A Veteran Speaks Out About His VA Clinic

The following is the most recent post from Max Harris in his blog, Every Day Is a New Day. As I have often said, I admire Max greatly for his passion, his service, and his willingness to walk the walk that he talks. He doesn’t pull punches.

Given how important recent events have been for him (see my last post, In Memoriam: Joseph J. Casagrande, PhD, 1943-2013), I felt it important to reblog this post as well.

I, of course, cannot speak personally as to his experiences with VA personnel over the past days.

I will say this, however: Grief is real, physically real, not an emotional option, but an emotional necessity. Of the seven primary emotions postulated by many modern affective neuroscientists, CARING and LOSS/GRIEF are two. It is the former that draws us to our families, our friends, our communities. It is the latter that lets us know that all is not right, that we are in danger, alone, in need. Our brains and minds take these basic emotions and elaborate them in all the ways we have to experience closeness and distance, from ways prosaic to those poetic. But at their bases, these emotions call us as deeply, as insistently as any other.

For combat veterans as well, it is these very emotions and their offspring, CARING and LOSS/GRIEF, that often waylay them most powerfully and, I must say, most predictably. Combat veterans learned the power of CARING, of the deepest of friendships, even of love in basic training, in the dorms and chow halls, outside the wire, together. And sadly they learned, sometimes in ways deeper than they ever had previously dared imagine, the power of LOSS/GRIEF, the loss of love that takes with it a part of one’s very soul.

I’ve said it time and again, as have many far brighter than I who have worked with those who have served in combat: never underestimate the love and the grief of a soldier, a Marine, a seaman, an airman, a Coast guardsman who’s put himself or herself in places where terror can sidle right up to him or her, tap the shoulder, and whisper a “boo!” that emanates from the depths of Hell. Never.

As professionals, even as loved ones, we cannot rescue the combat veterans in our lives from the loves they have lost, the pains they have endured. We can, however, do the best that each of us can—some a little, some more—to absorb at least portions of those griefs, those pains, never fully (believe me, the veterans never ask that of us; they know far better than we do the impossibility), but always genuinely.

It’s the least we owe them, the absolute least.

My heart goes out to you, Max, for losing Dr. Casagrande, for having lost all those you lost as you served, for having seen all the losses around you over which you had no control. You have always been a strong man. You are one. You will always be one.

Remember: strength and sadness, resolve and tears can co-occur. They’ve been doing so for centuries, yes, even among warriors.

That’s just the way it is.

For all who have loved and lost, who can be angry because of that, who still struggle to make sense of a world in spite of that:

After everything that happened yesterday, I needed to find answers. I was in no condition to work but tried anyways. I made through a little over two and a half hours of my shift before I couldn’t hide my grief anymore. I was emotionally drained and physically exhausted. I left work and I headed straight to the VA and asked to speak to the Patient Advocate. I was ushered into his office and he asked me how I was doing and what he could do for me.

I told him about the past month and the way that I had been treated and that I was very upset with the manner in which I had been informed of Doctor Casagrande’s passing. He responded without remorse that he and upper level administration had decided the best way to handle this ‘situation’ was to not allow non-clinical personnel to say anything and to keep mum until the vets came in for their next scheduled appointments. At that time another doc would be waiting to (sarcasm here) ‘blindside’ an unsuspecting veteran with this horrible news. I was stunned. I told the advocate that I don’t have scheduled sessions with Doc Casagrande and that I was only in his group CPT session. The advocate responded, “So many people come and go through the groups that we didn’t bother.” Again – stunned. I told the advocate it would have been easy to see, if he would have bothered to look at the rosters that I had been at EVERY session for the last six to nine months. Remorseless, he deflected my comment with something along the lines of what’s done is done and ‘gee, we’re so sorry you found out this way.’ I followed up by telling him that no one offered me grief counseling, nothing. He very quickly offered, :”would you like to talk to someone now?”

It was at this point that I realized that the administrators had no flipping clue how to handle these situations. This advocate, along with administration higher up, put hundreds of behavioral health patients at risk with their approach to dealing with the doc’s passing. I wondered if the disconnect flowed into the care side, so I said I would like to talk to someone. I was introduced to a clinician (I don’t remember if she was a doc or a nurse or a social worker) and talked about how messed up I was from all of this and it became very evident to me that she was distressed at how distressed I was. She told me that every veteran that she had seen in connection to Doc Casagrande’s death had reacted EXACTLY the same way I have. She also mentioned (although I don’t think she really meant to) that there were still veterans that didn’t know because they hadn’t been in for their scheduled appointments yet. She told me, “I know, after everything that’s happened that you have no reason to trust us, but would you at least talk to one of the docs tomorrow who is taking over Doc Casagrande’s patients?”

I could sense her frustration with the whole situation. This was an utter mess and Doc’s co-workers were just as caught in this storm as I was. I said I would meet with someone tomorrow and I scheduled my time to meet.

After I left and was on my way home, I thought about the whole situation and it made me incredibly disgusted. That patient advocate was to advocate for what was best for the patients. Either one of two things explain his decision: He was lazy and didn’t want to put in the extra work and due diligence to make sure every one of the doc’s patients was informed as quickly as possible OR he was put in the position to make this decision without any knowledge of what WAS best for us. The VA needs to understand how much danger they put the veterans in. If I was any less stable than I am, I would have done things I would have regretted (become a danger to others) or done something I would never be able to regret (committed suicide). Every veteran should have been afforded an equal opportunity to grieve and should have been told in enough time to attend the memorial services. The way they decided to handle this situation was reprehensible and inhumane.

So, I stand by what I said yesterday in my post. The VA needs radical change. And it needs it now. No longer can we continue to put our nation’s heroes at risk due to the ineptitude or apathy of bureaucrats. I will fight from now until my last breath to make sure this change happens. Come hell or high water. I have had people tell me the system is too big to change. I respond with this. Bullshit. When the people you are designed to serve are forced to go elsewhere to ensure they receive quality care and compassion, you have failed to meet the most basic of requirements for your continued existence. I will not bear the legacy costs of a broken VA when those legacy costs are paid for with the blood of my fellow veterans who have lost hope and take their own lives. The time for change is now. Let’s be heard, folks. Don’t stand silent and condone this with your inaction. Fight for the change we all deserve.

