VIP Treatment for VIP Healers

In the past few days, contributing writers for the TIME blog Battleland shared their thoughts about the recent death of Dr. Peter Linnerooth, a psychologist, formerly with both the Army and the VA, who shot himself on January 2, 2013. Their comments are worth sharing in full.

On Monday, January 14, 2013, contributor Bingham Jamison wrote the following, in Caring for Those Who Take Care of Our Troops:

What can you say when a mental health expert — who is married to a mental health expert — can’t get the requisite counseling help he needs to survive?

Dr. Peter J.N. Linnerooth’s story is as cautionary as it is haunting – hopefully it will shed much needed light on the tragic consequences of PTSD, and the overwhelming need (and moral obligation) for our government to marshal the very mental health resources for which Dr. Linnerooth so tirelessly advocated.

A former Army captain and mental-health professional whose mission in Iraq was to care for troops on the battlefield suffering from combat-induced anguish, Dr. Linnerooth succumbed to his own personal struggle with PTSD and depression when he took his own life Jan. 2. A Bronze Star recipient for his noteworthy service in Iraq, Dr. Linnerooth was a consummate advocate for providing comprehensive mental health resources to those in need, for both the warriors who fought and the clinical psychologists who healed them.

Yes, even military psychologists (“the Healers”) need help sometimes – in interviews with TIME and the New York Times several years ago, Dr. Linnerooth described the community of military psychologists, of which he was a part, as being overworked, understaffed, and prone to professional burnout. He acknowledged that the very trauma military psychologists are charged with treating can, if they aren’t careful, destroy the Healers from the inside out. With nauseating foresight, in describing the demons faced by military counselors just like him, he unknowingly foretold his own heartbreaking destiny.

How many tragedies like this must we endure before the government gets serious about providing the VA with the resources it so desperately deserves? Our veterans, their Healers, and the nation they both serve warrant better.

If our country is willing to send its young men and women off to war, then it damn well better find the will to care for these warriors, and their Healers, when they come home.

Then, on Tuesday, January 15, 2013, Elspeth Cameron Ritchie, another regular contributor to the blog, whose work I have previously mentioned in posts such as The Ethics of PTSD Disability, or “Meet Brandon, the Rational Soldier, wrote:

The tragic case of former Army psychologist Captain Peter Linnerooth reveals that wars don’t spare those there to help their comrades.

There have been numerous reports on suicides in active duty troops. Another report is hitting the streets Tuesday about the highest (again) suicide rate in U.S. military history — 349 suicides in 2012.

Less has been written about the effects of the suicides on their caretakers. When a patient suicides, as happens too often, it is devastating for their caretaker. Lots of investigations, reviews of records, self-recrimination: should I have done something differently?

“When my patient shot his wife and then himself, it made me feel how hard it is to predict, in a population chronically at high risk, who will ultimately lose control and who won’t,” says Dr. Chris Nelson, a civilian psychiatrist at Camp Lejeune, N.C. “You go into the clinic thinking, `Is he next?’”

Military mental health workers—Army, Navy and Air Force psychiatrists, psychologists, social workers and others—also face combat situations. When they return home, instead of returning to a lighter garrison schedule, they find themselves back in the clinic again. There they listen and treat the Soldiers and Marines, re-living the tales of war and gore. Caregivers are clearly not immune to the strain on their marriages, and the tension of not knowing then they will deploy again. Quietly they joke about their own Post-Traumatic Stress Disorder.

Leadership knows about these stressors and strains and tries to do something about them. Back in 2008, the Army surveyed its own workers for compassion fatigue. Overall, the medical force was doing well. A notable exception was for mental health clinicians, especially those who had deployed. While Dr. Linnerooth deployed and ended up with PTSD, he never lost a patient to suicide. “He was often called to the aftermaths of suicides, to provide counsel, etc.,” says Brock McNabb, who served alongside him in Iraq as a combat medic. “But never lost one of his own guys.”

Unlike Dr. Linnerooth, who repeatedly sought help, most clinicians are resistant to going into therapy themselves. They fear, as do all Soldiers, the effects on their careers. They know about the electronic health record, which allows other people with the right credentials to access all health records.

After 11 years of war, it is a very tough world for military mental health clinicians, many with PTSD themselves. They are a tough lot. They weep quietly, or not. But how long can they keep it up?

I cannot comment credibly on the situation for military mental health professionals. Their world is a more complicated one than mine, one in which competing demands of personal need and mission readiness vie for preeminence in every decision about what to do with a particular soldier, sailor, airman, or Marine. As an outsider, though, I will say it does seem to me that the latter trumps the former far more often than not; indeed, I have personally met former military whose careers were ruined by an admission of need for help.

