“Beam Me Home, Scotty!” 05, The Functions of the Parts of the Brain, The Brainstem

(Podcast)

In this next section, let’s temporarily transport ourselves off the USS Enterprise/Battleship Brain, back over to the brain itself so that we can learn the main functions of the four parts of the brain that we’ve already discussed. Once again, we’re in no-frills country here, so we’re going for the big ideas. Even the big ideas, though, take some time to explain, so I will address each of the four parts separately.

First, I would have you consider that the brainstem has two major functions:

  1. Reflex Center: The brainstem truly is the brain’s engine room. When messages come up from the body such as “Oxygen is getting low down here,” the brainstem will initiate the “Breathe!” protocol. No thought, just reflex. Or when the message is “Getting too hot down here,” it will implement the “Sweat!” protocol. You can rest assured that both you and the gecko on the GEICO commercials have functioning engine rooms with similarly functioning equipment. (For if they are not functioning, in fact, neither you nor the gecko are going to have much need for auto insurance.)

 

  1. Data-Gathering Center:  The brainstem is essentially the first stop for any sensory input from either the world inside the body or the world outside it. What you see, hear, smell, taste, feel: all of it is in some way first “detected” and “gathered” within the brainstem. Understand: this is just raw data, like 0’s and 1’s within a computer. Other parts of the brain determine whether this information is good news or not-so-good news (the limbic system) and then what this information is (the cortex) and what to do about it (the prefrontal cortex). But if you don’t know it’s coming, you won’t know what to do about it!

 

Think of it this way, in a brief preview of the USS Enterprise/Battleship Brain equivalent for the brainstem: The brainstem detects the incoming “atoms” of the new crew members/experiences as they are heading toward the transporter room.  This is a capacity that the “real” USS Enterprise didn’t have—and, as we shall see, it’s an extremely important capacity for understanding what happens to the brain during any trauma, and especially combat trauma.

Now that the ship is running and keeping an eye on the world, both inner and outer, let’s go on to the limbic system. On our way there, though, keep remembering our ultimate goal for all this: Decontaminating the Radioactive Emotions of War to Create a Radiating, Emotion-Filled Deployment Back into Life.

See you then!

05, The Functions of the Brain, The Brainstem

“Beam Me Home, Scotty!” 04, USS Enterprise/Battleship Brain, The Layout

(Podcast text)

Welcome back to our 4-part brain. Let’s now see how each part corresponds to a vital part of the ship. To do this, put your right hand up again, palm facing you.

First, look down at your palm and upper wrist, at what we already know is the brainstem. For purposes of this series, when we look down at this part of the brain, we are looking in the Enterprise’s Engine Room. Like the engine rooms of all ships, it keeps all systems in the ship running so that the ship may accomplish its mission. (More on how it does that next time.)

Now put your thumb back into your palm, forming what we already know is the limbic system. We are now looking at the Enterprise’s Transporter Room. For any of you not familiar with the series, the transporter room is the boarding station for the ship while it’s on a mission.

Basically, it is a platform that has a series of circles on the floor (like floor lights on a stage). To get on the ship, the crew in the Transporter Room pushes buttons and levers to allow the dematerialized atoms of the boarding person to appear above one of those circles and then to come together to form the solid person. To get off the ship, one simply does the reverse: one stands on one of the same circles; similar buttons and levers move; and the solid person dematerializes, his/her atoms being sent to some predetermined coordinates on the nearest planet or vessel.

I will define the Engine Room and the Transporter Room as comprising Engineering, and thus Engineering is the Enterprise’s version of the subcortex.

So now wiggle your fingers, and remember the cortex. In our Enterprise, the cortex represents the remainder of the ship, which I will refer to as the Crew itself. It represents all the functions that our brains do to make us human, and thus it represents all the “jobs” that our brain accomplishes on a day-to-day basis, usually unconsciously, to make life worthwhile.