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

Dear Sir,

Let’s now talk about the persons who should–sadly, I must italicize that word–be available to bear with you as much of the truth as can be spoken: your counselor or psychotherapist.

3. Decontamination and “Putting the Truth Into Words”: Loved Ones, Psychotherapy, Journaling (B)

As I said earlier, if medications are detoxifying agents of the pool, then psychotherapy (or its equivalent) is the decontaminating agent of the pool. I stressed “of the pool” because, as I said in the last post, the “contaminants,” i.e., the memories of the experiences of the War, still need to be detoxified. Psychotherapy, however, detoxifies outside the pool, on the observation deck. In Real World terms, that means that psychotherapy relieves the pain of the War by bringing it into the therapeutic relationship, feeling it, talking about it, and dealing with it there.

The Truth and Psychotherapy

First, let me say up front what every combat veteran already knows: not every therapist in the VA system (or for those of you in other countries, your national treatment system) is worthy of the name. I know that. In fact, one of my colleagues put it most colorfully when she described a VA clinician (fortunately) not at our facility as someone who “has all the empathy skills of a lower amphibian.”

Sad to say, I know the clinician whereof she speaks, and sadder to say, my colleague is spot-on.

I would ask you to consider, however, that sometimes the problem is more a mismatch between therapist and veteran. Just as combat veterans differ in how they rejuvenate, so do therapists. Perhaps through understanding this, you and/or some of your fellow veterans might be able to salvage some therapeutic relationships. At the very least, you might have a better understanding of why a particular relationship might not work, no matter how hard either party might try.

a. Psychotherapy, Kinetic-Energy/Extroversion, and Potential-Energy/Introversion

Generally speaking, psychotherapies geared toward helping veterans with combat trauma/PTSD are ultimately neutral as to whether they can be effective for kinetic-energy/extroverts or potential-energy/introverts. It is less about the therapy itself and more about how that psychotherapy can most effectively be used with any particular veteran.

That being said, therapists trained in most modern mental health training programs, i.e., psychiatrists, psychologists, social workers, mental health counselors, tend to have been schooled in a “world view”that is much more congruent with the kinetic-energy/extroverted style of rejuvenation rather than that of the potential-energy/introverted. As I have stated in earlier posts such as Treatment Plans and Is It Something I Said? (all right, I admit it: as I lamented), the ethos of much modern psychotherapy practice is get-‘er-done, get-‘er-done efficiently, and get-‘er-done fast. Even when particular therapists resist this type of practice mind-set, they often still have to justify to the powers-that-be why they in fact are resisting. “Expedient effectiveness” is the name of the game.

It is, of course, ridiculous for anyone (starting with myself) to argue that psychotherapy should not be expediently effective. All of us want suffering to end as quickly as possible, after all.

That’s not the point.

The point to remember in the following discussions is this one: kinetic-energy/extroverted veterans rejuvenate far away from the inner emotional pool. Potential-energy/introverts, in contrast, must rejuvenate right next to the emotional pool. Any particular decontamination technique (i.e., psychotherapy, especially an “evidence-based” one) might work equally as quickly for a kinetic-energy/extrovert as a potential-energy/introvert in terms of rate of pool decontamination. However, the former can escape the stench in order to rejuvenate, while the latter cannot.

To understand the ramifications of this, let us look at how the psychotherapies fit into our metaphoric system and then look at how the kinetic-energy/extroverted and potential-energy/introverted “environments” influence how these therapies may be most effectively used.

The Evidence-Based Psychotherapies

Two officially-sanctioned therapies for combat trauma/PTSD in the United States’ VA system are prolonged exposure therapy (PE) and cognitive processing therapy (CPT). (I would have also liked to have included in this list for my discussion eye-movement desensitization and reprocessing therapy, or EMDR, but given the time it would take to explain it, I’ll save that discussion for another day.)

Let’s go back to our pool analogy. Metaphorically, in PE the veteran dives right into the contaminated pool, with the therapist (hopefully) right there on the observation deck, gently pushing the veteran each time to swim a little longer, gather a few more contaminants, throw them out on the deck, and then get out of the water to sit with the therapist long enough to allow the toxins to seep out. In the Real World, that means that the therapist encourages the veteran to remember in detail the most traumatic experiences, usually recording them (e.g., cassette tape or digital recording) for later playback, so that with each episode of listening to the recording and remembering (i.e., jumping into the contaminated pool), at first in the therapist’s presence and then later on his/her own, the veteran can be less and less emotionally devastated by the memories and thus can be freer to experience a variety of emotions, both good and not-so-good, in that very same Real World.

In contrast, CPT is a bit more like both veteran and therapist sitting on the observation deck throughout the treatment, with the therapist giving the veterans lessons and guidance in how to use a net to fish out the contaminants and then bring them out to allow the toxins to seep away. In Real World terms, the therapist asks the veteran to observe the patterns of emotional responses, the thoughts and actions that trigger them and relieve them, all for the purpose of the veteran’s learning more effective ways to “think through” painful emotions before they get out of hand.

Kinetic-Energy/Extroverted Combat Veterans

In an earlier post, I wrote:

For kinetic-energy/extrovert veterans, [the “observation deck”] 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.

PE and CPT are more than just techniques, even though there is a “technique” aspect to how each therapy encourages the veteran to “decontaminate the pool” (“diving” for PE versus “net fishing” for CPT). Both rely heavily on the therapist’s and veteran’s having a good relationship within which to detoxify the contaminants once they are “out of the pool,” i.e., identified and discussed in the therapy.

Both therapies adapt quite nicely, however, to the kinetic-energy/extroverted veteran’s rejuvenation style. These veterans want to “get the job done” so that they can take back to The Real World better emotional states with which to live, interact–and thus rejuvenate. Being, in their classic form, very “goal-focused,” these therapies serve well the kinetic-energy/extroverted veteran’s goals by giving the veterans “something to do.”

