems whatsoever linking the word words with the word skewer. I also cannot deny that the linkage can, at times, be indeed quite a satisfying one. I so confess.

Still, while my old emotional injury provides its brief pleasures, far more often, as a result of it, certain interpersonal experiences are, to use my above word, unfathomable to me, where I mean unfathomable to be not about the experiences’ being impossible to understand, but rather about my being completely incapable of conceiving of experiencing them–and certainly for any appreciable length of time.

Admittedly, this is hard to discuss in the abstract, but, sorry, I have no plan to get too particular to help clarify. Suffice it to say this: at times I sense that people are sharing certain emotional experiences with each other–and perhaps more importantly, are willing to persist in sharing those emotional experiences–in a way and a depth that I simply don’t, at a gut level, “get.” For even if I can cognitively “get” the experiences themselves, I cannot emotionally, deeply “get” how and/or why one would persist in those experiences, even though clearly most people find it at some level satisfying to so persist.

In such situations, I cannot conceive of myself having those experiences because I cannot conceive that my body would ever not “jolt” whenever such experiences were to present themselves. Honestly, in such circumstance, I am always jolting long before I even consciously realize I’m jolting.

If you’re with me so far, then let me describe two practical, almost daily corrolaries from such truths:

1. Being an Outsider in an Insider’s World

Even though I lead a happy, fulfilling life, in a profound way I know that I’m “different” from the vast majority of folks around me. I am very fortunate: unlike combat veterans, I feel “different” in a way that can be kept relatively contained, and thus one that is relatively invisible to the outside world. Only those who know me best have a sense of what I experience.

My major concern has always been the effect of these experiences on my work. As a psychiatrist who was trained to do what I can to enter people’s experiences and remain there “for the long haul,” as I’ve put it, I frequently have to remind myself that most people, at a very deep level, need to persist in certain relationships in spite of the consequences. As long as those consequences are not the most severe ones (i.e., egregious abuse of some kind), that’s just the way they want to live and want to be–or better put, whether they want to or not, that’s just they things are going to be They have an emotional tug that brings them back to the complex relationship(s), holds them there, even in the presence of painful behavior on the part of the other.

This is not my baseline experience of the world.

It is that to which I refer when I wonder, as I have in an earlier post, whether I’m the one with the problem. My colleagues assure me that they have met combat veterans who have moved beyond a point of pain that had once felt foundational, that through prolonged exposure or through cognitive processing therapy or through EMDR, what once felt as that which inexorably separates the combat veteran from the “normal world” no longer does so in any meaningful sense. These treated veterans may still feel sad, even still feel intense pain with certain triggers, but they assure me that the veterans no longer feel this pain as “fundamentally different” from “normal” pain, but simply as an often-more-intense version of the latter. For many of my colleagues, apparently, cure or recovery does not mean an absence of such periodic pain, especially given what combat veterans have endured, but it does mean a meaningful absence of the sense of “otherness,” or “fundamental difference” that I feel in the world.

This is inconceivable to me, unfathomable. This is what I fear that I therefore might not recognize in my patients: their inherent ability to transcend their sense of “otherness,” to cross the chasm between “otherness” and “sharedness,” to become more worldly-wise, emotionally-experienced versions of what all non-injured human beings are.

In fact, in some of the discussions last week, some colleagues wondered aloud whether I do just this: because of my shortcomings, I keep combat veterans, in a way, “captive” to their feelings of otherness as a way to reinforce my own feelings of otherness, with the implication being that I therefore try (unconsciously, of course) to hold them back from the freedom they would otherwise experience in being released, in a fundamental way, from that sense of “otherness” that their combat experiences have bestowed upon them.

In other words, some of my colleagues agree: I am the problem. If I were better, my patients would get better. While the combat veterans might still feel pain in life, they would, in the hands of a different therapist, no longer feel “fundamentally different.”

Perhaps they’re right.

2. “Just” and the Linguistics of Hope

Well-meaning colleagues, well-meaning family and friends: they all tell me the same thing, basically: if I would just let go of my commitment to this sense of otherness, if I would just turn my life over to the process, to the techniques, to the therapy, to God, to whatever, if I would just follow the paths that they (i.e., my colleagues, family, and friends) have followed, take the chances they have taken, give up the fruitless emotions that they have given up, move beyond those fruitless emotions in the ways that they have so moved beyond them, then although I certainly wouldn’t be cured (the pain of trauma endures), I certainly would be farther down the road to recovery, to the understanding that the sufferings I perceive as separating me from most of my fellow humans are, thankfully, only the sufferings, in intense form, that are common to us all.

These words always start out quite heartfelt and supportive, without exception. Eveybody wants to encourage me: although the path ahead of me to recovery is hard, they all say, it is worthwhile, and if you just have patience, what feels so fundamental to you will no longer feel fundamental. No longer will you just feel better in spite of the trauma-induced sense of otherness, but you will feel better notwithstanding it, because it will just no longer have the full power it once did. Granted, you have been traumatized, so you will no longer, in one way, be the same as you once were. But in a fundamental way, you will again feel part of the human race, just part of the suffering common to all of us as humans, with an intensity that only trauma can bring, true, but no longer will you feel an outsider. You will be an insider: just one who has a special story to tell all of us of how cruel life can be, yet how that cruelty, ultimately, will not conquer our human spirit as a race.

