Wednesday, November 21, 2012

Symptoms of what?

A recent piece of research adds to our understanding of PTSD.  This article seems at first glance to show what's already known about PTSD: As usual, the vast majority (84%) of those experiencing combat show no significant ill effects.  But of those that do, the leading contributing factor is adverse childhood experiences.  This fact drives the "vulnerability" theory of PTSD I discuss briefly here.  But what's really important about this study is something else, described in the section below:

"Most notably, about 13% of the soldiers in the study actually showed temporary improvement in symptoms during deployment. These soldiers reported significant symptoms of stress prior to leaving for Afghanistan that seemed to ease in the first months of deployment only to increase again upon their return home."

Noting that these soldiers were more likely "to have have suffered emotional problems and traumatic events prior to deployment," the authors explain the results above by hypothesizing " that army life – despite the fact that it involved combat – offered more in the way of social support and life satisfaction than these particular soldiers had at home."  But I suggest these results should be understood as demonstrating the fundamentally interpersonal nature of that which we call PTSD.

First, it is no surprise adverse childhood experiences are associated with PTSD.  They are, in fact, associated with (major risk factors for) virtually every social ill as well as many medical conditions.  (If you are not familiar with the ACE scale and this research, I suggest a detour to this page first.)  The common model for understanding this progression is contained in the "pyramid" shown here.  According to that model, adverse childhood experiences lead, in ways not fully understood, to "social, emotional, and cognitive impairments" that eventually lead to medical and social problems.  But we, in fact, already have another model of this process with valuable explanatory power: attachment theory.

Attachment theory is based on the understanding that children need to be taken care of and evolution has "designed" an adaptive behavioral system to ensure even infants can adapt to the interpersonal/emotional environment they find themselves in and thereby get their needs met.  That is, "adaptive styles" (secure, avoidant, ambivalent, etc.) are understood as behaviors that are adaptive to the emotional/interpersonal needs of the child's care-taking figure.  These behaviors, and the emotional learning they are based on, are the basement layers of the child's developing model of how the world works.  As it is nicely put on the Wikipedia site re attachment theory:  "Early experiences with caregivers gradually give rise to a system of thoughts, memories, beliefs, expectations, emotions and behaviours about the self and others."  Which then determine how the person relates to others throughout life and thus become the roots of the "social, emotional, and cognitive impairments" that later lead to illness and social dysfunction.

The parenting behaviors that leads to insecure attachments (especially disorganized attachment) do not suddenly transform as the child ages.  On the contrary, the same parenting deficits may become intensified as the child's needs become more varied and less simple to to satisfy (e.g., not simply the provision of a bottle.)  The resulting dysfunction may directly result in the neglect, abandonment, and abuse assessed by the ACE scale.

Further, just as with adverse childhood experiences, the attachment experiences of the child have been shown to leave their mark in the behavior of the adult.  The attachment style observed in the toddler predicts how the adult will relate to their own children as well as the attachment style of their own children.  Indeed, it can be found to affect many adult relationships, especially those, I would argue, in which power and dependency are at issue. (For example, intimate/romantic relationships, as well as relationships with physicians, bosses, and therapists.  For a thorough analysis, see Attachment in Psychotherapy.)

What I am suggesting then is that "social support and life satisfaction" isn't something that comes with "army life" along with your uniform.  It can only be had, if at all, by successfully negotiating the complex interpersonal field of military culture.  Each soldier attempts to meet his/her interpersonal needs as best they can given the developmentally created strength and weaknesses they bring to bear on the task.  

It is not hard to imagine scenarios in which this process goes well, even for the "vulnerable" soldier: the new recruit, highly motivated to belong, makes it through boot camp, becomes an accepted member of a unit, does the job expected of him/her in combat (maybe even a bit above and beyond), earns the respect of fellow soldiers, encounters good leadership, and comes to see him/herself as a valued member of a valued community.  The essential rule of military life - do as you are told and you will be taken care of - is not that terribly demanding, though, of course, it can be severely challenging in combat.  But also in combat, most of ordinary life falls aside and as long as you are doing your job virtually everything else is overlooked.