The more trauma a kinetic-energy/extroverted combat veteran has endured (whether before deployment or during), the more contaminants there will be in the emotional pool and the longer the duration of the process will be. As the psychotherapy continues, however, there will be fewer and fewer contaminants to be removed and detoxified. Combine this with the fact that the kinetic-energy/extroverted combat veteran will always come “back” to the pool having rejuvenated “far away” from the pool, the veteran will almost certainly be able to take over the decontamination-detoxification process from the therapist more quickly than would have been the case if the veterans could not have rejuvenated in that way (i.e., if the veteran had been potential-energy/introverted).

Remember: it is not that kinetic-energy/extroverted veterans are not reflective, for many of them are. It is not that they do not ponder the existential and spiritual issues of War, for many of them do. It usually is the case, though, that they do not regularly seek to reflect and ponder, for (usually) they are much more focused on motion and interpersonal connection day-to-day. It’s not that they couldn’t discuss such “inner” issues in psychotherapy. It’s just that more often than not, they would prefer not to do that too much at all–and certainly not by having to take a couple hours out of their week to do so with a relative stranger.

Potential-Energy/Introverted Combat Veterans

In that same earlier post, I then wrote:

[For 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, [they] then need to move to an “adjacent” area in order to sit quietly within [themselves] and reflect not only on what [they] feel, but also on what [they] know, whom [they] know, what [they] might wish to do with such knowledge, all for the purpose of rejuvenation, of getting the energy/intensity [they] need to live out that knowledge in The Real World in the ways [they] 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.

Like their kinetic-energy/extroverted counterparts, the more trauma a potential-energy/introverted combat veteran has endured (whether before deployment or during), the more contaminants there will be in the emotional pool and the longer the duration of the process will be. Similarly, as the psychotherapy continues, there will be fewer and fewer contaminants to be removed and detoxified. The stench of the toxic pool will lessen over time.

But the potential-energy/introverted veteran must rejuvenate in the midst of the stench, no matter how long it takes for that toxic stench, through therapy, to lessen.

Here is the essence of the potential-energy/introverted veteran’s dilemma with the evidence-based psychotherapies as they are often presented by some practitioners: just as the emotional pool is only one part of the spa, so is the decontamination/detoxification of that pool only one part of the veteran’s recovering his or her ability to rejuvenate in any meaningful way.

In other words, once potential-energy/introverted combat veterans have decided to open themselves up to trying psychotherapy, they are usually expecting their therapists to help them out with rehabilitation of the whole spa, not just the decontamination/detoxification of the pool.

For the potential-energy/introverted veteran, the therapist who relies solely (or essentially solely) on evidence-based psychotherapy techniques and interactions is like a specialized subcontractor for the spa rehabilitation, rather than the general contractor  that the veteran is so desperately seeking. It’s as if such a therapist is saying to the veteran, “Sorry, I just clean pools. If you need someone to freshen up the air while I’m getting the job done or help you renovate spiritual aspect of the place, you’ll need to call somebody else.”

In other words, veteran and therapist never had, as we say in Law-land, a “meeting of the minds.”

I am absolutely convinced that this is why many combat veterans, usually the potential-energy/introverted types, can “successfully”leave an evidence-based therapy, whether individual or programmatic, and yet still wonder aloud, “I’m supposed to be fine now? So why do I still feel so bad?”

The answer is simple: the veterans “still feel so bad” because the toxicity of The War Within not only poisoned their pool, but also poisoned their entire spa. It’s as if the toxic fumes have rotted the walls, destroyed all the furniture, made the whole place inhabitable, with no place to be fed, no place to be revived, no place to be treasured. They had thought that if they were going to be opening themselves up to the pain of psychotherapy, they were going to be getting a full renovation–not a partial job (though a competent one) with options for referral to other providers.

So how can such a mismatch/misunderstanding happen? I have three hypotheses.

Different Veterans, Different Therapists, Different Systems

Hypothesis One: Potential-Energy/Introverted Veteran + Kinetic-Energy/Extroverted Therapist (with standard, modern training)

Even if a therapist is kinetic-energy/extroverted, one should not assume that she or he cannot understand the rejuvenation strategy and needs of a potential-energy/introverted veteran. My longstanding consultant/supervisor, for example, is as kinetic-energy/extroverted as they come (you ought to see her do West Coast Swing dancing), yet she is a well-known, well-respected psychoanalyst who specializes in understanding the inner world of trauma victims.

Similarly, one should not assume that just because a kinetic-energy/extroverted therapist has been trained in more contemporary training programs, the therapist cannot sit for longer periods of time with veterans and do more generalized, “inner” work that is not solely focused on symptom management and emotional regulation.

Still . . .

I do think that many kinetic-energy/extroverted therapists from contemporary training programs have little to no understanding of the potential-energy/introverted veteran’s (or any other patient’s) need for more extended inner reflection in order to feel that anything of value is being accomplished. In fact, many such therapists, from my experience, do seem to believe–quite sincerely–that focused, goal-oriented, shorter-term treatment is not only something valuable, it is something superior in value.

Some of them–and I do mean only some–even seem to believe with all their hearts that if a veteran is not responding with reasonable enthusiasm to a more standard, evidence-based approach, then the veteran is either a). suffering from longstanding trauma that must have predated the employment, or b). resisting treatment because of personality disorder issues or a conscious desire to seek the sick-role in order to maintain an illness that will allow disability benefits to be paid.

I wish I could say that I have never heard a VA therapist say such things. Even sadder, though: it’s not only the occasional kinetic-energy/extroverted therapist who does.

Hypothesis Two: Same Veteran + Potential-Energy/Introverted Therapist who cannot tolerate strong emotion for extended periods of time

I wish this were not as common a scenario as it apparently is.

I am going to make a boldfaced, general statement: most modern mental health training programs do an atrocious job in teaching their trainees how to work with individuals who have been severely traumatized.

I cannot fault a relatively-new therapist for struggling to deal with the emotions brought on by sitting with any traumatized individual, let alone a combat veteran. Classroom education cannot adequately prepare anyone for those challenges.

