Tuesday, July 24, 2012

"Thank you for your service."

Recently a segment on MSNBC described Rush Limbaugh's efforts to dodge the draft during Viet Nam and that he never volunteered after he got a high lottery number.  Nothing particularly troubling in that.  However, now he is an avid hawk, belligerently supporting  every war, and calling for more.  When I heard the piece, my response was "Go ahead Rush, thank me for my service."  If you can't hear it clearly, I was angered and deadly sarcastic.

I have a lot of respect for the impetus behind the present convention/practice of thanking veterans for their service.  In no small part this is because as a Viet Nam vet, I wasn't exactly thanked.  So I was appreciative of the maturing of the American culture where we learned to separate whatever feelings we had about a particular war from our feelings about those who fight it. Yet I know from my own feelings and my years of experience helping Veterans at Walter Reed that thanking and being thanked is a much more complicated matter than it appears.

Almost universally, veterans thanked for their service by a stranger report their response is to smile, nod, raise a hand, or verbally respond positively.  But when deeper feelings can be acknowledged in the safety of a therapeutic group, another side sometimes comes out.

Some describe feeling that it is meaningless because they were just doing their job.  Others complain about the impersonal nature of the thanks, feeling it's done more for the thanker than it is for them.  And there are a lot stronger response still:

"F#$@ you!  Don't thank me, go do you share."

"If you had any idea what it was really like, you'd know how meaningless and empty that sounds."

"That's it, 'Thank you' that repays what?"

"Where were you when the decision to send us over was made?"

"You want to thank me?  Then give me back my old self... take away this grief (or guilt)...

This and more I've heard from veterans, and not just "loosers" but men and women I respected for their honest efforts to come to terms with their experience of war.

I know what I'm reporting here is extremely controversial and many will be outraged by my saying it, going as it does against the grain of the primary military value of self-sacrifice.  But in order for soldiers to self-sacrifice, i.e., willingly risk their lives following orders, three things are necessary:  They must believe in the justness of their cause, that their leaders are concerned about their welfare, and that their fellow soldiers can be trusted.  If any of those are violated then self-sacrifice becomes suicide.  For those not so inclined, cynicism (and rage) may be the only protection.

So if you've come to believe that the justification for your war was false/specious/self-serving, what would it be like to be thanked for your service, as though you gave it willingly?  When you've come to continue doing it because you'd be killed or imprisoned if you didn't and to keep faith with your fellow soldiers?  And if you come to believe that your leaders were more concerned for their safety or careers than your welfare, could the sweetness of thanks quench the bitterness of betrayal?

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."



Tuesday, July 17, 2012

On the reification of trauma

Trauma is a word borrowed from medicine where it means the damage caused to tissue by the application of energy, e.g, blunt force trauma is damaged cause by hitting a body with a blunt object such as a baseball bat.  This is a different kind of damage than that caused by, say, a bullet, though both are trauma.  Indeed, the nature of the damage can tell us something about the causative agent.  My objection to the diagnosis of PTSD is largely based on my objection to the idea of damage and it's inevitability implied by the concept of trauma.

The damage done by a bullet is pretty much (I say facetiously) independent of the person struck.  It depends almost entirely on the characteristics of the bullet: its caliber, velocity, trajectory, impact point, etc.  Two people hit the same way will generally suffer similar damage.  Yet this is clearly not true about the effects of combat (or other severe stressors) on people.  For example, at the grossest level, research shows that no matter how trauma is operationally defined (in a combat zone, shot at, wounded, etc.) most of the time most people "exposed" to "the trauma" don't develop PTSD.  Yet one frequently hears discussions about combat, of even just being in a war zone, as if it is inherently "traumatic" for virtually everyone.  I think this is an effect of what I see as the reification of the psychological concept of trauma.

The damage done by a bullet is a real, objective thing.  It can be seen, and cause and effect relationships are easily established.  Not so for psychological "trauma."  Exactly what is "damaged" by killing another person?  Or being terrified?  Or seeing a battle buddy killed?  Is any of these inherently damaging? And even if so, surely not the same "thing" is damaged in all three cases.  Would it be the same for different people "exposed" to each of these?  Indeed, could there ever be the same "exposure" for different people, even to the "same" event?

Consider two humvees on patrol when one is struck by a rocket propelled grenade that, let's say, kills one person in the first humvee.  Looking at each person's experience, it quickly becomes apparent that even though everyone there was at the same event, their "exposures" differ radically.  Indeed, every difference in situation, conduct, relationship, and history (and more) will make a substantial difference in what each experiences and must deal with.

Note first the huge difference in being in the first humvee or in the second.  Those in the first may well see their comrade die before their eyes, perhaps disappear "in a pink mist."  But even then, not necessarily.  Depending on where each is sitting and where they were looking and what they were doing, what they initially see could be quite different.  And the people in the second humvee will only hear of this later.