But it is also not difficult to imagine scenarios when this doesn't go well.  There are so many ways the military recreates early childhood experiences that may stir maladaptive responses. There are innumerable ways to run afoul of the system and just as many by which the system can fail the soldier.  Though officially everything is "by the book," in reality what happens is entirely determined by the interpersonal interactions of those involved.  What constitutes "social support and life satisfaction" differs greatly before, during and after combat and a soldier's success at obtaining them is essentially determined by his/her interpersonal skill and is not the result of the mere presence of "social support" or somehow automatically obtained "life satisfaction."

So that drop in symptoms while deployed suggests that the "vulnerable" are not destined for dysfunction.  That there is an interpersonal environment in which they can and do function.  And that that situation is, in fact, more powerful, more impactful than "the trauma," both the childhood one and whatever occurs in combat.

It also implies that since how we fare in combat is primarily determined by interpersonal considerations, the treatment for the effects of combat must also be primarily interpersonal, whether done while waving a finger back and forth or with two people in a room talking to each other.

p.s.  I know that I have merely suggested, rather than fully made the case that this drop in symptoms should be seen as evidence of the interpersonal nature of that which we call PTSD.  And that this is the first explicit statement by me of that thesis.  So there is much to object to in what I've written.  Although it is my intention to take this discussion in that direction, my posting this now was the result of the research article having just been brought to my attention and my desire to capitalize on the immediacy of the topic.  In later posts I will fill in the data and the arguments I have merely suggested here.

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 or see a copy of it found on this blog titled "The Puzzle of PTSD."

Thursday, November 1, 2012

Avoidance, my old friend

I recently became aware that I have been avoiding writing about avoidance.  I'd think about it occasionally.  And I had written (in my head) one rather glib start about how avoidance is a problem only because it works so well.  But then I realized I was avoiding all the feelings connected to avoidance, which is, of course, the purpose of avoidance in the first place.

One of my problems with the idea of PTSD is that the definition focuses exclusively on the emotion of fear.  But what's so special about fear?  Torn flesh and dead bodies produce disgust. (That's why we vomit.)  We feel the anguish of injured, missing, dead comrades.  Murderous rage abounds.  And I can't begin to enumerate the endless daily opportunities, big and small, for shame about what we've done, or what we didn't do that we felt we should have.  Fear is just one of several intense emotions we likely experience in war; why is it the only one that leads to "trauma?"  Why is it the only one seen as damaging?  While that's an important question I'll take up later, fear is uniquely important to avoidance because of it's relationship to any and all aversive human experiences.

We are "designed" to seek out those stimuli/situations/events we experience as pleasant or pleasurable and avoid those that we experience as aversive.  It's how organisms work; how they can be programed by evolution to seek and find those things necessary to survive and reproduce and avoid those that put that at risk.  Fear is the experienced affect that guides us avoid the aversive.  If we've come to learn a particular situation results in an aversive outcome (being shamed, for example) we will fear similar situations. These simple, obvious truths immediately reveals the complications of avoidance.

It is "natural" to avoid anything we find unpleasant.  So if you were attacked on one or more bridges where you suffered painful losses, it makes sense to drive miles out of your way to avoid going over a bridge in your hometown.  Seeing a bridge stirs the memories, and all the associated feelings, of what happened.  Even thinking about driving over it does.  Going out of your way to avoid it, while still somewhat anxiety provoking, is a lot better than what you know will happen if you try to drive over it.  Avoidance works.  Sitting with your back to the wall at a restaurant works (it lets you scan for danger).  So does avoiding crowds and, if you can't, carrying a weapon (e.g, a knife).

Avoidant responses to threatening situations protectect from vulnerability to harm.  But veterans also protect from vulnerability to loss/distress by avoiding family members, loved ones, or any real intimacy.  Avoiding shame is more challenging but veterans do so by avoiding situatiations in which their fears could be revealled (crowds, possibilities of loud noises [e.g., fireworks], being responsible for others).  They also avoid situations likely to stir their rage such as driving, working for demanding bosses, interpersonal conflict.