Yet there is a final portion of the cortex that has a very specialized crew. Drop your four fingers over your thumb, and you form the prefrontal cortex, as we said earlier. When you do so, you then form the Enterprise’s Bridge. Yes, this is where we find Captain Kirk, who plays such a pivotal role in our experience of ourselves.

As in the program, we usually think that “the action happens” up on the Bridge, where we time and again meet our favorite crew members who interpret and lead us boldly where no one has gone before. Big Warning #1, though: the brain don’t quite work that way.  I won’t say that we don’t think that our Captain Kirks are in control of our lives. In a way, Kirk sort of is in control, even sort of meaningfully. But…

Suffice to say for now: don’t forget the other three parts.

If you don’t remember them, you see, you’ll be doomed never to understand what happens to a brain after war.

(BTW: Big Warning #2? There ain’t no Mr. Spock. But more on that later, too.)

Before we leave the layout and head over to the functional plan, however, one final “place” note. Look back at your hand, now folded with the Bridge looking right at you. Lift those four fingers and see the Crew again. Now notice the little pads at the bottom of your middle and ring fingers, at the very tip of the palm. With your left hand, feel that padded area, for it is a very important one in our series. You are now touching the Enterprise’s Processing Center/Sick Bay.

We’ll end up spending quite a bit of time there.

So, enough for now. As always, remember our motto:  Decontaminating the Radioactive Emotions of War to Create a Radiating, Emotion-Filled Deployment Back into Life. That’s our mission.

So on to a functional analysis of the brain. See you then.

04, USS Enterprise, Battleship Brain, The Layout

“Beam Me Home, Scotty!”: 03, The No-Frills, Four-Part Brain

(Podcast)

So this segment is our introduction to the brain. But before we start: why is it no-frills?

For this series, time and again I am going to refer to complex brain structures and events via simplified models. For example, we all know the brain is complicated, and I suspect that most of us would guess that it really has more than four parts, even if we wouldn’t know what those might be.

Yet I’d have you consider that, nonetheless, we can talk meaningfully about the brain by only talking about four general parts of it. To do this, raise your right hand before your face, palm toward you. (My thanks to Dr. Daniel Siegel in his book Mindsight for the example.)

Notice the palm of your hand, and then let your gaze go downwards, over your wrist, down your forearm. Imagine now that your palm and the upper part of your wrist are the deepest, most basic regions of your brain, sitting right atop your spinal cord (or, here, your forearm). This part of the brain, represented by palm and upper wrist, we are going to call the Brainstem. Again, this is no-frills: a lot of very distinct, complicated brain structures are in this area, with cool names such as the midbrain, the pons, and the medulla, with lots of other Greek-Latin names besides. We’re going to keep it simple, though—and for now we’re not going to worry what the brainstem does, but rather focus only on that it is.

Now, with your palm facing you, move your thumb inward (toward the left) until it is sitting in the middle of the palm. The thumb has now become our model of the Limbic System. As much as possible, try to keep your thumb’s first knuckle/thumbnail at a right angle to the rest of the thumb, forming almost a perch in the middle of your palm.

Now, spread the four remaining fingers apart as if to form the number 4. Wiggle them a bit. These four fingers represent the Cortex (or you might see neocortex). Think about a picture of the brain, with all the squiggly, worm-like stuff on top. That’s your fingers. That’s the cortex.

(And BTW: the brainstem and the limbic system make up what’s below the cortex, and thus they are often called the Subcortex. We’ll see that one pop up from time to time.)

Finally, take those four fingers and fold them down over the thumb, onto the palm of your hand. Your four fingers are now pressing into the base of the palm of your hand, the four fingernails looking right back at you. In our model, this is still cortex, but it is a special part of the cortex called the Prefrontal Cortex. This is a special part of the cortex that is going to play a major role in our U.S.S Enterprise/Battleship Brain. Don’t forget it.