The top brass may be trying, in other words, to reduce the stigma of mental health treatment, but at the ground level, life does not, to my eyes, appear to have changed much (although see a very encouraging blog post from today, from Sgt James Gibson, currently deployed in Afghanistan, entitled Nightmare). After four years of my own hearing such stories, it still seems like the same old, same old is going on, all press releases, high-profile conferences, and endless PowerPoint presentations to both the commissioned and noncommissioned personnel notwithstanding (although, again, Sgt Gibson gives me hope!).

Dr. Linnerooth, however, was a veteran. There is absolutely no reason whatsoever that his mental health treatment should have impacted his career. The Assistant Chief of Staff for Mental Health Services at any VA facility in the nation offering such services has the authority to approve treatment for any veteran who needs mental health services that cannot be provided at the local facility–and, I might add, that includes the authority to approve for services that should not be provided as well, e.g., cases in which a combat-veteran mental health provider would otherwise have to go into therapy with a colleague whom the veteran-patient might have to see every day somewhere in the hallways of the hospital.

The process is called “fee-basing.” It’s private, efficient, and straightforward. I know: I do some of the fee-basis reviews at my hospital.

Please understand: this is not to say that colleagues in general either should not or do not treat each other. When a level of trust between two people is present, anybody can find a way to deal with bumping into one’s therapist in the cafeteria, even daily. For decades psychoanalytic candidates have attended classes taught by their training analysts–as well as later, after completion of their analyses, have gone on to sit on committees with those same analysts, maybe for years on end. When two people are committed to the process of making life better for one of them, one just makes those things work.

Having that such an option, though, and requiring that option are different matters altogether.

Colleagues at the VA, for example, have to write notes in the electronic health record. (God forbid that wouldn’t happen, after all, both for good reasons [continuity of care among clinics and treaters, for example] and not-so-good reasons [The Joint Commission, the Sauron-eye of healthcare, and State Medical Boards say so]). Those records, fortunately, are specially-monitored by the Privacy Officer of every facility–and believe me, monitored they are.

Still, all is takes is a keystroke to get into the full record, and once that damage is done, it’s done.

It is true that many VA are located in areas where there are Vet Centers, treatment centers that are only loosely affiliated with the Veterans Health Administration. We on the VA end do not have access to those records. Many, many VA’s, however–especially those located in rural areas or those that are associated with community-based outpatient clinics (CBOCs)–do not have easy access to such care.

That notwithstanding, I’m going to make a bold statement that will likely get me into trouble, but there you have it: mental health providers are not “routine”patients, and they need more than “routine”care, no matter where. I’ll even make the claim more controversial: this is especially the case for mental health providers who are combat veterans.

No, I do not have evidence-based data with sufficient statistical parameters to say that, so there. I do, however, have two anecdotal (that dreaded word again) sets of experiences that convince me of the statements’ truth.

First, I have my own therapy as a guide. Fortunately I worked with a senior clinician for a number of years who understood well the pitfalls of treating “treaters.” We therapists are human, after all: if there is a way that we can put off feeling what we have to feel in life, we will. And what better way to do that then . . .

Spouting off psychological theory! Coming up with our own hypotheses for what is wrong with us! Knowing without a doubt what we need and what we don’t need!

I was so lucky: I had a therapist who was kind, yet who kindly wouldn’t put up with that nonsense.

My therapist, you see, was never going to let me forget my greatest fear, a fear common to so many of us and, if I may be so bold, especially to many therapists: my fear of being vulnerable and connected. I tried every which way to avoid that, but given that a). he’d already done his own therapeutic work, and b). he’d heard all the subterfuges before, my pitiful attempts at control came, alas, to naught.

Second, I have treated treaters. Although such work is quite rewarding–it ain’t necessarily easy.

Not only must treater-therapists be aware of all the usual “tricks of the trade” that treater-patients bring to their therapy hours, they must also watch out for the constant temptation on their own part to overidentify with their treater-patients. Because in these situations therapists and patients have similar interests, often similar backgrounds, perhaps even similar temperaments, sharing similar vocabularies and similar ways of thinking, it is oh-so-tempting as a treater-therapist to assume that one knows much more about one’s treater-patient’s mind and soul (and future) than is quite often the case.

But then, if I might one more time be so bold, there is the added challenge of treating combat-veteran treater-patients. How so?

1. In my experience, many, many graduates of modern treatment programs usually assume that therapeutic relationships are ultimately for the service of therapeutic technique. Even though you’re not going to find a therapist anywhere, of course, who is going to say that therapeutic relationships do not matter, you are nevertheless going to be hard-pressed to find many who see the relationship as the therapy, i.e., who believe that most techniques used in therapy are, in essence, primarily time-fillers and mini-experiments to give both parties something to do while the unfolding of the relationship does what it needs to do to heal.

2. Therefore, many combat-veteran treater-patients can even be less predisposed to discussing vulnerabilities than are their non-treater battle buddies. Many have been trained to believe that they know something that should suffice to heal (why spend all that time in school otherwise, right?). They enter therapy, therefore, even more prone to feelings of failure than do their buddies.

