Some important issues combat veterans struggle with

In thirteen years of working with veterans at Walter Reed, you'd think I would have learned something.  Well I did, but unfortunately, at the same time I was developing that disability associated with "maturity" known as CRS: can't remember stuff.  So I'd find myself in sessions knowing I knew what was going on but unable to remember how to best name or understand the issue.  As a result, I invented a mnemonic for myself that enabled me to call up what I thought were the central issues faced by those struggling with the effects of war and combat.  Since it might be useful for others, I'll share it here.

BRAVE

There, I hope that helps. ;>)

Betrayal

If I had to say the one issue I believe is universally common to those diagnosed with PTSD, I think I'd go with betrayal.  It is almost always a central thread of the story of a veteran's experience.  Most frequently the veteran describes his/her experience of being betrayed by a superior who's job it was to "look out for" the veteran (or his/her comrades.)  Sometimes "God" is seen as having betrayed an implicit compact. Examining the betrayal in detail is an important part of the work.  Having said this, I recognize I've said a tenth part of what could be said about this issue.  In this and the others below, I'm just giving the briefest of overviews of the issues.  I could (and will) say much more about them.  For now, I mainly want to bring them to you attention.

Responsibility

You don't come back from war without some questions of responsibility/guilt.  Each person has their own, private knowledge of what they did that they shouldn't have or didn't do when they should have.  There is always more one could/should do.  Even the smallest actions can have horrendous consequences.  When someone dies anyone involved feels responsible to some degree.  And our tendency to want to have an explanation for events leads the finger to point somewhere, often at ourselves.  Yet at the same time, truly accepting responsibility for our actions in the chaos and moral fog of war is a daunting challenge, especially since we so often overlook the compassion to which we are all entitled.

Avoidance

Of the "symptoms" of PTSD, this is the class easiest for most to recognize as really adaptive behaviors.  I remember a veteran who would drive miles out of his way back home to avoid going over a bridge.  If what happened to him on bridges in Iraq also happened to you and me, we'd all be forming a convoy taking the long route.  Yet this is also the issue that is, in many ways, the most dangerous.  The trouble with avoidance is that it's usually successful and therefore keeps you stuck. You'd think the person who could find the courage to do the things they did in combat could easily deal with his/her fears back in the world.  But it's one thing to do what you "have" to, another to do it for yourself.

Vulnerability

Whenever I make this list for myself, I always debate which is the most crucial, the one that plays the biggest part in keeping people stuck.  For men, at least, I most frequently land on the avoidance of vulnerability.  Men are, I believe, genetically predisposed to deny their vulnerability (their worldwide double risk of death by auto accident is a bit of evidence in support.)  The first fire fight frequently shatters their believe in their invulnerability and though they've got nothing to replace it, they must still go out on patrol and face their fear again and again.  When their daughter runs into the street, swamped once again with vulnerability and helplessness, they go immediately to the only defense at hand: rage.  This reluctance to tolerate feeling vulnerable makes intimate relationships near impossible.  And makes life in our crowed social world a huge challenge.  The avoidance of feeling vulnerable is, I believe, the main reason so many veterans are attracted to the idea of retreating to "the woods."

Entitlement

Here's another tough cookie.  In the "Official Version" of reality, soldiers are all about duty, loyalty, selfless service.  Yet, as I sometimes reminded them "You were a person before you became a soldier and someday you will be a person again."  And people want things for themselves. In the military culture, however, powerful mores prohibit acknowledging self-interest with a result that much of it goes "underground:" there, but it won't be acknowledged.  

War, however, even though truly hell, still provides many opportunities for pride where one can perform prodigious feats under the worst possible circumstances.  Though officially "just" doing their duty, is it really possible not to feel some pride and some wish to be acknowledged?  Read the account of Achilles finally routing the Trojans and I don't believe you will believe he expects nothing for what he has done.  But he certainly says nothing of it.

I believe it is impossible to come back from combat without some sense of entitlement, which, when unacknowledged, frequently leads to difficulties in relationships, work, and sometimes leads to an endless effort to wrest "benefits" from the military/VA. (The quotes are to indicate not that they aren't entitled to benefits, but that there may also be more to it than that.)

Obviously this is not an "all inclusive" list and I will address some in more detail later.  I would also love to hear any comments, questions, doubts, criticisms, etc.  Give me something to respond to.

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."