Now take your semi-fist of a hand and rotate it clockwise by ninety degrees. You should now be looking at the thumb-side of your hand, the thumb tucked in away from you, your index finger curled over the top of it. This actually isn’t a bad representation of your brain sliced down the middle and seen from the side.

There you have it: your first brain briefing. Keep that in mind, and always remember our ultimate goal:  Decontaminating the Radioactive Emotions of War to Create a Radiating, Emotion-Filled Deployment Back into Life. So time to board the ship. See you next time.

03, The No Frills, Four Part Brain

“Beam Me Home, Scotty!” 02: Introduction to “Radioactive Emotion”

(Podcast text)

In the last segment, I introduced the idea of “The Brain as the Starship Enterprise” (or, alternatively, “Battleship Brain”). Let’s use this segment to flesh that out better.

Whether or not you are familiar with the characters and story line of Star Trek, most of us have some notion of a “battleship” made up of a group of people who fall under a Chain of Command, all of whom are working together to accomplish some mission. To do that, everyone from the ship’s captain to the lowest sailor must know her or his job, as well as do it reliably and, when necessary, flexibly and creatively.

Think of your brain as a battleship that, in spite of its limited size, can absorb thousands upon thousands of new crew members throughout many years. Each new experience—whether of a TV commercial, your favorite meal, or your worst fear—is like a new crew member who has boarded the ship and needs to be readied to become part of the life of the ship (or not), like it or not.

The ship’s Command and crew need to have some way of recognizing when new crew members are on their way. Even more importantly, though, they must have a reliable way to process those crew members: to make sure that they are “healthy” (and thus will not endanger the crew already on board) and to figure out how they can be added (or not) to the crew that is already on board.

To understand how new experiences become new “crew members,” we have to become very acquainted with one word, a word without which we, literally, as human beings could not be conscious, let alone be fully human: emotion (sorry).

Now, let’s understand what I mean when I use the word emotion. In this series, don’t confuse emotion with feeling. Feelings can be quite complex: love, envy, hate, curiosity. In some way, feelings have to bring in a variety of “processed crew members” (mental processes) to do what they have to do. You need to use a lot of words to describe accurately a feeling.

In contrast, emotions are more like shout-outs, specifically ones of only two basic types: “Yeah!” and “No Way!”  Emotions are essentially wordless, which makes them hard to talk about. You’ve got to feel them, either in your gut or in whatever part of your body does the “yeah, that!” or the “no, not that!” job.

That’s why when I use the word experience, I am referring to what we’ll call from now on emotional experience. When an experience comes our way, our bodies (believe it or not), start classifying it as “Yeah!” or “No way!” long before we know what’s happening. (More on that later in the series. Bear with me.)

So on Battleship Brain, our own personal U.S.S. Enterprises, each new emotional experience boards our ship as a new crew member. The “Yeah!” crew members are warmly welcomed. The “No Way!” ones? Sometimes more so, sometimes less so.

Some emotional experiences in life. though—IED (improvised explosive devices) blasts, violent deaths, for example—are so “No Way!”, I am going to call them radioactive emotional experiences or radioactive emotions. These new crew members that are boarding our Battleship Brains, I’m going to call radioactive crew members. If you get near them? You get sick. Really sick.

Unfortunately, the crews of all our Battleship Brains (combat veteran or not) have no choicein the types of emotional experiences they must endure once those experiences are on their way to us. The ship gets the boarding crew members it gets.  As many a soldier has told me, “It is what it is.”

So that is “what happens” in war: radioactive crew members board the ship, sometimes in small numbers, sometimes as entire brigades of horror. The uglier the individual crew members, the larger their numbers?  You get the picture.

So the rest of this series will be about one simple question: “What do I (or does my loved one) do about these radioactive crew members?”

And while the answer will be long and complicated, I am very glad to tell you that you/he/she can do something about them. Remember our series motto: Decontaminating the Radioactive Emotions of War to Create a Radiating, Emotion-Filled Deployment Back into Life.

Decontaminate so that you can redeploy. Simple (ha, ha) as that.

