Therapeutic War Stories: An Introduction

In his course on book writing, Bill O’Hanlon first has his students go through a series of exercises to help focus the process. I have combined the first exercises into the following paragraphs:

Even therapists experienced in standard trauma-focused therapies can find themselves feeling inadequate when working with post-9/11 combat veterans. It is easy enough for therapists to learn how to differentiate between a soldier and a Marine (and why one would be well-advised never to confuse the two!). Often, though, they still end up wondering, “Why do some veterans avoid engaging fully in treatment in the first place, even after they have overcome, at least initially, the stigma of seeking mental health care?” or “What do I do about those combat veterans who do not easily move back into post-combat life, even after fairly successful ‘standard’ treatments?”

In this book, I offer therapists a way to answer those questions by suggesting seven narratives that they can use to make better sense of veterans’ lives both during and after combat. In any good story, actions and states of being imply consequences, so with these seven narratives in mind, therapists will be able translate veterans’ experiences into more “therapeutic war stories” so that the veterans may not only find more peace with what they felt, saw, and did while “down range” (as they call it), but also then consider better possibilities for their growth into more meaning-filled lives as civilians.

I write the book for mental health professionals who work with or who wish to work with post-9/11 combat veterans, yet who are not yet familiar with ways to conceptualize the stories that combat veterans may tell about themselves, stories that can sometimes limit the efficacy of treatments, whether evidence-based or not. While previous books have focused on what to do about the sufferings of post-9/11 veterans with combat trauma, I focus instead on how to conceptualize better the stories implicit in those sufferings so that the veterans might then be able to benefit even more from evidence-based treatments.

The book is structured as a series of reflections on seven veterans whom I “encounter” on a particular “work day,” sandwiched between two stories I “think” about as I “drive” to and from work on “that day.” It is what I imagine might arise if the Diagnostic and Statistical Manual (DSM) were to meet The Canterbury Tales.

Next, he has us consider a possible “back cover” of the book, with a summary and a bio. So he goes:

A young combat veteran enters a mental health clinician’s office and sinks into the chair next to the desk, as carefully as he once must have done when he had taken aim, as a sniper, at a target then mere yards away, now a world away from that consulting room, an eternity before that moment, and after a cautious glance left, then right, he fixates his eyes on his new counselor and whispers, “I don’t want to be here. I don’t want to be anywhere.”

In this book, Dr. Rodney Deaton, a psychiatrist and psychotherapist who has worked extensively with combat veterans from the conflicts in Iraq and Afghanistan, calls on doctors and therapists who have encountered such veterans in their practices first to ask themselves not “What should I do?”, but rather “What’s the story here?” He urges them to focus not just on the veterans’ symptoms, as important as those are, but also on the veterans themselves, on the persons the veterans have encountered on their journeys back home, on the paths they may or may not have taken, and on the stories they might be living out, stories such as:

–The Voyage and Return
–The Mystery
–The Modern Tragedy
–Overcoming the Monster
–The Ancient Tragedy
–The Quest Beyond
–The Rebirth


By considering seven veterans who embody the conflicts and the narrative arcs of these stories, Deaton, in a manner more reminiscent of The Canterbury Tales than of the DSM, offers guidance for clinicians who have wondered “Why do some veterans avoid engaging fully in treatment in the first place, even after they have overcome, at least initially, the stigma of seeking mental health care?” or “What should I do about combat veterans who do not easily move back into post-combat life, even after fairly successful ‘standard’ treatments?”


In the end, he argues, when both veterans and treaters embrace the parts each must play in the stories of hope-filled recovery that they are trying together to tell, both will learn more deeply not only what it means for one to accept what cannot be changed, but even more what it promises for one to live each day for what can be.

Rodney Deaton, MD, JD, is the Medical Director of the Warrior Wellness Unit at TriStar Skyline Madison Campus in Nashville, Tennesse and Assistant Professor of Clinical Psychiatry at Vanderbilt University School of Medicine. A graduate of Indiana University School of Medicine and Harvard Law School and the recipient of teaching awards from Indiana University and the American Psychiatric Association, his essay blog, Paving the Road Back: Serving Those Who Have Served in Combat, was named one of WordPress.com’s Editors’ Picks Blogs of 2013.

Finally, he has us come up with a  tentative title, so here goes, Part II:

Therapeutic War Stories: Seven Narratives for Therapists to Guide Post-9/11 Combat Veterans Toward More Meaning-Filled Lives

So there you have it folks, the work up ’til now. Any thoughts, responses, guffaws, quizzical “what the . . .”‘s, etc., will be welcomed. Really.

