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Thursday, August 23, 2007

Home from War

This is my latest article, which I wrote for the new vets. It is also posted on my website, in .pdf form if you want to print it out neatly.

Home From War
Patience Mason
Author of Recovering from the War: A Guide for all Veterans, Family Members, Friends, and Therapists
©2007 Patience H. C. Mason All rights reserved. No portion of this publication may be reprinted without express written permission of the author, which you have if you are a veteran, family member, friend or therapist. Please print, copy, and give to anyone it will help. .

My husband, Bob, spent the second year of our marriage flying a Huey slick in the First Cavalry Division in Vietnam 1965-66. His book, Chickenhawk, tells the story of that year. When he got back, I saw how skinny he was, but I was so glad to have him back, I didn’t notice the thousand yard stare. I had no idea what he had been through. I was just so glad he was alive. Neither of us had any idea that the war was, quite naturally and normally, going to affect both of us for the rest of our lives. We didn’t know any of what you will read in this pamphlet. They told Bob he would be fine in a few weeks. When he wasn’t, he thought he was nuts. I thought I was a bad wife, or he would not be having problems. He often agreed. Our life was not very happy for the next fifteen years, until we found out about Post-Traumatic Stress Disorder. We still deal with it, but today our dealings are informed, which makes things easier.
Stages you may go through when you get home:
Stage 1: I’m fine: Most soldiers come back believing it’s all over. Young, strong, proud, even if you are having some odd moments, you are not about to tell the doctors because you will be kept from going home. The changes that helped you survive war don’t seem that big a deal, and who is going to tell some guy in a white coat that you are seeing dead people? You may not know how much you have changed till you’re home. Life here is flat. People have petty problems. You can’t sleep, have bad dreams, get furious at everything, and keep looking for roadside bombs. When a car backfires, you hit the dirt. Still, you probably think the people around you have problems. Not you. Any comments about how you’ve changed may really piss you off. You’re fine! You survived a war! What kind of help could you possibly need after that? If you don’t know that it is normal to be affected, what else can you do but deny that you are? That’s what everyone else does. Denial can make your family feel nuts. You may be telling them they are nuts. This usually does not improve relationships. Furthermore, in today’s military, you probably will have to go back, so denial may seem necessary..
Stage 2: I’m not fine, but I’m not telling you: You notice some problems. You get angry too fast, you are yelling at people instead of talking to them, you keep seeing your friends die. When civilian things go wrong, you don’t care. (Is anyone shooting?) You may be shocked to feel nothing when a beloved relative gets sick or dies, or you may think you don’t love your spouse anymore because you can’t feel it. You hate civilians or Arabs. You are not fine, but you are not going to tell anyone, especially not anyone who wasn’t there and has been telling you that you have problems. You start to think that you can’t talk to anyone who wasn’t there. You begin isolating so no one will see how nuts you feel. You are pissed off about being affected. You also fear going for help because it may dull your edge, which you will need when you go back. It might also affect your career, and you don’t want people to think you are nuts. You exclude your spouse. He or she gets angry at you a lot.
Stage 3: I can’t talk to people who weren’t there: Since you can talk to other vets, you feel that no one understands unless they were there. This unfortunately is true. Most people make this clear by saying insensitive things like, “So what’s your problem? Get over it!” “Did you kill anyone?” “You’re a hero.” and the inevitable, “But why aren’t you over it?” So you increase your isolation from family and friends. This however tends to make spouses angry, because we are supposed to be understanding. Your sense of humor has become very black, and you laugh at things that would have horrified you once. You may even wonder if your spouse would still love you if they knew what happened over there. You might feel that everyone around you is spoiled and insensitive and it pisses you off. You have to stay so numb that your spouse feels you don’t love him or her anymore.
Stage 4: What’s wrong with me? The term “Post-Traumatic Stress Disorder” is a good description of the effects of war on normal people. The skills of war create a lot of disorder in your life. Shrinks and family members tend to see the symptoms of PTSD as the problem. Not me. I see war as the problem and the symptoms of PTSD as solutions to the problem of war, something right with you, not something wrong with you. Each symptom begins as part of your body’s hard-wired survival responses to danger, which your training has been designed to intensify and strengthen. They worked. You are alive. That is the bottom line. You have been through something that killed others. Having PTSD is proof of survival. I also believe that the people who get PTSD are the ones who care the most. You may feel like you don’t care, but if you didn’t care, you would not have to develop the symptom of emotional numbing to survive. Although PTSD symptoms originate in hard-wired survival skills built into all of us, unhealed, they can become your biggest problems over time.