So you can see why a cabin in the wilderness provides the perfect solution.  No people to care about and thereby risk the anguish of another loss.  No people to threaten you.  No people to see and shame you for hitting the dirt when a car backfires.  No people to to see being turned into wet hamburger.  No wonder so many veterans express a longing for such a solution.

However, as always, our problems are the products of our solutions.  Avoidance is adaptive because it works.  But just because it works so well, it's likely to be retained even when no longer necessary.  Avoidance is self-reinforcing and hence, like drugs, addictive.  And, just like drugs, the price of the payoff ever increases.  As avoidance successfully lessens the fear of dreaded situations, more and more of life may get "roped into" an avoidant lifestyle

We know how to treat avoidance.  A combination of psycho-neuro education, some form of systematic desensitization or exposure therapy, and maybe some medications, all provided, of course, in the context of a theraputic relationship with a respectful, engaged, skillful therapist.  But that's not to say it's easy.  We avoid at the feeling level as well as the behavioral.  Even if the veteran has left the cabin in the woods the wall around his/her heart may long endure.  Dismantling the wall is no small task, especially with life all too often providing incentives to rebuild it.  What man hath put together even god (love) may labor to put asunder.  But let us try.

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 or see a copy of it found on this blog titled "The Puzzle of PTSD."

Tuesday, October 9, 2012

Duty, Trust, and Betrayal

My last several posts have been about vulnerability and how it affects the re-deployed solider.  Returning to the BRAVE mnemonic of an earlier post, let's move on now to betrayal.

Some people are smarter than others and Jonathan Shay must be one of those.  He had the wisdom to see that the Homeric story The Iliad had much to say to the veterans of Viet Nam.  Specifically, about the betrayal they felt.

About five years ago, I re-read the Iliad after having last read it in high school.  I was astounded by it's relevance to what I had experienced in Viet Nam and to the South West Asia veterans I was working with at the time.  The Iliad is the story of Achilles's rage at his betrayal by Agamemnon.  King Agamemnon takes for himself Briseis, a queen who was rightfully Achilles's war prize.  Achilles sulks and refuses to fight until his friend Patroclus is killed, whereupon he slaughters the Trojans (Note 1). There were no beautiful queen war prizes in Viet Nam and I couldn't have sulked if I'd wanted to, but nonetheless this story had much to offer me.  It's story of the abuse of power by a leader and how that impacts the combat soldier was intimately familiar to me and many of the veterans I've worked with.

I have seen - with my own eyes, ears, heart, and mind -  other officers make decisions not for strategic or tactical reasons but to further their careers.  This criminal betrayal of duty was one of the main reasons I resigned my commission.  But this blog is not about my experience in Viet Nam, and I mention my experience only as I believe it is useful to help understand the experiences of combat veterans.  Specifically, when I heard about the betrayal experienced by the veterans of combat in SWA, my experience led me to listen carefully and openly, and not simply discount such accounts as blaming others to diminish one's own responsibility (though that was sometimes the case.)  Again and again I heard credible stories, often backed up by more than one source, of gross dereliction of duty by senior non-commissioned officers and/or officers of all ranks in the chain of command.

It's been said that to get men (and now women) to face arms in combat the soldiers need three things:  a belief in the justice of their cause, trust in their leaders and faith in their fellow soldiers.  Like a three legged stool, if any is compromised the stool will not stand and the soldier will not fight.  When a senior in any chain of command fails to do his duty or abuses his position for personal gain, he betrays the trust of all his subordinates in that chain and sabotages the moral, command legitimacy, and fighting spirit of all who serve under him.  Those under him will pay with their lives or with their peace of mind for this betrayal.  This is especially true when the stakes are life and death in combat and the duty not performed was the duty to look out for the welfare (lives) of your subordinates.

I was a at a conference once when another psychologist presented data about his work with a soldier with PTSD while still in SWA.  The psycholgist used Prolonged Exposure Therapy and showed a graph demonstrating the soldier's decreasing symptoms over mere days of treatment.  I had what I called data envy because while I had confidence in our program at Walter Reed, I knew our data showed no such quick recovery.  Struggling to understand the reasons for this difference,  I coined the term fulminating PTSD to describe what I thought our soldiers/sailors/marines/airmen came to us with.  They had been through horrific incidents much like the one experienced by the soldier above treated with PET.  But by the time they got to us, they had been through much more.  Their attempt to get help might have been refused.  They were unable to talk about their experience of betrayal.  Their weapons were taken from them and they were relieved of responsibilities for the merest mention of emotional difficulties.  Drinking let to fights, domestic altercations, insubordination with resultant disciplinary action. And more and more and more.