Granted, at one level they know that they cannot heal themselves. But many still feel that ideally they should have been able to do so, i.e., that there exists somewhere in this universe of ours a Master-Combat-Veteran-Therapist who never needed to rely on anyone, who was nonetheless able to come up with and then apply to his/her own life what s/he already known about how to recover from trauma. It is that Master-Therapist-Other to whom many combat-veteran mental health providers, even without consciously acknowledging it, are comparing themselves.

And they find themselves coming up wanting.

Because many (if not most) left their training programs believing that the healing comes primarily from the knowing, and only secondarily from the relationship, they are even more prone to not showing their treater-therapists what’s really going on. It ends up a double-whammy for them: like any patient, they try to avoid dealing with their feelings of vulnerability and need for connection. In addition, though, they have to avoid dealing with their feelings about not already knowing what to do about those feelings.

But that’s not all.

Once treater-patients get through all that (which may or may not be quickly, depending on the treater-patient’s history), once they finally can express what is on their hearts and minds, treater-therapists get their own double whammy: they get the feelings and experiences of the treater-patients and of all the other combat-veteran patients that the treater-patients, as part of their work, have already absorbed.

In other words, as a treater-therapist, I never have just one person in the room with me. I have to deal with two sets of trauma at the same time: my treater-patients’ and those of all their patients. It’s basically de facto group therapy, but only with two people in the room, especially if the treater-patients are, at some point in the future, going to be seeing any of the patients whose emotions and experiences the treater-patients have already absorbed into their souls.

Have I convinced you that it might be useful to think of treating combat-veteran mental health providers with something more than “business-as-usual,” whether or not such business-as-usual treatment is “evidence-based”?

These combat-veteran professionals are, in my experience, the best of the best. They have given and continue to give their heart and souls to their military and combat-veteran patients. Never forget: they are all military, so these treaters very much feel, at a profound, deep level, that they are not just serving “clients,” but rather are serving their very brothers and sisters. They are intense. They are passionate. They bring their “do your best” mentality into all that they do, with a sense of mission that many mental health professionals have never even conceived of having.

My point is a simple one, and I’ll state it bluntly: not every Tom-Dick-and-Harry therapist is ready to take on a combat-veteran treater, and every combat-veteran treater deserves the best that they can get.

Bottom line: there are plenty of senior therapists out there who are up to the challenge of working with these brave men and women. Even if they are not living down the street from treaters, that’s what God created Skype for. It’s quite easy enough to set up local follow-up for any medication issues, and treaters, no matter what their theoretical orientation, can take advantage of the thoughtful caring of any good, senior therapist no matter where in the world the latter is. Trust me on that one.

VIP Healers deserve VIP treatment. Period. They’ve served their time. We the People should be willing to pay for such services, and the best don’t come cheap. In my opinion, too bad, so sad. Get over it.

Bad enough that we have thousands of combat veterans scattered around the world who have to deal with the trauma of War. We the People have also created situations in which good men and women have to bear their own trauma as well as the traumas of others, day in, day out, for years. No paycheck suffices to cover that. None.

We the People owed better to Peter Linnerooth. Let us not continue to fail to give the same to his brothers and sisters in “psychic-arms.”

In his memory.

Combat PTSD, Pools of Emotion, and Putting the Truth Into Words (I)

Recently I received the following comment to one of the posts of The War Within (TWW) series, in the Thoughts section, above.

Doc,

I can’t thank you enough for putting this website together, it may have just saved my life. You have really got something here. I find this article a very accurate narrative of my personal existence. After reading this I’m an introvert for sure, and I feel like I’m losing it again.

I was doing very well for a while. I went from being homeless to completing a program at the Chillicothe VA hospital (during which time my wife divorced me) and getting a great job. I did so well there I got picked up by another company and now I have a bright future. From the day that I left I the VA hospital I felt great but TWW, as you call, was always right there.

I went to counseling and met with my doc for a few months after until I got my job and then I focused on that and the counseling went by the wayside. The echo of my past was always right there but I was able to focus on my job. It was very fast paced and revolved around helping others and working with highly motivated people. I recently ended a relationship and switched to a new job.

The new job is super slow paced corporate job. People, quite transparently, whine and complain at this job and make up excuses to avoid doing work. I feel myself getting lost and falling back inside of myself. My apartment used to be immaculate and now it’s a mess, and I am finding it harder to go to work even though it’s ridiculously easy and pays very well. I feel unworthy of asking for help from anyone, but I feel like you really get what’s going on. What can I do? What should I do?

Thank you,

The veteran who wrote this comment has given me permission to answer it via a regular post. As I have a lot to cover, I will be dividing the posts into two. Here goes:

Dear Sir,

Thank you very much for your courage in sharing with me some of what has been happening in your life and heart. I do hope these thoughts can be of some help.