Too many recently-trained therapists, however, have zero conceptual inkling of even how to understand such challenges. They don’t even know what they don’t know, and too many of them think they do. These are often the therapists who reduce PE and CPT to mere technique, almost as a way to assure themselves that they are a). competent and b). accomplishing something.

At one time, you could assume that therapists had undergone some type of more extended therapy themselves. You can no longer assume that. In fact, I’d say you’d be more often right if you were to assume that any particular therapist has not. That is not to say that the therapist has maybe not done a counseling session or two or three at some point in his or her life. But it is doubtful that he or she has done much extended work. The modern ethos of psychotherapy is “keep it focused, keep it quick.” You don’t need to have that much such self-understanding to do that relatively successfully and graduate from a decent program.

In fact, after a session or two of instruction, you could probably do all the rest of the therapy with an app on a good iPad, right?

Admittedly, kinetic-energy/extroverted therapists usually can get away with minimal therapy of their own. Usually they do work that is focused, and they prefer to work with people who are able to stay focused. As I often say, no harm, no foul.

The ones I worry about are the potential-energy/introverted therapists who, by their very nature, spend a lot of time in their inner spa, yet who are not that particularly aware of what’s going on in there. My experience is that many of them do evidence-based therapies particularly badly with potential-energy/introvert veterans: at their core, the therapists know that a lot more than the emotional pool is at stake, but they can’t even keep their own inner world in order, let alone another person’s.

One can get away with such semi-blind-leading-the-blind therapy (sort of) with standard issues such as depression or anxiety. But with the horror of combat trauma? Usually bad news, all around.

Hypothesis Three: Same Veteran + Potential-Energy/Introverted Therapist who is caught up in a “do more with less” System

The majority of potential-energy/introverted therapists whom I know fall into this third category. I am not going to rail against my employer here. I work for the largest healthcare system in the United States, and it’s a very public-faced one within a highly political context. Everyone is doing what they can with what little they have–oh, yes, and we’re going to have to cut back, you know, spending beyond our means, so the wise ones of Congress and the think tanks say, and all that . . .

There are no surprises here: a (massively) underfunded War with no clear strategy for providing afterwards for the large number of combat veterans in general, let alone a strategy for differentiating treatments based on underlying personality dynamics (although there are those that hope against hope one day to find a blood test to figure it all out). Combine that with a challenging economy without a lot of leeway for those with interpersonal challenges or mild cognitive challenges, within a group of young men and women who have families that need to be not only provided for, but watched after, requiring packed schedules with little room for play in them, and what do you get?

Why, eight visits within fourteen weeks of focused, evidence-based therapy, with supplemental support through veteran-run groups, right?

Don’t get me started.

There are a lot of excellent, overwhelmed, and semi-demoralized potential-energy/introverted therapists out there in the public sector, trying to help potential-energy/introverted combat veterans who are looking for more than a few well-run individual sessions followed by groups of “veterans helping veterans” (only a kinetic-energy/extrovert could have come up with that line and felt it to be the self-evident goal so many want to make it out to be). Many such therapists  love their work and the veterans whom they serve, yet they are finding every day of work to be so very, very frustrating.

Well, dear Sir, even if all that does supply some valuable background information, it does not help you much with your challenge, does it?

At this point, I’m going to go out on a limb, speaking as an individual and not as an employee of the federal government: if you are a potential-energy/introverted combat veteran who, because of your emotional intensity, is looking for an opportunity to meet more regularly with a therapist to try to reconstruct your “inner spa” in as many ways as is feasible so as to maximize your meaningfulness in life?

Look outside the VA.

I wish that weren’t the case. But as of today, I believe I can say: it just is.

The following three national organizations might be able to help you in this search:

1. The Soldiers Project is an excellent organization that is continually trying to recruit experienced therapists to provide free, ongoing therapy for combat veterans who are looking for longer-term solutions to their inner turmoil. As of this point, they are primarily hindered by the relatively-limited geographic availability of therapists, but they are working to increase their supply of referrals daily. I cannot recommend them highly enough.

2. Give an Hour is a larger organization that provides similar services, i.e., referrals for free care in the community for veterans with a wide variety of needs. This organization tends, from my understanding, to draw on a variety of therapists using a variety of modalities, so it is not solely about therapists seeking to provide longer-term services for veterans who feel a need for them. Yet they remain ready to consult with veterans  to try to find a therapist who will best meet a veteran’s personality style and goals.

3. The Pathway Home is a superior, residential facility located in the Napa Valley of California that provides intensive, four-month-long, twenty-four-hour-a-day programming in an unlocked, residential setting to help combat veterans deal more intensely with their emotional struggles. It is a nonprofit organization using a variety of funding sources to provide care for veterans without requiring insurance or private pay, and they have access to a variety of national programs that help veterans with transportation to California, as well as to a nationwide network of alumni who provide 24-hour support to each other through texting, social networking, and other avenues.

I wish, dear Sir, that I could offer you more in the way of longer-term treatment options, but they remain limited at this time. I am thus fully aware that none of these options may turn out to be viable ones for you.

Therefore, in the spirit of the military’s “change course and keep going,” let me conclude with the next post on alternatives, including “spiritual”or “ritual” retreats, work with clergy, and, when all else fails, journaling.

Semper Fi (x 2)

You gotta hand it to Marines: they’re Marines.  Really, what else can you say?

With an amazing amount of accuracy, you should be able to spot one from about twenty feet down the hall.  No one quite walks like a Marine, let’s face it.  Yet worry not: if you miss said Marine at twenty feet, you won’t at five, given that every article of clothing he’s wearing (almost certainly including his boxers) has some permutation of “USMC” emblazoned somewhere thereupon.

And you had better show proper respect for each article thereof, too, if you know what’s good for you.

I met him just this past week.  While probably a bit stockier than he had been right out of San Diego, he was not so by much.  I would have said “Yes, sir” to this guy no matter what my rank.  Every muscle on his face was advertising “resolve” in luminescence just short of neon lights.  He walked into my office with resolve.  He sat down in his chair with resolve.