Most frequently a sense of betrayal was at the heart of such stories.  They had done their part: put their lives at risk to do what was asked of them.  But someone whose duty it was to look out for them turned a blind eye to their danger.  Or failed to do her part in the heat of battle. Or failed to provide help when it was asked for. This sense of betrayal becomes a gnawing wound, festering inside, preventing trust in anyone in authority, covered over by a self-protective cynicism that denies anyone is trustworthy thereby ensuring they will never be fooled again.  Unaddressed, this is a recipe for a functional loss of life.

I'll have more to say about treatment issues later, but here I want to emphasize that this is a relational issue.  It is about how a particularly vital (but not necessarily close) relationship between the soldier and a senior she needed to trust went awry and the consequences of that relational disruption.  It can't be fixed by addressing only symptoms. For treatment of such veterans to be successful, a new relational experience is necessary.  The veteran must have a corrective relational experience. A start is for them to encounter a helper who is willing to engage them at the deepest levels, communicates deep respect, and exhibits unwavering integrity.

Roy Clymer

Note 1: For an excellent article by Jonathan Shay about the Iliad and military leadership, what he calls complex PTSD, and other issues go here.

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here or see a copy of it found on this blog titled "The Puzzle of PTSD."

Monday, October 1, 2012

When Johnny comes marching home

It's not just young men and soldiers who deny their vulnerability, it's all of us.  We all know that we can die or be incapacitatingly injured at any time but mostly we manage to keep that knowledge well away from day to day consciousness.  That's probably a good thing because otherwise we'd never get out of bed.

But for the combat veteran, life becomes more complicated.  "Death is a distant rumor to the young." (Andy Rooney)  After the young soldier has experienced the immediacy of death in his/her first fire fight, however, it is distant rumor no more but a hissing, in your face presence.  And unless you're very lucky, it isn't just a one time encounter you'll have, but a repeated affair you face each time you go "outside the wire."  So you have to find a way to deal with the vulnerability and associated fear that you used to, but can no longer, just deny.   Fortunately, laying right at hand, waiting for your call, is your new best friend: anger/rage.

It is, of course, no news that soldiers in combat get into rage.  It's also probably fair to say that anger/rage, more than any other "symptom" is what brings re-deployed soldiers initially to the attention of the mental health system.  I don't know it that's true, but the most frequent story I would hear is of altercations with the spouse, with neighbors, with superiors at work, and/or with strangers on the street (especially in cars.) But to understand anger, you must understand vulnerability.

Constantly living in fear is immensely wearying.  I remember describing to my therapist how sick and tired I became of being always afraid.  How I wanted to just put it aside, rid myself of the fear, and go on patrol looking to blast anything that moved.  And how ashamed of myself I was that I couldn't do it.  I was shocked and, ultimately, transformed when he responded, saying how glad he was that I hadn't done that.  I expected him to join me in my castigating myself for my fearfulness, my cowardice.  He, instead, told me how he believed that honoring my fear had kept me (and my men) alive, how it had kept me human in an inhuman situation and how it had led to his being able to know me.

I don't think I'm the only veteran who returns from combat "sick and tired" of feeling vulnerable.  Who makes it back, hoping, maybe believing, that he'll/she'll never have to feel that way again.  The awful truth turns out to be that while we were always vulnerable, but able to deny it, now, whenever something happens that stirs vulnerability, the veteran is all too likely to immediately react with anger/rage.  So his young daughter runs towards the street, and he is instantly screaming at her, grabbing her up, and maybe shaking her.  Neither her nor the daughter know why.  Or he's driving and someone "cuts (him) off" (which is, in fact, a danger to him) whereupon, in a rage, he blocks the other car in and beats in the windshield in righteous anger.  Or his wife asks him to talk to her and she persists even after being told "You wouldn't understand" and suddenly he blows up in a rage and storms out of the house, barely aware that her loving interest, if allowed in and responded to in kind, would put him right in the middle of all the pain, and terror, and longing; the vulnerability that he has worked so hard to keep at bay.