First, let me share with you an analogy I often use with both patients and trainees. I like to think of the emotions as an indoor pool within each of us. When functioning well, there is a certain temperature variation to the pool’s water, but nothing drastic or too uncomfortable. Like a well-running whirlpool, it also has a certain circulation going on within it all the time, again nothing too drastic or too uncomfortable, yet enough to keep the water from stagnating. Some pools are brightly lit. Some are less so.

Next to the pool is a deck for observation. This is where we “get out of the emotional water” and from where we can “observe” our emotions and take actions vis-a-vis them (e.g., change behavior, alter ideas, consider medical intervention).

Second, let me share a passage from the book that I’m writing, The War Within: Different Veterans With PTSD, Different Missions To Recovery:

I would have you consider the usefulness of thinking of certain combat veterans as kinetic-energy veterans. Like the extroverts that most of them are, kinetic-energy veterans are energized/rejuvenated by movement, literal or figurative, usually via participating in group interactions. Talk = Life for them. If such a veteran feels emotionally empty, depleted, then it’s time to slap a few backs, make a couple calls, gather ‘round ESPN, head down to the local pub.

In contrast, think of other combat veterans as potential-energy veterans. Like the introverts that most of them are, potential-energy veterans are energized/rejuvenated by stillness, literal or figurative, either via solitary or one-on-one activities, or via watching group interactions. Quiet = Life for them. If such a veteran feels emotionally empty, depleted, then it’s time to sit back, make one call at most to a close friend, open a book or fire up a computer, sip a glass of wine or a nice Pilsner and take a deep breath (even if you find yourself in the middle of the pub!)

With that as background, let me say this:

1. The Role of Medications

Although my “role” at the VA is “prescriber,” I do not see myself as a “pill pusher.” Instead, I believe that my job is to help combat veterans understand what, at least for most individuals, medications can or cannot do.

Medications are about “pool management,” nothing more, nothing less. They can warm up overly-cool water, cool down overly-warm water, add a certain flow to stagnant water, calm down waters that are too stirred. In other words, they manage the physical part of emotions: the muscle tension that will not go away, the emotional heaviness that will not relent, the pit-in-the-stomach sensation that accompanies the loneliness of rejection and despair.

Traumatic experiences–the worst that Reality can offer, whether in combat or in any other of Life’s events–are, in this metaphor, pool contaminants that continually release toxins. The toxins they release can change the emotional water’s flow, temperature, volatility. Thus, as these are physical-like phenomena, the effects of the toxins open up the possibility that medications (also physical “phenomena”) can be of partial (although, hopefully, significant) help.

Genetics and environment–Nature and Nurture, if you will–play their role in setting up the basic “chemical structure” of the emotional pool before any traumatic contaminants have been introduced. Some pools are naturally more “active,” for example, some more “still.” Some have a temperature that always runs on the warmer side, others on the cooler side. Some have already had other Life-contaminants added–abusive homes, assaults, poor educational experiences, drugs and/or alcohol– that have already been releasing toxins into the mix.

In a word, it’s complicated, this emotional-pool “stuff.”

Two important take-home messages, therefore: first, particular emotional states most likely arise from a complex mixture of traumatic toxins with the inherent qualities of any particular individual’s emotional pool. Cleaning up certain toxins with certain medications might or might not help the inherent qualities of the emotional pool, and vice versa. In other words, medications can often help a lot–yet at the same time, paradoxically, can sometimes help only so much with any particular physical manifestation such as tenseness, emotional heaviness, and physical despair.

Second–and for combat veterans, more important–medications are almost always detoxifying agents, not decontaminating agents.

I ask my patients to understand the “emotional pool” as located within their whole bodies, not just their heads. Anger, terror despair, shame, even joy: these are full-body experiences, not just head-ones. Detoxifying agents can often help relieve the body of the consequences of those contaminants, their “toxins,” by reducing the effects of external triggers and by putting a damper on the emotional volatility and reactivity that can destroy the interpersonal lives of so many combat veterans.

But the contaminants themselves, those actual traumatic memories that either linger or are reignited by a particular scene, sound, smell: rarely, if ever, do medications remove them. That’s where psychotherapy comes in.

The tasks of the different therapies are usually quite distinct, then. Medications, something physical, detoxify. Psychotherapy, something interpersonal, decontaminates.

Bringing this back to your case, Sir, I do wish to say, therefore, that I am concerned that you may be becoming increasingly physically depressed. Depression as a physical illness is much more than simply sadness. It is a physical tenseness, heaviness, interpersonal loss that can be felt in the musculature and the gut. When the body gets involved in that way and does not recover after a few days, one is more often than not in a physical depression–and physical depressions often do respond at least somewhat to medication interventions. Not always, of course, and sometimes the side effects of the medications are not worth what little relief they might provide to the physical aspects of depression.