Caveat Lector

Yes, I’m alive, and yes, so much for the “1K a Day” flash pieces, I know, I know…

I can blame my absence on many easy targets—work, kids, flu shots, polar vortices, the usual, all true—but I actually do have two legitimate reasons as well, believe it or not.

First, I am starting to submit some longer essays to literary journals to see if I can get a nibble, who knows. Unfortunately, the rules of the game require that I not have published my submissions anywhere prior to submission, including on-line. So longer pieces will still be coming, but they might be a bit more sporadic. (Don’t worry: after I get all my rejection letters, I’ll put them on the blog!)

Second, though, and more pertinent: I am seriously embarking on writing a book, no lie. My previous project, Listening to War, is still simmering on the back burner as I consider possibilities for expanding some of the blog entries into other media. My new project, though, is going to happen and it is going to happen this year (not published, of course, which may be another pipe dream, but it will, at least, get written!) In early January I learned of a book-writing course by the therapist Bill O’Hanlon, who is big in the positive psychology movement and the author of over thirty books. I decided to go for it, and it has turned out to be worth more than the price I paid for it. Through a series of guided exercises, published over the course of about eight weeks, he guides would-be authors quite masterfully through the book writing process. I will get it done. No “1K a Day” promises. I will.

But that’s where family, work, and polar vortices come in.

Much of my writing over the coming weeks will therefore be book-focused. However, I plan periodically to publish excerpts on the blog (or perhaps summaries of the exercises that O’Hanlon has us students do), not only to make a public commitment to keep myself on track, but even more to get whatever feedback people might have about the project. Any comments, suggestions, critiques, rants will be welcomed. I mean that.

The tentative title of the book will be Therapeutic War Stories. Subtitle is coming later, as will be summaries of the book’s premise and outline (those are the exercises I’ll be working on.) The book will be geared toward mental health professionals, whether they work in the military, at the VA, or in the community, and whether or not they are currently seeing (or hope to be seeing) post-9/11 combat veterans in their therapeutic practices. What I am posting today is my “homework” for the section O’Hanlon entitled, “Your Origin Story”: the background “story” that helps begin to explain to both myself and, maybe, to readers why I am passionate about my subject and about the ideas in my book.  I am, in fact, considering that  I might use this indeed as a preface.  As  I’ll probably say repeatedly in these periodic posts: thoughts?

So, here we go. And, as the title of this post says, let the reader beware.

            As I closed my VA office door behind me, my final young patient of the day having wiped away his tears sufficiently to permit himself to stumble out of my room with adequate dignity to face that hothouse of veteran discontent known otherwise as “The Pharmacy,” I, his much-older psychiatrist, dared gaze over at the Dell monitor on my desk long enough to ask myself—one more time, dear God—those three questions that had been attacking me (for how many years, now?) after almost every such patient encounter; like three well-positioned snipers on a dark Afghan street, each managing somehow to ambush me, even though I knew—I knew—they were there, not only poised, but destined to fire every time, every damn time:

            1). Dare I look at his therapist’s assessment or most recent notes and risk seeing—one more time, dear God—some reference to his “narcissistic traits,” his  “noncompliance with treatment goals,” maybe even (ah, mightiest of all) his “sense of entitlement,” epithets disguised as clinical observations, memorialized forever in an electronic record immediately available to any clinician at any VA in the country with just a click on the “Save,” all describing some twenty-eight year-old dude with an attitude, sure, he knows it: no surprise, given that on his twenty-first birthday he was wandering the hills of the Afghan-Pakistani border (“not there,” of course), a “narcissistic (i.e., cocky) character” who, six weeks later, before he’d even had a chance to play a decent game of legal beer-pong with his buddies, was cradling his best of his best in his arms, praying to catch one last word from him, hearing instead only gasps that seemed to be flowing out of his friend far more slowly than was his blood, a buddy whose very memory had, only minutes before, caused this wisecracking tough-guy to shed tears in my office that flowed just as rapidly as blood, while gasping just as slowly as death rattles, “Why him, Doc? Why not me?”  

Or . . .