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 or see a copy of it found on this blog titled "The Puzzle of PTSD."

Friday, September 14, 2012

The tip of the spear

One more post on the collision of vulnerability and combat violence.  I heard this from a Operation Dessert Storm Vet who had come to our program.  This matters to a degree because it wasn't uncommon for some veterans of other campaigns, especially Viet Nam, to put down ODS vets.  In this view this was a quick and "easy" war and to be affected by it, especially, clearly put you in the "weak" category.  Perhaps some will think differently after hearing this story.

He came to the program when it was mostly focused on the medical symptoms veterans of the first Gulf War were reporting, what was then called Gulf War Illness or Gulf War Syndrome.  Except he didn't have any of the usual complaints of joint/muscle pain, headaches, difficulty breathing, etc.  He complained of feeling nothing.  Now five years after the war, he described how ever since he has just felt "blah".  He described no interest in much of anything, never feeling excited or happy, maybe an occasional instance of fear, but not much of that and not really depressed.  He said he couldn't find work he wanted to do and didn't have friends or relationships that lasted any length.  He didn't really even have much energy for complaining either, but thought he'd check out the program "'cause why not?"

When asked he told this story.  You may recall there was a huge buildup of forces in Kuwait before the invasion of Iraq.  He was part of that and when the order to invade was given, he was in a unit that was one of the very first to enter Iraq.  The battle plan had them entering through a purported mine field, which, because the Iraqis wouldn't expect that, was supposed to provide a critical element of surprise and advantage.  The plan called for Engineers to arrive first and sweep a path through the minefield that the battalion could enter through.  But when they got there, the engineers were no where to be seen.  The battalion commander radioed back to HQ and he was told to cross anyway and attack.  Per Army doctrine at the time, the Commanding Officer told his Sargent Major to order the most junior member of the battalion to walk across the mine field, forging a path that others would follow.  And shoot him if he refused or turned back.  My patient was that junior soldier.

He was able to pretty vividly describe his terror: literally shaking in fear, barely able to haltingly put one foot in front of the other, sweating profusely, moving only when yelled at by the Sargent Major.

But suddenly, a miracle, something changed.  One second terrified, the next, he amazingly felt no fear at all.  He started walking, then skipping through the mine field, turning to hail his fellows, shouting back, "Come on in, there's nothing to be afraid of." And he laughingly lead the way across.

You don't need to be either a rocket scientist or a psychologist to know that he was somehow able to trick himself.  By throwing some mental switch he was able to not-know what he knew, convince himself there was no mines (or no danger) and push away his overwhelming fear.

This (probably uniquely) human capacity to not know what we know is a last ditch method of dealing with the intolerable, a way to continue living in the face of realities that challenge our reasons to live, a way to push away feelings that would make living impossible.  It works and most of us have used a variation of it or two in our lives (Scarlett O'hara: "I can't think about that right now. If I do, I'll go crazy. I'll think about that tomorrow.")  But the ability comes with a high price tag and this Dessert Storm veteran was paying it.

You can't go to war and come back unaffected.  No one can.  Experience changes people and there are very few more powerful experiences than combat.  But affected doesn't mean damaged.  We do what we do to survive. But what we do may incur a cost that must be paid or the interest adds up.  By suppressing his feelings, this ODS veteran was able do what he had to do to keep from being shot.  But the history of human experience indicates that the mechanism we use to suppress negative feelings is blunt.  It can block fear, distress and anger, but also blocks excitement and joy.  We may rid ourselves of the lows but at the cost of the highs.

A switch turned off can be turned on and the history of psychotherapy since Freud strongly suggests that the way to do so is to make the decision to tolerate the very feelings we believe we can't.  To choose to feel that which feels intolerable: all the fear, and pain, and loss, and rage, and shame that we have worked so diligently to keep at bay.  Nothing in life is easier said than done than this.