Yet you wrote that you’re finding it hard to keep up with activities that you once did without much thinking (e.g., maintaining a clean environment), to start activities you once had little trouble starting, whether or not you particularly liked them (e.g., going to work). You find that you’re feeling “unworthy” in a deep, physical sort of way. These sound, to me, like indications that you might benefit from speaking with a prescriber–a psychiatrist, a clinical nurse specialist, a physician assistant, a primary care provider–about either a medication trial or a re-examination of your current medications, if you are already on some. I’d recommend that you check back with your former counselor to see to whom she or he refers–or if your former counselor is prescriber, to see what that person would recommend vis-a-vis more physical (i.e., medical) responses to your challenges that might be available.

2. Potential-Energy/Introvert Veterans and the Contaminated “Inner Spa of Rejuvenation”

As to issues particular to your being a potential-energy/introverted combat veteran, let’s get back to the metaphor of the “observation deck” surrounding the emotional pool.

For kinetic-energy/extrovert veterans, this “area” is not a particularly large one. It is an “area” that is large enough to allow them to take the time necessary to reflect adequately on their emotions–but that’s it. Again, they want to be back out in The Real World, using their knowledge of their changing emotional states to get “moving” into activities and relationships for the purpose of rejuvenation, of getting the energy/intensity they need to live out those emotions in the ways they most desire.

It’s a totally different world for potential-energy/introverted combat veterans.

For those of us who are potential-energy/introverts, the emotional pool sits in the middle of a figurative “inner spa” that is not solely about emotions. Like kinetic-energy/extroverts, we too need a space near the pool to reflect adequately on our emotions. However, we then need to move to an “adjacent” area in order to sit quietly within ourselves and reflect not only on what we feel, but also on what we know, whom we know, what we might wish to do with such knowledge, all for the purpose of rejuvenation, of getting the energy/intensity we need to live out that knowledge in The Real World in the ways we most desire. In other words, for potential-energy/introverted combat veterans, their pool of emotions is an integral part of that rejuvenation spa, but it is not the only part of the spa.

Kinetic-energy/extroverted veterans go inside primarily for reflection on the emotional pool in order to focus on rejuvenation efforts out there in The Real World. Potential-energy/introverted veterans go inside primarily for rejuvenation efforts, stopping by the emotional pool as a first step in those efforts, in order to live more effectively and meaningfully in The Real World.

So what do you, as a potential-energy/introverted combat veteran, do when a dump truck called The War unloads a few tons of painful experiences–some of which may be inhumanly horrifying–into your emotional pool, creating a toxic quasi-cesspool called TWW, or The War Within?

Rule Number One:

NEVER, ever forget, no matter what or how you feel: your emotional pool has not turned into a cesspool. It may look like one. It may smell like one. It may feel like one. But it is not one. In other words, it has changed its state (i.e., how it is now), not its trait (i.e., it has not turned into something different permanently).

As I said in an earlier post, many veterans feel that The War Within was all that returned from the combat theater. That is never the case. Always two “people” return: the troop/veteran and The War Within. Nothing has changed inside the troop/veteran in function, even though a lot has changed in form.

Rule Number Two:

NEVER forget that you are military; that once you are military, you are military; that those lessons you learned in boot camp about focused energy are no less true today than they were on the day of your graduation ceremony. While TWW smells so bad that it is hard to remember anything, your not remembering your capacities for focused energy does not mean they are no longer so. Yes, you have a very hard mission ahead. Yes, The War Within is contaminating not only your emotional pool, but your whole place of rejuvenation. Yes, you’re going to have to find a way–temporarily, but likely a long temporarily–to rejuvenate the best you can in the midst of stench.

But think of it this way: you survived those God-awful latrines (if you were lucky enough to have even them) in the middle of Hell-temperatured nowhere without showering for days. You’ve been there. You’ve done that. True, this one’s inside you now, so in some ways it’s a totally different ball game. I know that. You know that. But in many ways, it ain’t different at all. It’s just another fun-time day in Paradise. You had what it takes to make it through the first ones. You have the same to make it through this one.

Rule Number Three:

Accept that this day, i.e., this day in which you have to reduce your activity in The Real World and face The War Within, is going to arrive one day, whether you want it to or not. Ask many of the Viet Nam vets: sooner or later, Life catches up with you. If the day is here, take it. It ain’t ever gonna be fun. See Rule Number Two: you’ve got what it takes, whether or not you feel like it.

Therefore, Sir, for you: although this job is hard for you, in that the relative quietness has brought you to this point, my advice is to stick with it for now, get started on your road toward recovery, and then play it by ear day-by-day. No, you won’t like that. But remember: that’s often how missions go. You’re military. You know that. You keep focused on your goal–and you adjust. Granted, this is the longest mission you’ve ever had to or will ever have to go on.

Again, see Rule Number Two.