            2). Dare I open up my email Inbox instead and risk reading—dear God, one more time—another bevy of accolades about the latest data disguised as wisdom, heralded by experts both East Coast and West, assuring me that the newly-published study or (ah, mightiest of all) recommendation will make my evidence-based treatments even more precise and veteran-centered, studies done on veterans who do share, indeed, with my young patient the clinical-research tags of “OEF/OIF veteran” and “PTSD,” but who (for reasons of scientific study design, of course) do not share tags such as “severely depressed” or “with TBI (traumatic brain injury)” or “abusing substances” or “unable to commit to an eight-week, uninterrupted course of treatment because I can’t find anyone to take care of my kids on a reliable basis or because I’m too freaked out to take the second bus down to the VA, since most days the driver is some guy who looks just like that Iraqi I shot only seconds before he would have shot me, and the researchers can’t afford to pay my cab fare for eight weeks, and I’m still not sure how I’m going to make up last month’s rent, let alone this month’s, so I might have to drop out at a moment’s notice to take that job repainting the insides of those scummy, repossessed houses if my uncle calls”?

            Or how about my personal favorite: “not suicidal for at least three months”? Seriously? And they’re seeing me?

            And, of course, out of that group who did meet the study criteria, how many of them dropped out before the study was completed, you say? 40%? Did I just read that right—forty per cent?

            Or . . .

            3) Dare I this time—dear God, one more time, but this time I mean it, I really do—just wheel around, take a right, and then make a beeline straight down D Hall, full sprint, out the door, over the White River Bridge, into the setting sun, all the while screaming at the top of my lungs “I can’t take this any more!”, thereby, in my final triumphant act, providing my colleagues, both present and future, the ever-ready, casual query at Holiday and retirement parties, caffeine-free Diet Coke and oatmeal raisin cookies in hand, “Hey, remember that shrink who went over the edge that one time? Odd duck, what was his name again?”

            So, at that day’s end, I too stumbled, reached my desk, plopped down in front of said screen, bleeding from my three bullet holes all the while, and asked myself—dear God, one more time—”Am I about to keel over and die of a heart attack?”

            For guilt has a way of doing that, you know.

            You see, some of those colleagues who had dropped the occasional epithetic clinical observation were, I knew, wonderful people, passionate, yet exhausted; eager to learn, yet overwhelmed; committed to bringing some semblance of peace to the lives of the men and women who have served in combat, yet frustrated by treatment approaches that sometimes hit the nail smack dab on the head and other times just whack thumbs, leaving therapists confused and self-doubting, veterans angry as all get-out.

            Moreover, some of those researchers and recommenders were people whom I’d heard speak, whose sharp minds and passion for the best care possible for veterans had been quite evident, who were simply trying to figure out what’s going on, enough so that not only veterans, but investigative reporters and Congresspersons can get at least some tentative answers to their questions of “Why?” and “So now what?” I had even had a national leader in the field, a complete stranger to me, try more than once to call me on my cell phone to see what he could learn about the comments (not too dissimilar from the ones above) that I had left on a webinar evaluation.

            War is war. We’re all doing the best we can with what little we have. Nobody, including psychiatrists who can wisecrack with the best of them, gets a free ticket out.

            So that day, progress note completed, screen logged off, I sat back in my chair and had to ask myself, “What’s going on? Why are I and all these good, well-meaning people seemingly stuck on this hellacious merry-go-round, recriminations popping out of the center calliope in a never-ending 4/4 meter, data bobbing up and down, never going anywhere, always daring us to figure out how to surmount their never-ending motion without falling off onto our heads?”

            I’ve thought much about that since then. I’m nobody special: privileged to have been well-trained at excellent university programs, yes, bright, yes, but so are most of my colleagues. I’ve had my successes and failures, fortunately more the former than the latter, but (I hope) I am smart enough not to take too much credit for that happy imbalance. People have told me—combat veterans and clinicians—that I am “not like most of the psychiatrists that they’ve met.” I take that as the compliment it is usually meant to be, but I have to admit that since I have had the honor of working with—and even more, learning from—many superior psychiatrists, psychologists, social workers, and mental health clinicians in multiple settings, both VA and non, I am not quite sure what to make of that, either.

            That day, though, I knew that I was going to have to put into words what I was living as a psychiatrist trying to guide post-9/11 combat veterans to more meaning-filled lives, to add understanding to experience, my own, certainly not as a way to prescribe “the” best way to work with these veterans, but rather as one way to share with other clinicians some habits of thinking about and being with those veterans that appear to be working for me more often than not, as well as a way to tame my sometimes acerbic tongue so that I can become another person trying to solve the challenges, rather than be one simply harping on them.