This struggle, this conflict within that I've outlined here is central to almost everything I've ever said or will have to say about PTSD.  It is the reason I object to the name we give this struggle, post traumatic stress disorder, because I believe the name itself tempts the veteran to see himself/herself as not what he/she really is, a person struggling to endure the unendurable, make sense of the incomprehensible, and let go of the unforgettable: no, not that but instead a far lesser being: someone "traumatized," damaged, diminished by what they have experienced.

The work of all, veteran, therapist, society, is to keep this distinction every in mind and for each to do their part to hold to the extremely difficult, but ultimately freeing path of compassionate accountability.

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 or see a copy of it found on this blog titled "The Puzzle of PTSD."

Friday, August 24, 2012

Not just a river

Before I take up how realizing one's vulnerability in combat affects life back in the world, I want to say a bit more about my contention that men are pre-disposed to ignore/deny their vulnerability.  Maybe, if someone asks, I'll describe why I think it's so, but in this post I want to tell a story that will describe an extreme, hopefully convincing case that it is so.

In my division there was one sailor, an E-4, who had already done one tour as an ARMY sniper.  I capitalize that to indicate how extraordinary that was.  Even though in the Navy, he was apparently such a good shot that the Army "borrowed" him, sent him to sniper school, and then to Viet Nam for a one year tour.  In that tour, he would go out into the jungle, by himself, climb a tree and shoot the highest ranking person he could see coming down the Ho Chi Minh Trail.  Now, however, he was one of 10 forward gunners in the division.  On patrol, he would sit in a turret in the bow of the PBR and man the twin 50 caliber machine guns that were the main armament of the boat.

You might imagine he would have been admired, but he was widely disliked:  no doubt a result of his near open contempt for the fearfulness of the other sailors on the boat.  While in ambush they were all anxious, managing their fear, he was not.  He saw no reason for fear and was quite relaxed "in the bush."  Not cavalier:  he did his job, maintaining a watchful alertness, but he was not afraid.  They might start firing at a snapped twig in the night.  He expected more evidence before he would break the ambush.

Although unpopular in the division, he was very useful to me because he would volunteer for the occasional insane missions we would be directed to do by headquarters.  As an example, in order to "lower our profile," we were provided a Boston Whaler and told to send patrols out on it.  It's hard to convey how insane we thought this was.  Standard tactics had two PBR's going out on patrol together.  Each had twin 50 cal. machine guns forward, one 50 cal. in the rear, and an M-60 amidships.  The Boston Whaler was armed with one M-60 and the M-16's of the four man crew.  I had to go on the first missions since I was in charge of the division at that time.  Fortunately for me, this ex-sniper volunteered.  Fortunately for all of us, we were soon able to stop these patrols.

One night, back on the river in ambush tied to the bank, he was in the forward gun turret when a grenade struck him in the forehead and fell into his lap.

Had it not landed in his lap, it would have fallen into the boat and he wouldn't have been able to get out of his seat before it exploded.  But, though dazed by the blow, he managed to pick it up and  throw the grenade off the boat where it exploded.  A brief fire-fight ensued and the boats returned to the base with no one injured.

The next day he came to see me in private.  "It could've killed me!  I might've died!"  "No fucking shit." I said to myself.  It was shockingly clear that he had never realized that before.  It took a grenade off the head, into his lap for him to see, to feel.   But with that realization, he was now afraid and he did not want to go back out on the river.   "What's real courage?" I asked, "Going out when you're not afraid, or when you are?"  In spite of my efforts he all but refused.  This was a problem for me because no one wanted to go on the river and either he had to or I had to court martial him.  Since he was scheduled to go to Hawaii in two weeks for 5 days of R&R, I made a deal with him.  I'd keep him off until he went but when he returned it was back on the river or else.

Though I didn't know if he would, he returned from R&R, resumed his duties and he was much better warrior: more alert, more cautious and, yes, less arrogant.