The words then shift over time. More importantly, though, the tone of voice, the posture, the positioning of the eyebrows, the intensity–or opposite, the hesitancy–in the approach, all begin to shift. Truly (now comes the message) if you would just trust what we say. If you would just give up this hold on the past that seems to keep you bound. If you would just give our way a fighting chance, just a try, you will see.

Eventually the tone darkens: if you would just give up your need to hold on to this. If you would just regularly apply the principles we taught you. If you would just try to understand why it is you seem to be unable to give this pain up. If you would just accept that all of us sometimes simply have to move forward from the past. If you would just give us and our way a chance.

Sometimes it darkens even further: if you would just accept that things are the way they are. If you would just give up the need you seem to have to make everything right. If you would just stop asking for perfection when there will never be any. If you would just accept that life has to move on and that this attitude you keep holding on to is getting you absolutely nowhere. If you would just accept that no matter how satisfying this attitude of yours may be in one way, to hold on to this grudge, to this pain, you’re only hurting yourself. If you would just learn to accept what all of us humans have to accept: life can be a pain, but you just move on, you just have to believe that it’s got to be better than just holding on to trauma like you are, that this feeling you say you can’t get rid of just isn’t getting you anywhere.

The endpoint of the above encounters usually is a certain silence between me and the one who has my best interest at heart, a silence that screams–or at least to someone like me, who has this problem of just not letting go, sounds like “screams”–”when you’re finally ready to live life again, you just let me know.”

Just is an interesting adverb in our colloquial language, more what linguists call a “particle,” really: a word that primarily serves as an emotional, attitudinal marker, a word the purpose of which is to convey to the listener, the reader not what the speaker is trying to say, but rather what the speaker feels about what she or he is trying to say. The word just always carries a certain “of course” feel to it, or a “that’s all, no big deal” feel, sometimes an “of course” of encouragement, sometimes one of admonishment, a feel of “dont’worry, I’m here with you” or a feel of “look, pal, it’s high time you got over yourself,” a feel of “really, it’s no big deal, you can do it” or a feel of “you know, it’s not that big a deal, even a kindergartener would have gotten the message by now.”

I can only tell you this: if you are just trying to be helpful so that I don’t feel so alone in my sense of differentness, just don’t say just. For just after you say it, I just won’t be listening to you.

I will only be thinking: Oh, brother, you’re just like everybody else. You just don’t get it, none of you does. I just need to remember: just smile, just say thank you, and just hightail it out of this conversation just as soon as you can.

After all the therapy, all the techniques, all the conversation, all the theological reflection, that’s just the way it is.

I’m just one of those types.

This is what I just don’t get: so there really are people in the world who just don’t believe that the world can be so horrible, that the stars can become so misaligned, that as a result a person just can’t, for any meaningful period of time, recover the full spirit of what one once just had been? Can they just not buy into the notion that Life can do that to person? Is it just because they don’t want to believe that at any moment, just such a turn of Life could just happen to them?

There really are people who cannot accept that this chasm between us is just not a mirage, an irrational fear, a pointless refusal to accept what must be accepted?

Oh, God, then I finally realize: yes, there really are such people. A lot of them. It’s, in fact, most of “us.” If I’m not finally recovering on the other side of the chasm, they say, knowing life’s truths in their hearts, then there’s just only so much a person can do. Remember: you can lead a horse to water, but you can’t make it drink.

Oh, there’s just so much I’d like to say in response. But it’ll just get me nowhere if I do, so it’s just better to let it go, and find a way to live on my side of the chasm such that the other person will just not even have to ask whether the chasm is still there.

I often wonder how combat veterans can tell me that I “get it,” when I haven’t even come close to experiencing the horror that each of them has.

Perhaps this is what some of the combat veterans feel that I’m getting, that finally someone with an MD behind his name and a job at the VA gets: that even though life can get much better, Life can mark you, not on the outside, as it did Cain, but on the inside, hidden from all but the Abel-avenging God, that recovery will always be a process that can bring joy and relief–but that will always be a process on the far side of a chasm that was not there before, one that is not welcome, that is not going to go away, no matter how many therapy sessions or educational sessions or prayer sessions one might undergo. Perhaps, for a few combat veterans, it helps them to know that someone believes that there is hope even next to the chasm.

But, then, perhaps this is all me, unwilling to accept that the human spirit can transcend even the worst, that most combat veterans have something that I just don’t have, that someone better, even with just a bachelors degree behind his or her name, gets it: that hope, if one will just trust it, can jump any chasm, wherever, however, and land safely enough on the other side, still hurting, yes, but wiser for that pain. And no longer separated. Just recovering.

Maybe that’s just it.

Paving the Road Back

Serving Those Who Have Served in Combat

Monthly Archives: June 2012

Quite the Handful

Relationship, Relationship . . . Mission

On Grossman, On Combat, On Lake Huron: An Introvert’s Manifesto

The Long Haul

A Love Remembered

Combat Vet Seeking Outlet, References Available Upon Request

The Mockingjay, Revisited

Just a Chasm: Afterword

Just a Chasm

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