            I figured there had to be a story behind it all.

            And thus, this book.

And thus, I should probably add: Valeat scriptor.  Translation: let the writer be brave.  Amen to that.

Thanks again to all.

As Times Goes By

As I walked through the outpatient waiting area, I passed one of the young guys in the civilian program, I thought, communing with his smart phone. Upon reaching the nurses’ station, though, I realized my error, walked back, and for a few moments stared at the soldier unobserved, at his stocking cap with the chic, mirrored sunglasses perched thereon, sunset orange, at his technicolor tennis shoes facing no visual competition from the all-gray track suit that most likely cost a fraction of the shoes’ price, from Target, likely.

Texting completed, he looked up and smiled. “Hey!”

“Good holidays?” I asked.

Shifting to a frown that spoke volumes, “We need to talk,” he said.

Marital tensions, again. Similar ones had brought him to me only weeks ago with a near-suicide story worthy of the name. Today, though, he was only angry, willing to keep trying, but only for so much longer.

In the ensuing weeks, you see, he’d begun to forgive himself for imagined errors and real deaths. No longer was he feeling unworthy of happiness because he’d happened to have decent-enough numbers in War’s lottery.

“I’m not a bad man,” he said to me. “I deserve better.”

Music to my ears, my young friend, to my ears.

Dark Shadows

‘Twas The New York Post, (ah, venerable news source), that published the review of Demon Camp, the story of a combat veteran who sought to rid himself of War’s demons—the “Destroyer,” shadow of Death—via a husband-wife exorcism team in eastern Georgia. The book’s author postulates that whatever good the soldier experienced must have resulted from a mental “virtual exposure therapy” that still allows him to fight his demons and “always win.”

Perhaps.

I write with no interest in exorcisms. In an age of statistics, pills, and cognitive techniques, though, I sometimes wonder how many of my colleagues believe that their words, printed or spoken, adequately contain the horror of even the metaphorically demonic, confident that by exclaiming “Prefrontal Cortex!” in lieu of “Be Healed!” they have given superior succor to a war-tortured soul.

How many, I can only wonder, have abandoned words long enough to allow their own prefrontal cortices to absorb the limbic horrors of the veterans before them, enough so that the dark shadows of soldiers’ nights invade them just enough to feel in their depths, even momentarily, one whispered word: “Die!”

Talk about cognitive restructuring.

The Vet Whisperers

Hippotherapy, it’s called: horses that calmly offer the wounded a chance to re-find connection, a mutual gaze, to venture a stroke of a hand across a neck, proposing the possibility of trust once again. In Pennsylvania’s Lehigh Valley, Straw, a mare once gravely injured herself, offers herself up as equa semper fidelis et parata, always faithful and prepared to engage combat veterans in a silent conversation about what it means to heal, to move forward again.

In War, the soldier at another soldier’s side is not merely a back-up, but rather an extension of one’s very being, a part of one’s self who just happens to be a few steps ahead, behind, a chunk of one’s soul who might, moments from now, be propelled into oblivion, leaving in the wake a crater in land and heart that dares anyone to try to fill it.

When one has a gaping hole in one’s essence, one often does not find comfort in language spoken by any human, no matter how loved she or he may be. Yet a gentle nudge along the edges of the wound by a horse, a dog, can possibly begin its closure, one tail wag, one snort at a time, an unspoken whisper to remind man now, not beast, that peace, even if it never seemed possible again, still perhaps can be.

Brainspotting

After thirty years as a psychiatrist, I have come to a certain detente with my field. Experts smarter-than-I gladly inform me, in press or in person, of what constitutes adequate “evidence” for the identification of maladies, the efficacy of treatments, the title of “best practices.”

Oh, so lucky am I.

I always look forward to the day when a combat veteran first encounters “Brainspotting,” a trauma recovery technique so unworthy of notice by the scientifically rigorous. How can a patient’s gaze at a pointer, stalled at a particular point in the visual field, lead to anything but a feel-good parlor trick, after all?

“What was that Houdini s*** she just did with me?” my patient asks, a mere hour after his session with my colleague. “How can just looking at a particular spot cause my mind, finally, to stop racing down godforsaken alleys?”

Just yesterday he sobbed before me, despairing that Life could get better. Now he flashes a smile that seems both to fear and to dare Fate’s vengeance for his hopeful hubris.