And it was taking every last bit of his resolve to hold on to his resolve.  For the boy had been jonesin’.  And I ain’t talkin’ a little bit.

He had just made the decision: it was time to stop the pain pills.  They weren’t helping that much anyway, and they were taking over his life.  He’d come too far to let that happen.

And far he had come: he had partipated in engagements that every single one of you who is reading this either a). heard of, or b). had to work really hard not to hear of.  Casualties were many.  He lost men he was so close to, he could finish their sentences.

When he came back home, it was hard, really hard, on his wife as much as on him.  Two girls were born during the time.  He struggled, the usual, the nightmares, the flashbacks, the emotional outburts, the whole bit.

He came to the VA the first time and ended up with a therapist he didn’t find that helpful.  Yet he hung in there.  He’s a Marine, after all, once a Marine, always a Marine, hang-in-there Marine.  She assured him, after all, that if he just stuck with this “prolonged exposure therapy,” he’d feel better.  She knew it.  She’d seen it happen.

Finally he’d had it.  He called it quits.

Soon, however, both he and his wife had had it with how he’d become after he’d “had it” that first time.  So being a Marine, he tried again.

This time it worked.

He has felt understood.  He has felt that he has been taken seriously.  He has felt that he doesn’t need to worry about falling apart every time he walks out of the Clinic door.

The therapist meets with him and his wife.  There have been some challenging encounters.  But he and his wife are together, working together.  He’s even doing more than his fair share of the childcare.

“And you know what?” he said to me.  “I’m not that bad at it.”

Of course not.  He’s a Marine.

True, I know: many will not associate “Marine” with “caretaker,” and they will be right (and often, quite painfully so).  Yet this man is a Marine’s caretaker: he has taken on his daughters as a mission.  He has looked hard at his behavior.  He’s “loosened up”–I won’t say “quite a bit,” but “a bit” isn’t fair either.  He is proud of himself.

He still has bad days.  Certain days of the year are harder than others.  He and his wife still have their struggles.  Nightmares can still come to haunt.  But by his report, he is doing much better.

Day One, he started on Suboxone, the opioid substitution medication.

Day Two, I had a chance to meet his wife and daughters.  His wife is a pleasant no-nonsense, armed with very appropriate questions for me about her husband’s care.  The older girl actually sniffled a bit and crawled into Mommy’s lap upon first meeting me, yet within a good ten minutes, she was–well, not exactly warming up, and not exactly flirting, but more like, what, letting me know that she might give me a chance, but on her timetable, thank you.

And the younger daughter?  If that girl ain’t a general in the Marines by the time she hits retirement, then clearly there is no justice in this world.  She marched into my office, chatting full force, headed straight to the Keurig carousel and demanded to know the difference between Tazo Zen tea and Starbucks French Roast, and right now, buddy, understood?  She then began to inspect my bookshelf.  She was not impressed.  Fortunately a pen, a pencil, and some paper spared me further dressing down à la Full Metal Jacket.

By Day Three, our Marine was feeling much better.  And the General?  She was pooped, so she stayed in her stroller.  But both Papa and I knew that we’d better get our business done and fast, lest the demand for freedom come now, I told you, NOW!

I am indeed coming to the conclusion that Semper Fi has its own nucleotide chain on at least one chromosome.

Semper fidelis, however, “always faithful,” need not apply just to Marines.

I would also like to honor a mulier semper fidelis, i.e., an always-faithful woman: our Marine’s therapist.

While one may complain about the VA ad infinitum, one matter is undisputed: we have a great (and I mean, great) electronic medical record system.  With a few pecks on a keypad, I can get access to a veteran’s medical records from VA’s across the country.  And that is useful because, in this case, our Marine does not usually get his care in Indianapolis.

When I went to his full record, I counted up the number of sessions that our Marine (and sometimes his wife) have had with our faithful therapist.

Over the course of the past year, twenty-seven.

That’s 2-7.

Why, pray tell, you might ask, am I making such a big deal of said number?

Well, the answer is in the therapist’s notes.  For you see, with each note the therapist was assuring me, the reader, that she was performing “evidence-based CPT,” i.e., cognitive processing therapy.  She applied evidence-based CPT at her last session.  She applied it at the session before that.  I can only assume that she will apply evidence-based CPT at her next session (next week), as well as the session after that and the session after that.  I have no reason to assume otherwise (either as to her documentation or as to the fact that she will be seeing him at least three more times).

Let’s have some fun, shall we?  Check out this for link for Wikipedia, that final answer for all matters human.  It is to the article for, you guessed it, Cognitive Processing Therapy.

Read said article now.

Did you notice anything?

Did you notice the number 12 appearing in several places?

Pray tell, to what did said number 12 refer to?

What, you say?  The number of sessions needed to complete a course of said Cognitive Processing Therapy?

Hmm.   12.  27.  Correct me if I’m wrong, but 27 is 2.25x 12.

Am I right?

Hmm.  But the studies say . . .

Ah, the studies.

Let’s have us a little chat about my world at the VA, shall we?

The VA is really into evidence-based therapies.  Really, really, really, really.  (So’s the Department of Defense)

Now, the evidence assures us that 12 sessions of CPT should be quite significant in reducing the symptoms of PTSD.  I do stress reduce, for as we know, there is always an escape clause in every application of a therapy study, i.e., it’s statistical and actual results may vary according to the clinical situation.

I love that.  I mean, as a lawyer, I really love that.  Really, really, really, really.

I mean, give me that clause, and I’m good to go.

Clearly, so is our faithful therapist.

For you see, if we were to be honest here, our therapist is misusing critical human resources in caring for our Marine.  Why, if she were truly following what the evidence shows, by this point she’d have sent two Marines into the world, filled to the brim with new schemata to counteract their maladaptive beliefs, thus allowing them to move forward, beyond their stuck points, now on their own, to apply their newly-formed coping skills to myriad newly-arising life situations.