So let’s get going. Next stop? Why, intelligence gathering, of course. Let’s get the “lay of the land” before us. Let’s talk about the brain.

See you then.

02, Introduction to Radioactive Emotion

“Beam Me Home, Scotty!”: 01, Combat Veterans, PTSD, & How the Brain Is Like the Starship Enterprise

(Podcast text)

Hello! My name is Rod Deaton, but the soldiers and combat veterans whom I’ve had the honor to serve usually just call me “Doc.”  I am a psychiatrist, meaning that I have a medical degree and that I have training and experience in working with persons with a variety of emotional challenges using psychotherapy, medications—and explanations.

Currently I am the Medical Director of the Warrior Wellness Unit at TriStar Skyline Madison Campus Hospital, located just outside Nashville, Tennessee, in the U.S. Previously I worked at the VA Hospital in Indianapolis, Indiana. In both places I have worked with combat veterans who have served in the United States military during the country’s most recent conflicts in Iraq and Afghanistan. My job has been—and continues to be—to help them begin to find ways to heal their emotional wounds of war so that they can go on to live richer, more meaningful lives.

That’s why I’m here: to talk to you about those emotional wounds.

People disagree about what to call those wounds, believe it or not—and quite passionately. To be honest, I often find myself agreeing with many criticisms.

Still, let’s face facts: almost everybody who has ever heard a newscast or read a newspaper since 9/11 has heard of Post-Traumatic Stress Disorder, or PTSD. Almost everybody knows, therefore, that combat experiences can lead some veterans to struggle with the symptoms of PTSD. So, let’s not reinvent the wheel: I’m going to call these emotional wounds combat PTSD and leave it at that.

But I’m not here just to talk about combat PTSD.

You see, usually when combat veterans or their loved ones ask me about combat PTSD, they want to talk about, “What’s wrong with me or with my loved one after the war?”

We’re not going there, for talk like that doesn’t help. Why? Because it explains absolutely nothing.

Instead, let’s you and I talk about, “What happened to me or to my loved one during the war, and what keeps on happening now?” That is the kind of talk that can lead to explanation and by which we can not only begin better to understand combat PTSD, but also by which we can even do something to start healing those emotional wounds of war.

Life happens to all of us, every day. Our brains do the best they can to make sense of what happens, not only to survive, but also, thankfully, to thrive as much as possible, no matter what happens.

That is all combat PTSD is, then: the brains of combat veterans, doing the best they can to make sense of what happened over there.

So let’s you and I talk about what happened back then to you or your loved one, about what is happening now and, thankfully, about what can happen in the future so that all those emotional wounds can stop hurting so much.

I want to help you understand better what happened so that you can make life happen again.

That is why I am making these series of PDF files and audio recordings: I cannot treat you or your loved one with therapy or medication, but I can try to explain to you about combat PTSD. The PDF files are transcripts of the audio recordings.

Even if I cannot be your treating psychiatrist, I hope I can be someone you can sit down and have coffee with or ride in the car with, some four or so minutes at a time, as often as you’d like, as we try to understand what happens during and after war by taking an extended, metaphorical trip, believe it or not, on a ship that’s been flying through space for some fifty years now, Star Trek’s Starship U.S.S. Enterprise.

Trust me:  “Battleship Brain,” as I’ll also call it, is a lot more like the USS Enterprise than you might ever have imagined. In the course of the series, for example, we’ll cover topics such as:

  1. The Ship Itself (i.e., the brain itself)
  2. Starfleet Academy, the Crew, and Standard Operating Procedures, or SOPs (i.e., our caretakers and their longstanding effects on us)
  3. The Ship on a Routine Mission (the brain and “normal” experiences)
  4. The Ship on a Combat Mission (the brain and what I’ll call “radioactive” experiences)
  5. The Decontamination Team: The Chemical Warfare Team and the Special Forces (the crucial role of nurturance in our lives)
  6. The Decontamination Process (how therapy and medications work)
  7. The Withdrawal of Starfleet Command (the effect of leaving military service)
  8. Deactivation vs. Deployment (how to make life work again).

