VI. 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:

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.”

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