And furthermore, a third Marine would, even as we speak, be preparing to leave mere psychoeducation to enter into a phase of practice and Socratic dialogue, his or her redemption being assured, naturellement, before Halloween.

OK, here’s where it gets really fun.

Let’s go back to our “clinical situation.”  OK, 27, twenty-seven.  All right, now all we’ve got to do is come up with why we’re still at 27–and counting!

Oh, let’s see, what could we say?  Our Marine did not fully incorporate his learning sufficiently during the first twelve sessions because, oh, what, he didn’t try hard enough?  Oh dear, no, that can’t be it.  He lacked the requisite cognitive capacities needed to do so?  Oh, ditto, shoot.  His clinical situation was more complicated than those who participated in said studies that produced said evidence for said evidence-basis?  What, more of his friends died?  He got knocked around more than the other participants?  His dad beat him senseless every third day as he was growing up?  (Oh, shoot, no, the initial assessment tells us that’s not the case, darn it.)

Well, how about . . . this:

How about, 1).  His therapist knows what to put in the chart to keep the honchos-who-know happy.  OK, check.

Now for 2):

His therapist takes him seriously.  She does help him learn to think more usefully before his emotions get away from him.  She sits with his tears, as long as he needs to cry, no shame whatsoever, knowing that, yes, one day the flow of the tears will slow, that then will be the time to think, and feel, and think, and feel, and maybe not say anything for a few minutes, and then feel, and then . . .

And she’ll do this week after week.  She’ll remind him of the progress he’s made so far.  She will assure him that setbacks are part of the game.  She won’t even think about when Session Eleven becomes Session Twelve becomes Session Thirteen, because at the end of each session he says that it’s been helpful to talk, to get new ideas, just to get all this sh** off his chest, and he looks forward to getting together in a couple of weeks, and then a couple weeks after that, and then after that, because each time they’ll talk, and he’ll get new ideas and will get all this sh**off his chest, and then . . .

Fidelis.  Faithful.  This resolute man, though still struggling, is proud that he has regained some of his resoluteness.  People can still irritate the you-know-what out of him.  He still really can’t handle Target or Wal-Mart, let alone a job in which he actually has to act as if this buffoon he’s working with truly knows his head from a hole in the ground.  But he can talk more with his wife about the “problems of daily living,” as many of my fellow mental health professionals so disdainfully spit out.  He can take some time before bed, pull himself together, and even sleep more nights than not without revisiting Hell one more glorious time.  And if he runs into problems, he’ll talk to his therapist about it in two weeks–wait, no, it’s this week, isn’t it?

Whew.

And he can even manage to take care of the General.  By himself.

Well, what do you know.

I have only one thing to say, to the therapist and to the General:

You go, girl.

A Mennonite at the VA?

As some readers know, just this past week I enjoyed my one Warholian fifteen-minutes-of-fame:  one of my posts made it to WordPress’s home page, sort of my version of being “on the cover of the Rolling Stone,” if you know what I mean.  It was in that Warholian post, Conical Combat Linkages, that I revealed that I’m a “Mennonite by choice.”  According to my stats, more than a few people now know this about me.

Interestingly, also last week Anna Groff, an editor of one of our Church’s national periodicals, The Mennonite, contacted me about an article she’s putting together on Mennonites who work at the VA.  Apparently there is not a huge crew of us, surprise, surprise.

For readers who may not know: Mennonites are a Protestant group who were originally known as “Anabaptists” during the Reformation.  Originally from Switzerland, southern Germany, and Holland, many came over to the United States in the eighteenth century, first living in the Pennsylvania area, then moving to the Midwest, especially Indiana and Ohio, with later groups settling in Kansas and points West, or in the western regions of Canada.  There also is a large group who live in Central America and in Paraguay.

Don’t ask about the latter two.  It’s complicated.

(I did feel compelled to mention the latter, however, given that a group of one of our more distant, conservative cousins, the Beachy Amish Mennonites, living in Nicaragua, were described in a not-too-flattering front page article in the New York Times today.  For those who have read the piece, just rest assured: when I say distant, I mean distant.  I’ll leave it at that.)

Traditionally Mennonites, like the Quakers, have felt strongly that the Christian faith requires its adherents to avoid violence, seek peace, and refrain from participating in wars.  In other words, we are usually referred to as pacifists.

Ergo the title of this post.

Anna sent me a list of thought-provoking questions to answer for her article, and so I decided: well, since I’ve identified myself as Mennonite on the blog, I might as well answer her questions in a post.  After all, readers–and even more, patients–should know whom they are getting when they get me so that, well, they can decide whether they even want to get me at all.

Because this is such a complex issue that speaks so directly to many areas of my life about which I feel strongly and deeply, my essay in answer to her questions is quite long, even for me!  Also, it has a certain in-group-ness about it which may not be agreeable to many readers.  Moreover, for many readers a discussion of issues of faith itself might not be the way you’re wanting to while away your next more-than-several minutes of your life.

Given that, I have posted the essay separately, under the title Letter to a Mennonite Pastor, which can be accessed either through the link just provided or through the “Thoughts” menu above.  It may end up of interest only to fellow Mennonites.  (It may end up of interest to absolutely no one at all.)  Still, as I deal in it directly with my role as someone who is both a member of a particular faith community and as someone who serves combat veterans, I hope that others might find that the discussion in it will, at least in some way, prove enlightening.

Many thanks to all those who have visited the blog these past few days, and especially many thanks to those of you who “liked” the Conical Combat Veteran post and to those of you who have subscribed.  I hope that I continue to write posts that each of you will find worthy of the respect and caring every returning combat veteran deserves.

Just a Chasm

As I said in an earlier post, last week I had a fruitful discussion with colleagues from VA Hospitals around the country about what it means to recover and what it means to be treated for combat trauma.  Several posts will probably arise from it.