“So many meds, so much therapy, all these years—and after two hours, I feel a calm I’ve not felt in years. Seriously?”

Nothing up my sleeve, I only reply, also smiling, “Seriously.”

Grand Opening

I still recall Dr. Hook’s The Cover of the “Rolling Stone,” my generation’s lament over what it takes to get noticed around these parts. What lyrics might have been spawned had BuzzFeed, The Daily Kos, and YouTube then been available?

Sean Azzariti, cannabis activist, twice-deployed Marine with PTSD, got his notice as he made his purchase of Colorado’s finest Bubba Kush yesterday, before God and all news outlets, as the cries of hurrah and humbug began wafting their way around the globe.

If only I could decide which way to waft.

Intoxicants are dangerous. There are successful PTSD treatments.

Yet the existence of treatments does not entail their availability. Sadly, even the available is sometimes the incompetent.

“Bird’s ready to land, green light’s on,” the soldier tells me. “You see it in each other’s eyes, no need to talk, the fear, Death. I still see them, those eyes.”

No hymn to weed here. But I see those eyes, too, of the so-called living.

So many eyes. So much to be done.

Amicus Optimus

“Diamonds Will Safeguard the Next Generation of US Soldiers,” Mashable announced on my Facebook page, assuring me, as only the “top resource” of “digital culture” can, that (at least for now) we may have the “upper hand” in the battle over our soldiers’ bodies. The subtitle said it all: “Looks like diamonds aren’t only a girl’s best friend anymore.”

I hope so.

“He was my best friend,” the soldier told me today through his tears, he who had nearly sacrificed his own life to save his buddy’s, only to find himself too late, yet right on time for the grenade that should have killed him as well.

But didn’t.

“I hear their cries, Doc,” he whispered to me, “his, the other guys’. I should have gone down with them. It’s not right, Doc, not right.”

Will War no longer penetrate soldiers now, sixty years after Marilyn cooed her way through that bevy of tuxedo-clad charmers, or will otherwise gentle men (and women) prefer not blondes, but rather one more chance, please, God, to get to him, to her in time?

I keep scrolling down my Facebook page and can only pray that Hope is more than a gem in the Smithsonian or a barrier for bullets, that hope will whisper a soldier comfort tonight in the voice of his best friend.

1K a Day

So much has changed in the past year. There could have been so many words.

So how about a challenge to myself: although I will continue to write longer essays, each day I will try to write no more than 1000 characters about my life, my thoughts, my emotions concerning the men and women whom I have the privilege to serve. Perhaps I will reflect on a particular person, a blog post, an article, a news item, who knows.

“Talking around Robin Hood’s barn” was what my father always used to call it, i.e., my propensity for prolixity. Great word, prolixity. My wife just rolls her eyes, kindly reads what I write, and then hits the Like button on Facebook. God bless her.

There is a time for prolixity. There is a time for conciseness. Many of the soldiers I serve are persons of few words. Perhaps it’s time I give their way a try. After all, there’s always tomorrow.

736 characters. Not bad for a start.

Editors’ Pick of the Year 2013, Best of WordPress: Thank You!

Yesterday afternoon, I received an email referring to the following blog post:

This week, our editors dove into the archives to find and rediscover notable posts published this year on WordPress.com, from nonfiction to poetry, and photography to illustration. These posts have been especially resonant to us and the community, and represent the diversity of voices of our users all over the world. . .

Even as he displayed that puckish smile over and again, he also displayed a certain resolve, a certain protector-warrior sense, even if only in glimpses, that reminded us all—that reminded him—that he was still ready for duty, ready to assume a role that he loved, ready to face again, if necessary, a violence that would perhaps destroy him, but that would not—would not—destroy those whom he loved.

Rod Deaton is a psychiatrist with an extensive background working with military troops and combat veterans. His blog, Paving the Road Back, offers a glimpse into the work he does, as well as the lives of the brave men and women who’ve served the US military. Always crafted with care, his stores are poignant, like this post on “Ethan,” who became hooked on opiates after suffering a traumatic brain injury while serving in the Middle East.

To the editors, to my readers, and especially to the men and women I have the privilege  of serving: all I can say is “Thank you.” At the end of the day, writing is simply the opportunity to relish in words those at whom I continue to marvel—those whom I honor—in deed every day: combat veterans who were willing to face the unforgiving ambiguities of War not for some abstract idea of the  Nation-State,  but rather for those whom they loved, those at home and those at their very sides.

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