I cannot strongly enough recommend that you read and follow the blog of Max Harris, Combat Veterans with PTSD. Max is an Army veteran from early in the current conflict, an Arabic linguist who saw more than his fare share of what War can bring. Max is as intense a potential-energy/introverted combat veteran as you can get, and he’s been brave enough to share his life and struggles in all their ups and downs in his blog, both for his own sake and for the sake of his fellow combat veterans. Recently Max has begun his own personal psychotherapy with a private therapist who volunteers for The Soldiers Project, as well as has been participating in a Cognitive Processing Therapy (CPT) group at his local VA clinic. Max has been struggling these past six to nine months quite honestly with his emotional intensity and symptoms, and he has demonstrated how looking honestly at his employment–and dealing honestly with his employers–have made a difference in his life. I know that he’d be more than happy to share privately with you about his challenges and about how he is learning–day-by-day–to meet them.

In the next post, then, I want to talk about what it means to take all this and then apply it to the problem of how kinetic-energy/extroverts and potential-energy/introverts approach differently the combat veteran’s task of “putting The Truth into words.”

Routine, So They Say

He’s not a combat vet.  So why write about him, right?

Actually, he’s the childhood best friend of another of my patients who is a veteran of the early invasion of Iraq.  They served in different branches.  They give each other no end of grief about that.  Well, no, what am I saying:  his friend gives him no end of grief.  I’m not sure that my patient gives anyone grief.

He’s too good-hearted.

He grew up in a very working class neighborhood of Indianapolis.  He did not have it easy.  He never knew his biological father.  He still remains connected with the stepfather of his childhood, although that man has long moved beyond my patient’s mother into another relationship, with a woman who’s not exactly that enamored of my patient.  His biological mother?  A long story, very long.

He’ll admit it: he has not exactly lived a life worthy of being enamored of.  Certainly the mothers of his children have not been.  It’s been ugly.

It was heroin, with painkillers thrown in for good measure.  He was a heavy abuser.

He also has recently been diagnosed (by someone other than I) with bipolar disorder, a mood disorder formerly known as manic-depressive illness.  Some in my profession believe the diagnosis is thrown around a bit too freely these days.  They have a point.

My patient, however, is the real deal, although of a more depressed type.  He cannot take standard antidepressants, as they cause his mood to shift into a very painful state of hyperactive mood shifts and racing thoughts.  His moods do respond relatively–stress on the relatively–to standard mood stabilizers.  Still, he has a rough go of it.

Yet his desire to get better is nearly palpable.  He’s hurting down to his core to try to get better.  And when I sit with him?  His core finagles its way right into mine.

I often talk about the problem of “countertransference,” i.e., the challenges I as a treater face when I experience within me the strong emotions of my patients.  Today marks the thirtieth anniversary of my beginning my career as a psychiatrist.  Thirty years ago I was standing at the VA Medical Center in Durham, North Carolina, across the street from the then newly-built Duke University Medical Center North Hospital.  Countertransference got to me more than once as that young, quite-insecure doctor back then.

It still does.

My patient is slender, but now well-built.  I suspect that as a much younger man he was, to put it mildly, lanky.  He has a Southern drawl typical of persons who grew up in his area of town, and he reminds me so much of those boys from Hillsborough and Butner and Rocky Mount who would make their way over to the Durham VA so many years ago.  He’s very deferential, with a good-old, Andy-Griffith “aw, shucks” way about him.

I suspect he was not at all that likeable when he was high.

But in the past, when he would get so sad, think about his life, the mistakes he made, that he continued to make, when he would regret actions taken, would miss his children so, so much: heroin made it all go away, even for just an hour or so.

There are only so many tears a man can shed–especially when he has to shed them alone.

It was about three months ago that he came to me, practically dragged to my door by his buddy.  He was a wreck.

“I’m so sorry, sir,” he kept repeating.  “I don’t mean to be like this, but I just can’t stop.  I shake and I shake and I shake.  I want to stop the drugs.  I hate my life.  I hate myself.  I want to see my son again, and his mama said she won’t let me see him if I don’t clean up.  I’m so scared.  Please help me.  Please.”

His wasn’t the most straightforward of cases medically, and I made some clinical decisions that some colleagues might frown upon.  (Lord, everybody’s got an opinion, don’t they?)  Yet he stabilized fairly quickly, and he was clearly relieved.

He lives, though, quite a ways from our hospital.  He long ago lost his driver’s license.  His father works constantly.  His stepmother can’t drive.  His buddy is his only means of reliable transportation, and the friend can’t get out there to my patient’s place very often.  We’re not exactly in a situation that allows for a lot of close follow-up.

But he does stay in touch with me.  And last week, he let me know that he was not doing well.  By hook and crook, he managed to bum a ride to the hospital, but he was about three hours late for his appointment.  He was panicked that I wouldn’t see him.

“I get so scared,” he told me.  “I miss my son so much.  His mama is just beginning to talk to me again, and I can’t mess up, I just can’t.  But I just sit in my room and cry.  I hate it.  I don’t want anybody to know.  I don’t want to kill myself.  I want to live for my kids.  But I don’t know what to do.  I can’t work.  I’m alone most of the time.  My parents are always thinking I’m going to start using again.  I haven’t, I swear.  I don’t want to.  I’m staying away from all those people.  But it’s so hard.  It’s so hard.”