If the soldier didn't die immediately then who did what when can matter a great deal.  Did others provide first aid or not?  If not, why not?  In either case their may be intense feelings.  For example, the person who did provide aid my feel guilt when the victim dies.  And the person who didn't may feel ashamed for not doing so.

But these gross, obvious differences only begin to scratch the surface of all the differences that could make a difference.  Did someone have the job of being the lookout for ambushes?  Did everyone return fire or not?  Was this the first casualty each has seen?  Or the twentieth?  Was this someone's best friend?  Had they just had a fight?  Does someone else despise the deceased?  What experience has each had before the war with death?  With vulnerability?  What degree of loving support has each experienced in their life?  Etc, etc, and so forth.

Given all these potentially highly significant differences between the experiences of people, it is, I believe, completely erroneous to believe that the characteristics of the external event per se give us any useful information about its impact on the individual.  Yet every time someone talks about "the trauma" or the "exposure" this is, to some degree, what they are doing.

What I have said here will, no doubt, be obvious to many.  Yet it is, I believe, another way that the concept of "trauma" has coarsened and dimmed our understanding of what veterans must cope with following combat and thereby lessened the effectiveness of our efforts to assist them.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."

Tuesday, July 10, 2012

ONE of the problems with "vulnerability"

Lying somewhere on the cutting room floor of Psychotherapy Networker is nearly half of the original article I wrote.  That part dealt with the other half of Lao Tzu's statement (see previous post), the righteous error.

When faced with trying to understand why some (but not all) of those exposed to the horrors of war "get" PTSD, many of us choose the idea of "vulnerability" as the favored explanation.  The idea being that some event(s) in the person's past made him/her more susceptible to the "damaging" effects of combat (or other awful events.)  I will have more to say about what I believe are the deficiencies of this idea in later posts but want to illustrate its dangers but telling a story from my time at Walter Reed.

One day my administrator, a retired Army Sargent Major, came to me distressed after attending a lecture by a therapist, an author of a book on war and PTSD.  The author had described the research linking difficult upbringings (abuse, neglect, etc) with subsequent combat PTSD.  "He shouldn't have said that," my administrator said, "even if it's true.  In the Army that will come to mean those with symptoms will be seen as previously damaged, already broken, and that's why they're sick."

My administrator was pointing, I believe, to a fundamentally important dynamic about how we respond to those who don't "bounce back" after horrific events.  You and I don't really think we're likely to get schizophrenia or bi-polar disorder or some other serious mental illness after we've reached adulthood.  But PTSD is different.  All of us harbor some concern about our ability to handle the very worst that life has to offer.  Who among us would "guarantee" our ability to come back from, say, the brutal slaying of our loved ones, or worse?  Knowing how we judge others who "fail," we fear others' judgements and seek ways to reassure ourselves we'd do better.  "Vulnerability" provides just what we're looking for.  By seeing those with problems as having them because of pre-existing "deficiencies" we can tell ourselves what happened to them won't happen to us.  Useful if you're headed into combat.

I'll have much more to say about vulnerability in later posts, but for now can you smell the hints of contempt, the righteousness behind the concept?

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."

Tuesday, July 3, 2012

The Great Way and PTSD

"Whenever we loose the Great Way, we get benevolence or righteousness."
Lao Tsu

This quote is a central touchstone for me, both for therapy in general, but especially for my work with Vets with PTSD.  But if you're like me, you may not be at all clear about what it means on first reading.  That quote was originally the epigram for my article about PTSD but it didn't make it into the edited version published in the Psychotherapy Networker (viewable here).  In fact, I considered my original article an attempt to illustrate the meaning of Lao Tzu's statement.  With this and subsequent posts I'll show what the quote means and how useful it is as a guide to therapy (and life!)

A careful reading of the PN article would reveal that it is really a warning about one side of Lao's statement: the benevolent side.  The "Great Way" refers to what we know as the Tao, from Taoism.  It is Lao Tzu's description of the essential way of living, more of a philosophy than a religion.  Leaving aside for the moment a definition of this "Great Way", how could benevolence be bad?  We're taught to think of benevolence as a good thing, like doing things for others or being kindly.  But Lao Tzu knew otherwise.

In my article you'll note I talk about the effects of a kind of "helping" that, in my view, crosses a line from caring for or about a person to taking care of the person.  Indeed, I suggest much of the motive behind the PTSD diagnosis was attempt to lessen the stigma associated with having troubles after combat by saying it was wound caused by combat.  Though this may sound like a good thing, my article describes some of the risks of doing so.  But Lao Tzu shows us that benevolence, is an attitude of superiority, of something flowing from a better to a lessor.  As though somebody needs our help.  This is a subtle but important distinction about which there is much to say.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."

My private practice

I've recently decided to start a private practice in Austin focusing on PTSD, men's issues, and health.  As part of that effort, I'm energized to begin posting on this blog again.  I'll be talking about how veterans and PTSD are portrayed in the media as well as a discussion about how to treat PTSD.  I intend to make it interesting.

You can make referrals via my website here.