Although his was an extreme case, I believe most who go to war share his capacity.   We have ways to diminish, manage the fear.  But when the uber-violence of modern warfare meets the powerful capacities of the human mind something's gonna happen.  In my next post I'll talk about the impact.

plato told
him:he couldn’t
believe it(jesus
told him;he
wouldn’t believe
certainly told
him,and general
and even
(believe it
told him:i told
him;we told him
(he didn’t believe it,no
sir)it took
a nipponized bit of
the old sixth
el;in the top of his head:to tell
e.e. cummings

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 or see a copy of it found on this blog titled "The Puzzle of PTSD." 

Wednesday, August 15, 2012

Degrees of death

In October of 1969 I reported to a miniscule "base" on a river north of Saigon to assume the position of the Executive Officer of River Division 594.  Although my primary duty was not to lead combat patrols, as part of learning the job, I had to become qualified as a Patrol Officer.  A Patrol Officer is a junior officer or senior enlisted personnel who leads a "patrol" of two river patrol boats (PBRs), usually to set an ambush trying to catch Viet Cong personnel crossing the river in order to transport troops or supplies.

The training consisted of four break-in patrols where I would ride along with a senior Patrol Officer, followed by patrols thereafter on my own.  On my last night break-in patrol I suddenly heard a boom and then everyone started shooting.  (We had been attacked, I later learned with a B-40 RPG.)  I instantly felt the most overwhelming feeling of helpless vulnerability imaginable.  I felt totally exposed, "naked" to injury and death.  I was standing on the engine covers, the highest point you could stand with nothing between me and incoming death.  It was crystal clear to me that I could be killed at any instant.  Indeed, the bullet that would render my hopes and dreams for my life a mere puff of air may have already left the barrel of a rifle. My whole body shaking, I somehow managed to pick up an M-16, flip off the safety and start shooting back. Even though it felt much better to be doing something I still felt the undeniable reality that at any instant I could be rendered a pile of flesh.

When I spoke of vulnerability in my last post, this is the experience I am talking about.  Different than fear, though fear is obviously a part of it.  It is the knowledge that you are not in control of your fate/your life.  I believe this knowledge is particularly difficult for young men to accept.  Indeed, I believe it is so threatening that most men commit a form of suicide in order to protect themselves.

As you might imagine, I was quite scared to assume my position as XO in a combat division.  Any qualms I had were only reinforced as I flew up the river in a helicopter from Saigon to my base.  I will never forget the sight of the river, totally pockmarked with craters, dead trees everywhere, nothing moving.  Yet as scared as I was, the men of my division scared me even more.

It's not that they were a bunch of bloodthirsty gangsters.  They were simply dead.  They had no life to them.  No emotion, no affect at all. No pleasure, no connection.  When they spoke, it was robotic, saying what needed to be said and no more. They seemed to be actual zombies.  Indeed, I was so frightened of them, the fate for me they represented, that I did what I had never done before, wrote a letter to my father (a fomer naval officer) asking for help.  I did not want to become like them.

I have come to believe that their emotional suicide was a defense against the ever presence of death.  By being already dead, they tried to rob death of its power.  Death was not so terrifying if life isn't much anyway.  This self death made it just barely possible to go back out on patrol after having had the experience of helpless vulnerability to the loss of everything.

Yet a strange thing happened after my first firefight.  When we got back to the base the men went through an amazing transformation.  They became alive, friendly, celabatory.  The beer came out and there was a party.  The ribbon on my black beret was cut to symbolize I had "lost my cherry."  Story after story of previous firefights were told, the whole history of the division.  And then the next morning everything was the same, back to zombie.  It was as if the beer had been a dessert rain, producing a brief flowering.  The rain came after each firefight when no one was hurt.  When the VC starting hitting us harder there were no more parties.  Yet, strangely, these men came to seem to me to be the best bunch of men in the world.

When Churchill said "There is nothing so exhilarating as to be fired upon without effect" he is correct but incomplete.  He fails to mention that the cost of the exhilaration is the fearsome vulnerability that precedes it.  In my next post I'll say more about how the experience of vulnerability affects veterans when they return to the world.

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 or see a copy of it found on this blog titled "The Puzzle of PTSD."

Tuesday, August 7, 2012

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.


There, I hope that helps. ;>)

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.

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.

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.

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."

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 or see a copy of it found on this blog titled "The Puzzle of PTSD."

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 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 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 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 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.