I still, though, have to go back to my original post, Was It Something I Said, now with new questions.  In one of my VA correspondences last week, I wrote the following:

I suspect that I simply experience the world and myself in ways that are fundamentally different from the ways that many of you [my colleagues] (and many . . . veterans) experience your (their) world and yourselves. What I fathom, you may be able to understand, but not fathom, and vice versa. We use the same words—treatment, evidence, cure, recovery, time, therapy—and yet we have profoundly different experiential understandings.   I meet veterans who resonate with my understanding—and I meet veterans who do not.  Clearly persons such as I are now in the minority of our profession, and perhaps that is good. Perhaps most experience the world quite differently than I do, and thus my job is to accept that and enjoy their hard work, resilience, and—by anybody’s definition—recovery. It truly is a cautionary tale for me . . . that I do not try to create what another cannot—and even should not—ultimately fathom. We do what we can as we live in the times . . . we do.

I’ve thought long and hard about these words.

Quite early in my life, a series of events occurred around me that have had a profound impact on my experience of the world.  While most of these events were purposeful, none was malevolent.  People simply lived out their lives in the only ways they knew how.  Sadly, those ways were not the most propitious ones for me.

That’s the way life goes.

I have spent many hours in therapy discussing these matters, many hours in intimate, personal conversation, many hours in theological reflection doing the same.  These hours have paid off: I find myself feeling much more invigorated in life, much less reactive, much calmer, much more hopeful.  I know for certain that growth, change, and significant recovery are quite possible–and quite rewarding.

Yet after all these hours in all these endeavors, something quite deep inside me remains not right.  Even though I rarely have to confront that fact outright, I cannot say that I never have to.  Certain triggers still bring an intense jolt in my gut that can wipe out (now usually only for a few moments, thankfully) any useful, couterbalancing thought in my forebrain, a jolt that demands–no, screams for–emotional expression.

Previously that expression was usually sadness, often mixed with a certain anxiety.  Now it is almost exclusively anger.  Fortunately I have become far better able to squelch the latter when it is not a useful response, although that often means that I may have to abandon a conversation, even if only simply by turning quite taciturn quite rapidly.

Moreover I will not deny that there are times when I’m more than willing to let that response sashay right into the open light and  skewer some of the people who happen to be in proximity (verbally only, of course).  Given that I love words, and given that I was well-trained as a lawyer, I frequently have no problems whatsoever linking the word  words with the word  skewer.  I also cannot deny that the linkage can, at times, be indeed quite a satisfying one.  I so confess.

Still, while my old emotional injury provides its brief pleasures, far more often, as a result of it, certain interpersonal experiences are, to use my above word, unfathomable to me, where I mean unfathomable to be not about the experiences’ being impossible to understand, but rather about my being completely incapable of conceiving of experiencing them–and certainly for any appreciable length of time.

Admittedly, this is hard to discuss in the abstract, but, sorry, I have no plan to get too particular to help clarify.  Suffice it to say this: at times I sense that people are sharing certain emotional experiences with each other–and perhaps more importantly, are willing to persist in sharing those emotional experiences–in a way and a depth that I simply don’t, at a gut level, “get.”  For even if I can cognitively “get” the experiences themselves, I cannot emotionally, deeply “get” how and/or why one would persist in those experiences, even though clearly most people find it at some level satisfying to so persist.

In such situations, I cannot conceive of myself having those experiences because I cannot conceive that my body would ever not “jolt” whenever such experiences were to present themselves.   Honestly, in such circumstance, I am always jolting long before I even consciously realize I’m jolting.

If you’re with me so far, then let me describe two practical, almost daily corrolaries from such truths:

1.  Being an Outsider in an Insider’s World

Even though I lead a happy, fulfilling life, in a profound way I know that I’m “different” from the vast majority of folks around me.  I am very fortunate: unlike combat veterans, I feel “different” in a way that can be kept relatively contained, and thus one that is relatively invisible to the outside world.  Only those who know me best have a sense of what I experience.

My major concern has always been the effect of these experiences on my work.  As a psychiatrist who was trained to do what I can to enter people’s experiences and remain there “for the long haul,” as I’ve put it, I frequently have to remind myself that most people, at a very deep level, need to persist in certain relationships in spite of the consequences.  As long as those consequences are not the most severe ones (i.e., egregious abuse of some kind), that’s just the way they want to live and want to be–or better put, whether they want to or not, that’s just they things are going to be  They have an emotional tug that brings them back to the complex relationship(s), holds them there, even in the presence of painful behavior on the part of the other.

This is not my baseline experience of the world.

It is that to which I refer when I wonder, as I have in an earlier post, whether I’m the one with the problem.  My colleagues assure me that they have met combat veterans who have moved beyond a point of pain that had once felt foundational, that through prolonged exposure or through cognitive processing therapy or through EMDR, what once felt as that which inexorably separates the combat veteran from the “normal world” no longer does so in any meaningful sense.  These treated veterans may still feel sad, even still feel intense pain with certain triggers, but they assure me that the veterans no longer feel this pain as “fundamentally different” from “normal” pain, but simply as an often-more-intense version of the latter.  For many of my colleagues, apparently, cure or recovery does not mean an absence of such periodic pain, especially given what combat veterans have endured, but it does mean a meaningful absence of the sense of “otherness,” or “fundamental difference” that I feel in the world.

This is inconceivable to me, unfathomable.  This is what I fear that I therefore might not recognize in my patients: their inherent ability to transcend their sense of “otherness,” to cross the chasm between “otherness” and “sharedness,” to become more worldly-wise, emotionally-experienced versions of what all non-injured human beings are.

In fact, in some of the discussions last week, some colleagues wondered aloud whether I do just this: because of my shortcomings, I keep combat veterans, in a way, “captive” to their feelings of otherness as a way to reinforce my own feelings of otherness, with the implication being that I therefore try (unconsciously, of course) to hold them back from the freedom they would otherwise experience in being released, in a fundamental way, from that sense of “otherness” that their combat experiences have bestowed upon them.

In other words, some of my colleagues agree: I am the problem.  If I were better, my patients would get better.  While the combat veterans might still feel pain in life, they would, in the hands of a different therapist, no longer feel “fundamentally different.”

Perhaps they’re right.