Stage 5: I’m screwed up and no one can help. Deciding that no one can help is pretty human, but it is not true. I don’t think you are screwed up, either. You are in survival mode. What helped you survive one deployment will probably help you during the next one, unless your symptoms become debilitating. What you will need, when you are finally haome for good, and decide you want to change, is information and tools, someone to talk to, and hope. So will your family. You can get treatment without diagnosis at the Vet Centers and for two years after you get back at the VA. This can be a problem since it might be two years before you realize you have problems.
Admitting you have a problem and asking for help is hard, but you survived the war, and you can survive getting help and healing. If you don’t get help, you can be stuck in any one of these stages for the rest of your life, losing friends and family in the process, like so many veterans of previous wars. War affects people who live through it. There is evidence of PTSD throughout written history. People not affected by war are usually actors in war movies. It’s worse when it’s real. You may have noticed this.
This pamphlet is meant to explain the normal effects of war. Today, you don’t have to feel crazy, weak or defective, or blame each other, like Bob and I did. You can find ways to heal.
What causes PTSD?
Four types of traumatic events, common in war, cause PTSD:
1. When people are trying to kill or injure you.
2. When people are trying to kill or injure those you are close to (and many soldiers are closer to their buddies than to anyone in their lives.)
3. When you suddenly lose your home or community, which happens to soldiers who are wounded and medevacked or when they lose a lot of buddies to an IED or firefight.
4. Seeing anyone who has recently been seriously injured or killed (stranger, enemy, civilian).
Most soldiers have hundreds if not thousands of traumatic events during a deployment.
Traumatic events are cumulative, starting in childhood.
Traumatic events are made worse by human cruelty, neglect, and betrayal. Suicide bombing and the constant killing of civilian men, women, and children by factions in Iraq and Afghanistan make this war very cruel. What an incident means to you may also make it more traumatic. If your friends were “wasted”, it is worse than if they were killed doing something that was noble and important. It’s worse if the deaths were because they had no armor (betrayal). If you shot a car that was full of women and kids, it is a lot worse than if you shot guys with guns. Such incidents can destroy your sense of who you are.
Three other things also cause PTSD: Your brain is designed to keep you alive, so built in systems are activated by war. You care about other people or you would not have to get and stay numb. And finally, you lived. Dead people do not get PTSD.
Who gets PTSD? Given enough trauma, everyone gets PTSD. Most people have all the symptoms right after, but some of them seem to heal better than others. The people who develop PTSD have the most exposure to war, the greatest losses (not only friends, mental health and body parts, but trust, faith in the government or God or the military), the greatest number of previous traumas, the fewest resources [not just family and friends, but also the capacity to know what you feel or sit with a bad feeling and let it peak and fade (emotional intelligence), to let other people think differently, etc.] , the greatest vulnerabilities, and the least social support. PTSD seems to be a disorder of healing. That’s why it is important to be informed about post-traumatic reactions and about different kinds of help. There is no one-size-fits-all treatment for PTSD and no drug that makes it all go away, although research continues. Individuals need different things to heal. However healing seems to be dependant on being able to talk about the war, feel the pain, learn to moderate your reactions, and stay present in the present instead of being stuck back in the war.
What is PTSD? Many people think of PTSD as “the problem.” To me war is the problem, and PTSD is actually a solution to the problem of surviving war. All the symptoms start out as skills that help you survive
What are the symptoms of PTSD? Watch for these three categories. They grow out of the fight-flight-or-freeze survival mechanisms hard-wired into us all.
Set 1: Hyperarousal: Your brain is designed to pay attention to anything new, especially to threats, so you can survive. Hyper-alertness is a capacity that keeps you alive. Under the hammer of war constant watchfulness and expectation of danger (hyper-vigilance) become ingrained. Extremely effective startle responses [the shrrinks call it exaggerated] keep you alive and moving (fight or flight). Irritability and outbursts of anger, keep you alive and fighting instead of giving up. The inability to fall or stay asleep keeps you from being killed in your sleep. Shrinks also mention the inability to concentrate, but that is not exactly what is going on. It is the inability to concentrate on regular everyday stuff like picking up diapers at the store on your way home. Believe me you are concentrating on safety and on survival information. These hyperarousal symptoms are appropriate and effective in a war zone, where you have to do whatever it takes to survive, including things you may regret later. You have developed rapid responses, faster than thought, which can move your body before you know what you are doing. Keeping this edge is very important if you face redeployment. At the same time, at home these can become some of your biggest problems.