He was doing everything he could not to weep, and to give the boy his due, he was succeeding.  Hearing him say those words, though, in that Kentucky accent, all caved in on himself, even though he’s actually quite muscular and attractive, in a farm-boy kind of way–he ripped my heart out.

“Who calms you,” I finally asked him, “when it gets this bad?”

I was afraid of the answer to that question.  I almost didn’t ask it.

He looked up from the floor that he had been staring at so long.  The word puzzled has ne’er been so well embodied.

“Excuse me, sir?” he whispered.

“I said,” now whispering myself, “who can calm you when it gets this bad?”

He swallowed.  He didn’t want to say it.  I didn’t want to hear it.

“Nobody, sir,” he finally said.  “Everybody’s just mad at me.  I did it all to myself, sir.  I’ve got nobody to blame.  I just . . . no, sir, there’s nobody.”

“Who’d you live with growing up?” I asked him.

“My mom, sir.”  He paused.  “When I was wasn’t in a foster home.”

I didn’t ask more.  I knew enough.  He didn’t volunteer more.  He knew all too well.

I can’t begin to tell you the number of stories there are like his.  The VA’s full of them.  Mental health centers (what few are left) are full of them.  Emergency rooms are full of them.  It’s routine, so they say:

Child, usually a boy, is caused trouble, causes trouble, all in an endless cycle of in-home/out-of-home/run-from-home.  Sometimes he finds stability in the structure of the military, but ghosts come back to haunt within days of discharge.  Eventually he makes himself clear enough to a person who’s ready enough to listen, and the pattern emerges: the dramatic mood shifts, the family history of substance use and emotional chaos, the boy’s, the man’s own personal history of the same, obediently re-enacted as the next generation’s example of all the forefathers’ (mothers’) chaos and suffering.  Medications help stabilize him.  He gets better.  But still, there has been so much pain endured, that is yet enduring.  There’s only so much a poor, little pill can do, after all.

Many guys with this story just blow up, over and over and over.  My patient’s buddy struggles with that.

He, however, is the opposite.  He just caves in on himself, over and over and over.

Heroin used to help, that’s for sure, even allowed him to muster up some good, old-fashioned obnoxious sneers and threats when he was high, a sort of “jackass’s relief,” if you will, from all his misery, his self-condemnation, allowed him to spread his misery around to all who dared venture into his vicinity.

Now he’s clean.  Now at least he’s not jonesing.  But now he’s hurting, 24/7.  He doesn’t want to die.  But he has no clue how to live.

Thirty years ago today, I was the age he is now–a little younger, in fact.  We grew up in the same city, in some ways even in similar cultural worlds.  Now I sit with him, old enough to be his father, same city, worlds apart.

I want to fix everything for him.  I want to fix him.  I can’t.  I know that.  He knows that.  I do my best.  He does his.  We’ll keep trying.

No combat trauma today.  Just life’s routine trauma.  So they say.

I wish.

Sitting with Pain, Sitting with Life

Before we continue with male professionals and male combat veterans, some concepts to get on the table:

Remember:  do not assume that all veterans who return from combat are suffering from post traumatic stress disorder (PTSD).  Many who have served in Iraq and Afghanistan are managing fine, thank you.  However, the more a veteran saw combat engagements, physical destruction, etc., the more likely the veteran will be suffering from some form of PTSD.

Also, do not assume that even if the veteran is suffering from PTSD, the veteran will be emotionally charged in all contacts with you.  For professionals such as attorneys, educators, salespersons, for example, you might see veterans only briefly, perhaps in settings that are not at all that stressful or important.  You’ll be working with men and women who are just trying to live their lives.  Aren’t we all.

The more you are interacting with a stressed veteran with PTSD, however, the more likely that you are going to be experiencing yourself a variety of strong emotions as you sit with the veteran, even if you are discussing (what should be) relatively  unemotional material.  As I stated in a post several days ago, just sitting in the presence of a distressed combat veterans–even a mildly distressed one–can be an experience unto itself.  Most of these veterans are already quite intense in their emotional responses; if you add anxiety to that intensity, you can have a quite a combo on your hands.

And it will be a combo that you yourself are going to feel inside you.  The way our brains are built, most of us quite naturally experience the emotional states of others because of the capacities of parts of the frontal lobe of the brain (the part of the brain behind the forehead and, to some extent, the eyes).  These areas of the brain sense the nuanced physical expressions of people with whom we’re talking–how they’re looking, sounding, acting– allowing us to form quick, working assessments of their overall emotional state at the time.  This is nothing more than one biological explanation for the phenomenon of empathy.