My motto for the series is going to be: Decontaminating the Radioactive Emotions of War to Create a Radiating, Emotion-Filled Deployment Back into Life.  So next time, let’s start with what it means for an emotion to be “radioactive,” and let’s start to think what it might be like to see how the brain is like a Chain of Command on a mission.

Talk to you next time.

01, Introduction

 

Alive & Kickin’, Writin’ & Recordin’

I was startled to see how long it has been since I posted an entry on the blog. Although times have been challenging, I and my family have been fine. I haven’t forgotten about the book. I haven’t forgotten about writing. Far from it. Given my responsibilities both at home and at work, though, I have had to focus my writing energies in a different way for now.

In the parlance of the publishing world, I’ve been focusing on my “building a platform.”

As one prepares to write (and, even more, to sell) a book, one has to prove to potential agents and publishers that someone might be considering buying said book besides the author’s immediate family and a few friends who can be guilted into anything. There has to be, in other words, a “platform” of people from which one can launch such an expensive (and in today’s publishing world, risky) project.

So, for me, “platform” met an old project I had said I would complete and also met my day-to-day world of working with active-duty combat veterans. What came out of such a meeting?

A podcast.

In January 2013, about a month before I looked at my new position in Nashville, I attended the Annual Meeting of the American Psychoanalytic Association (APsA) as a member of the Teacher’s Academy, a project that sponsors persons to teach modern psychoanalytic principles (yes, there is such a thing) to persons who might not otherwise have a chance to learn about them in a relevant, useful manner. I was awarded my position because of a plan that I had made to implement such teaching within the VA system, first in Indianapolis and then, possibly, elsewhere.

As readers who have followed the blog know, Life changed that plan quite radically.

Still, I have felt an obligation to give back in some way, and I have been trying to figure how I could do so within the context of my new position at the Warrior Wellness Unit. My psychoanalytic interest has been in neuropsychoanalysis, a modern branch of psychoanalysis that seeks to combine the insights of neuroscience with the longstanding (and yet constantly changing) insights of psychoanalysis. From my earliest readings in the area, I became convinced that the ideas (in their broadest sense) could be quite helpful to explain many aspects of the experience of combat trauma/PTSD. But how to make fairly technical ideas useful for soldiers who, frankly, Scarlett, just like Rhett, couldn’t give a damn about Sigmund Freud?

Then an idea came to me, in my usual “idea spot”: the shower.

Star Trek and the USS Enterprise.

No lie.

In the past few months, I have been thinking, writing, re-thinking, re-writing, rinse, repeat. From that I have begun to write a podcast series that I’ve entitled:

“Beam Me Home, Scotty!: Combat Veterans, PTSD, and How the Brain Is Like the Starship Enterprise.”

The web address for the podcast is beammehomescotty.podomatic.com.  It is available through iTunes: just search “Beam Me Home” and you’ll find it. As of today, I have seven episodes recorded and available. Each segment lasts from about four to six minutes. They build on each other gradually. There are plenty more to come.

Rather than spending any more describing the project, I am going to show you. I will be publishing the text of each podcast on the blog, one a day for the coming weeks (who knows how long?). I will also publish a downloadable PDF file of the text of the audio file, as well as a link to the podcast itself.

Please feel free to let others know about the series if you feel it might be helpful. Everything is free. All references to Star Trek for educational purposes only. Also, please feel free to comment on specific topics. I will always be available to edit and readjust as suggestions and new information come forward.

Please consider this my contribution to the better understanding of combat PTSD for all combat veterans and their loved ones. As you will see, the motto of the entire series is

Decontaminating the Radioactive Emotions of War to Create a Radiating, Emotion-Filled Deployment Back into Life

I hope that I succeed in doing that at least somewhat.

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.

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