Set 2: Numbing and avoidance:
Numbing: The brain has a natural capacity to rapidly adapt to circumstances, especially danger. This is so we can be in control. It enables warriors to numb their feelings automatically so they can do whatever it takes to survive and to help others survive. It’s called professionalism, part of your training. Among the numbing symptoms are feeling like you have no feelings anymore, feeling like there is no future (so why worry when you could be killed tomorrow?), and feeling like no one can understand you unless they were there. Trauma happens so fast that you also may not remember all or part of some incidents. Our brains are also capable of dissociating. When this happens it is like being an observer of what is happening, as if you weren’t there.
Avoidance: We use avoidance to keep from feeling the painful emotions we have numbed. You maintain professionalism through numbness. You must not lose control. Avoiding emotions, thoughts, situations and activities that remind you of the war is easier if you are using substances, like alcohol, or behaviors, like workaholism, TV watching, the internet, or creating chaos (affairs, gambling, fighting). If you think you should be over it and your family and some of your outfit think only weaklings get post-traumatic reactions, avoidance seems like the perfect answer.
Set 3: Re-experiencing: Re-experiencing symptoms make you feel nuts. They include intrusive thoughts of the war, which you can’t stop having, dreams, nightmares, acting/feeling as if you were back in the war, blasts of adrenaline when thing that remind you of the war, and anniversary reactions (see PTSD & Holidays at Your brain is a better-safe-than-sorry system designed to keep you alert and alive. Trauma happens so fast and is so overwhelming that the more primitive parts of the brain don’t know it is over. They do not speak English, nor can they tell time. They want you to spend the rest of your life looking for roadside bombs and ambushes, so you won’t die. You know you are home, but your brain doesn’t seem to. Although this part of your brain is trying to keep you alive, the effect of re-experiencing can be the opposite. Acting as if today were the past can get you killed or get other people killed. You have to be reacting to today to stay alive and not harm those around you.
Many people have horrible flashes of non-verbal memory burnt into them by the war. They may be triggered by situations like confrontation, sounds like a backfire, emotions like guilt or shame or fear (many people turn these big three into anger so fast that they don’t know they are feeling them), thoughts like “I should/shouldn’t have…, sights like a car at the side of the road, or smells like cooking meat on a grill. Triggers can remind you of incidents of which you have no coherent memory. Further complicating your life, some sights, smells, emotions, sounds, etc., that are going on around you if you are triggered back home can become second or third generation triggers. This will make you feel even crazier when something with no connection to the war starts to trigger you.
Oddly enough, moving a non-verbal memory up into your frontal lobes, which do speak English and can tell time, either by writing and re-writing or telling and re-telling the story, often stops the re-experiencing. There are several forms of short term exposure therapy that can help with intrusive re-experiencing so you can keep your edge for the next deployment.
Why don’t they just get over it? Avoidance is very understandable, but it is also the main factor in perpetuating PTSD symptoms. By avoiding thinking about the traumatic events, you can’t make sense of it. Part of you is still back in the war zone trying to figure out what happened, going over and over it, hoping for a better ending.
Avoiding triggers leads to isolation, which means you don’t get the help you need to heal.
Avoiding bad feelings means you suppress them all, which can lead to depression and family problems. People can tell you are not feeling what you once felt, and rather than ascribe it correctly to PTSD, they think you don’t love them any more. You may think that, too.
The symptoms of PTSD can reinforce each other, too. Perhaps you are so numb, the only time you feel alive is when you are filled with adrenaline. You may unconsciously create arguments at home or do dangerous things that anger your spouse so you can feel alive. Then you start remembering and feeling, so you have to clamp back down to numbness, and they feel unloved as well as angry.
What you tell yourself can also perpetuate the problem. “I shouldn’t feel like this,” “I should be over it,” “What’s wrong with me?” “I must be crazy!” all can serve to keep you stuck. You are having normal reactions to war, reactions which John Wayne and Rambo never had because they were never in a war.
Although you may need your hypervigilance and emotional numbing in your next deployment, if you have significant re-experiencing it may endanger you and your buddies.