Therefore, you the professional, must be prepared to have a physical-emotional response to a distressed combat veteran.  Furthermore, if it is likely that you will be interacting with veterans regularly under such circumstances (making tough legal decisions, talking about how a class is going, negotiations for the purchase of a home), you need to have a “game plan” in mind for managing your own responses as effectively as possible.

The best metaphor I have found to help you formulate a game plan is the metaphor of place and distance.  Imagine yourself in front of the distressed veteran.  Your goal is to keep an “ideal distance” between you and the veteran, certainly figuratively, and perhaps even literally.  You don’t want to be drawing “too close” to the veteran (for now, let’s focus on emotionally), but neither do you want to be “puling back” from the veteran.  You want to keep yourself firmly planted where you are, smile, and do what you know to be helpful.

Remember:  if the veteran is experiencing strong, distressing emotion–it’s not about you!  Even if in a way it is (e.g., you’re a teacher giving a grade), the intensity of the emotion is always about their war experiences, never about the current situation.  Granted, you will be the one in the room with the intense veteran, so it is about you in that you’re going to have to deal with the situation.  You will absorb the emotion, whether you want to know or not.

Absorbing, however, does not imply a responsibility for figuring out what to do with the emotion.  For some of you (mental health clinicians), yes, it will.  More for you below.  For most professionals, though, you have the following mantra available to you at all times:

1).  I don’t like this emotion.  The veteran doesn’t like this emotion.  It’s about the war, not about me.

2).  If I focus on the task at hand–while recognizing to myself that this situation is a little hot–I can keep both of us focused on that task.

Think of it this way:  you want to be aware of the “elephant in the room” (i.e., the distress), while not focusing on the elephant.  You can certainly acknowledge the distress in a straightforward, humane way (“I know, this stuff’s hard to get through, but really, working together, we’ll get the job done”).    But you stay firmly planted in the (relatively) neutral psychic middle ground between you.  (I’m reluctant to call it a “demilitarized zone”:  too many ways the connotations could go.)

No need, in other words, to withdraw emotionally and become too cool and analytic, on the one hand, or too timid and indecisive on the other.  But also no need to get more emotionally involved, i.e., get too close.  If you’re not the veteran’s therapist, then, think of it this way:  congratulations!  Since you can’t heal the war’s wounds in the veteran’s life (neither can the mental health clinician, but that’ll be for another day), you don’t have to get too caught up being “helpful.”   Such “help” rarely turns out to be so.  Trust me.

Be nice.  Do your job.  Stay put.  Acknowledge the pain, but work with the life.

Briefly, though, for those who will have to address that emotions directly, let me say this.  Without doubt, the best way to be able to sit with someone else’s strong emotion over time is for you to have a solid, workable sense of the following–and not just intellectually, but down to your bones:

1.)  There can be a good-enough coherence to a life–never perfect, but good-enough.  And I’ve got that.

2).  Just being with a person in pain makes a difference–a real one, not just a this-is-the-best-we-can-do, compromised one.   I know that.  People have made a difference for me by being with me at crucial times.  I can do the same for this veteran.

3).  The more coherent you feel, the more comfortable you will feel in your middle-ground place and therefore the more you wil be able to offer yourself emotionally to the veteran, for from the beginning you will be confident that the middle ground is not only precisely where you need to stay, but also where you can indeed stay, even while opening up, in a truly vulnerable way, your heart.

Back in the day (I hate to say it, but I’m old enough, I can), all mental health clinicians were taught that the best way to achieve this confidence in your position was to undergo your own therapy–why?  So that, simply put, you will know in your own gut that it can happen and it can stick.  You don’t have to rely on textbooks or what others have told you, for someone stood warmly and comfortably in your own middle ground, managed well whatever came her or his way, and voilà, consequently your own life eventually felt much more manageable.

Today, my sense is that many younger clinicians are, at best, encouraged only to get “pieces of work” done to manage specific “challenges” that arise in the clinician’s professional or personal life.  Long-term, intense sitting with one’s pain in the presence of another is now, apparently for some, considered to be 1).  too expensive, 2). too time-consuming, and 3). not all it’s hyped up to be anyway.

Well, maybe.  But warning:  if you’re sitting for any length of time with a distressed veteran, with a goal of helping that veteran in that distress, you are heading right into “Danger, Danger, Will Robinson” territory (check out Lost in Space in Wikipedia).  I certainly know that I would never have been able to manage myself well with combat veterans had I not had the insights and experiences of my own therapy.

“Catching pain” is real.  Sitting with pain–and with a life trying to go forward in the midst of pain–is hard.  Really hard.  As mental health clinicians, our hearts (and sometimes our bodies) often want to bolt smack dab upright from the sitting position and get moving, darn it, this is war!  Fight or flight, right?

No, not right.  Sit.  Absorb.  Teach and demonstrate what you can.  But then “metabolize” that emotion, as the psychoanalyst Wilfred Bion once said.  Over and over.  It won’t be fun, trust me.  But it will be worth it, for the veteran–and for you.

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