2.  “Just” and the Linguistics of Hope

Well-meaning colleagues, well-meaning family and friends: they all tell me the same thing, basically: if I would just let go of my commitment to this sense of otherness, if I would just turn my life over to the process, to the techniques, to the therapy, to God, to whatever, if I would just follow the paths that they (i.e., my colleagues, family, and friends) have followed, take the chances they have taken, give up the fruitless emotions that they have given up, move beyond those fruitless emotions in the ways that they have so moved beyond them, then although I certainly wouldn’t be cured (the pain of trauma endures), I certainly would be farther down the road to recovery, to the understanding that the sufferings I perceive as separating me from most of my fellow humans are, thankfully, only the sufferings, in intense form, that are common to us all.

These words always start out quite heartfelt and supportive, without exception.  Eveybody wants to encourage me: although the path ahead of me to recovery is hard, they all say, it is worthwhile, and if you just have patience, what feels so fundamental to you will no longer feel fundamental.   No longer will you just feel better in spite of the trauma-induced sense of otherness, but you will feel better notwithstanding it, because it will just no longer have the full power it once did.  Granted, you have been traumatized, so you will no longer, in one way, be the same as you once were.  But in a fundamental way, you will again feel part of the human race, just part of the suffering common to all of us as humans, with an intensity that only trauma can bring, true, but no longer will you feel an outsider.  You will be an insider: just one who has a special story to tell all of us of how cruel life can be, yet how that cruelty, ultimately, will not conquer our human spirit as a race.

The words then shift over time.  More importantly, though, the tone of voice, the posture, the positioning of the eyebrows, the intensity–or opposite, the hesitancy–in the approach, all begin to shift.  Truly (now comes the message) if you would just trust what we say.  If you would just give up this hold on the past that seems to keep you bound.  If you would just give our way a fighting chance, just a try, you will see.

Eventually the tone darkens: if you would just give up your need to hold on to this.  If you would just regularly apply the principles we taught you.  If you would just try to understand why it is you seem to be unable to give this pain up.  If you would just accept that all of us sometimes simply have to move forward from the past.  If you would just give us and our way a chance.

Sometimes it darkens even further: if you would just accept that things are the way they are.  If you would just give up the need you seem to have to make everything right.  If you would just stop asking for perfection when there will never be any.  If you would just accept that life has to move on and that this attitude you keep holding on to is getting you absolutely nowhere.  If you would just accept that no matter how satisfying this attitude of yours may be in one way, to hold on to this grudge, to this pain, you’re only hurting yourself.  If you would just learn to accept what all of us humans have to accept: life can be a pain, but you just move on, you just have to believe that it’s got to be better than just holding on to trauma like you are, that this feeling you say you can’t get rid of just isn’t getting you anywhere.

The endpoint of the above encounters usually is a certain silence between me and the one who has my best interest at heart, a silence that screams–or at least to someone like me, who has this problem of just not letting go, sounds like “screams”–”when you’re finally ready to live life again, you just let me know.”

Just is an interesting adverb in our colloquial language, more what linguists call a “particle,” really: a word that primarily serves as an emotional, attitudinal marker, a word the purpose of which is to convey to the listener, the reader not what the speaker is trying to say, but rather what the speaker feels about what she or he is trying to say.  The word just always carries a certain “of course” feel to it, or a “that’s all, no big deal” feel, sometimes an “of course” of encouragement, sometimes one of admonishment, a feel of “dont’worry, I’m here with you” or a feel of “look, pal, it’s high time you got over yourself,” a feel of “really, it’s no big deal, you can do it” or a feel of “you know, it’s not that big a deal, even a kindergartener would have gotten the message by now.”

I can only tell you this: if you are just trying to be helpful so that I don’t feel so alone in my sense of differentness, just don’t say just.  For just after you say it, I just won’t be listening to you.

I will only be thinking: Oh, brother, you’re just like everybody else.  You just don’t get it, none of you does.  I just need to remember: just smile, just say thank you, and just hightail it out of this conversation just as soon as you can.

After all the therapy, all the techniques, all the conversation, all the theological reflection, that’s just the way it is.

I’m just one of those types.

This is what I just don’t get: so there really are people in the world who just don’t believe that the world can be so horrible, that the stars can become so misaligned, that as a result a person just can’t, for any meaningful period of time, recover the full spirit of what one once just had been?  Can they just not buy into the notion that Life can do that to person?  Is it just because they don’t want to believe that at any moment, just such a turn of Life could just happen to them?

There really are people who cannot accept that this chasm between us is just not a mirage, an irrational fear, a pointless refusal to accept what must be accepted?

Oh, God, then I finally realize: yes, there really are such people.  A lot of them.   It’s, in fact, most of “us.”  If I’m not finally recovering on the other side of the chasm, they say, knowing life’s truths in their hearts, then there’s just only so much a person can do.  Remember: you can lead a horse to water, but you can’t make it drink.

Oh, there’s just so much I’d like to say in response.  But it’ll just get me nowhere if I do, so it’s just better to let it go, and find a way to live on my side of the chasm such that the other person will just not even have to ask whether the chasm is still there.

I often wonder how combat veterans can tell me that I “get it,” when I haven’t even come close to experiencing the horror that each of them has.

Perhaps this is what some of the combat veterans feel that I’m getting, that finally someone with an MD behind his name and a job at the VA gets: that even though life can get much better, Life can mark you, not on the outside, as it did Cain, but on the inside, hidden from all but the Abel-avenging God, that recovery will always be a process that can bring joy and relief–but that will always be a process on the far side of a chasm that was not there before, one that is not welcome, that is not going to go away, no matter how many therapy sessions or educational sessions or prayer sessions one might undergo.  Perhaps, for a few combat veterans, it helps them to know that someone believes that there is hope even next to the chasm.

But, then, perhaps this is all me, unwilling to accept that the human spirit can transcend even the worst, that most combat veterans have something that I just don’t have, that someone better, even with just a bachelors degree behind his or her name, gets it:   that hope, if one will just trust it, can jump any chasm, wherever, however, and land safely enough on the other side, still hurting, yes, but wiser for that pain.  And no longer separated.  Just recovering.

Maybe that’s just it.

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