Once you are home for good, PTSD symptoms can become your biggest problems if you simply ignore them and expect them to go away. Although some people seem to heal, a large percentage of veterans exposed to high war-zone stress develop chronic cases. This is partly because of the lack of treatment available before the ‘80’s, but it is also due to the stigma people attach to “being affected”. I hope to reverse some of that, since normal people are affected by what they live through. Since PTSD can also be triggered by subsequent events throughout the rest of your life, it is wise to learn how to heal. Many older veterans have lost their friends and families because of the struggle to hide symptoms and seem fine. The current war has also re-triggered PTSD symptoms in many older veterans because they remember. They know what you’re facing. If this has happened to you, don’t think treatment didn’t work. It worked before and it will work again. Go back for more.
Getting Better: Each symptom of PTSD develops from a bodily-based, God-or-evolution-given built-in survival mechanism, designed to keep you alive. We all have these survival mechanisms, and if we had been through what you have been through, we would also be affected. You learned these survival mechanisms under the hammer of war. When you are ready to get better, you have to learn what they are, when and how they are useful, and new skills for when they are not. Each met a need, usually for survival, and finding other ways to meet your natural needs for safety and security is the job of recovery.
We also have built-in healing mechanisms. Attention (eye contact, being listened to, receiving empathy and respect), telling your story, safe touch, acceptance (bad things happen; they are painful), crying, making a contribution (working for the common good [altruism] and to support your family), justice, and spirituality are some of our built-in healing mechanisms. Our culture finds some of them awkward.
While avoidance strengthens and perpetuates PTSD symptoms, it is much less painful than the work of healing, especially if you have lost buddies, your sense of yourself as good or competent, and/or have shame or guilt or despair associated with the trauma as most people seem to. Somehow feeling like it is your fault, and if only you had done something, it wouldn’t have happened, makes you feel less powerless. The essential ingredient of trauma, however, is that it is overwhelming and you are powerless. No one can stop bombs or bullets with if-onlys. Many people spend their lives after trauma waiting and wishing for a better past, instead of working through the pain and anxiety for a better future.
Exposure is the basic task for healing PTSD. It teaches the parts of your brain that don’t speak English and can’t tell time that it is over. Exposure to what you are avoiding in small safe doses with a trained trauma therapist makes a huge difference. Often this is telling parts of your story again and again so that details come back and you can comprehend the whole experience. If you want to avoid these details because you think whatever happened was your fault, talking can help with that, too.
Most vets feel that if they ever let themselves feel, it would destroy them, but numbing bad feelings means the good ones are gone, too. Healing means you learn how to sit with a feeling and let it peak and fade, so you can process your memories. You went through hell. The feelings will hurt, but they will also pass eventually. Your therapist can teach you how to identify your feelings, that you are not your feelings, and that other people can have different feelings without either of you being wrong.
You can even learn to go in and out of numbing, since it can be handy, as can many of these survival skills. If you have developed an addiction to help you maintain numbness, you probably need to get clean, sober or abstinent from the substance or behavior.
The best way to deal with non-verbal memories is to move them from the non-verbal parts of the brain up to the frontal lobes and turn them into narrative memories, in other words: remember. Writing and rewriting something that happened to you is one way of doing it. Talk therapy is another. You get to tell your story. This is painful but you made it through the event, and you can make it through the memory.
For hyper-arousal, I always suggest basic un-training. Every soldier I’ve ever met thinks the military taught him to take care of himself. “Oh, really?” I often say, “So you used to say to your drill instructor, ‘Sorry Sergeant, I can’t do that. I need a nap.’” This usually gets a big laugh, but that is the kind of self-care you need to learn. After you have been to war, there are some things you simply can’t do. Sometimes it’s parties (don’t bunch up), cookouts (burning flesh), family fights. Sometimes it’s “Don’t ever come up behind me and grab me.” Whatever it is, learning to speak up is important.
You have to learn self-soothing methods, so you’re not always yelling and angry. You have to expose yourself to triggers in small safe doses, too, so they lose the power to trigger you. Learning that what triggers you is not necessarily dangerous here is also important, so your family doesn’t have to avoid your triggers.
Learning to meditate helps with these tasks and keeps you present in the present. The book Wherever You Go, There You Are, by Jon Kabat-Zinn helped Bob a lot. He also reads Thich Nhat Hanh. You may also find ways to heal your body’s constant state of tension through somatic therapies or yoga.
You may have to heal your beliefs. During extremely traumatic events, such as having a buddy die in your arms, or get killed when you weren’t there, people often decide “I will never love anyone again” or “I should never have left” or “It’s my fault.” Other beliefs that can interfere with healing and with everyday life include ideas like “Don’t talk about it,” “Only weaklings and whiners ask for help,” “You can’t trust anyone who wasn’t there,” and it’s converse, “You can (and must) trust anyone who was there.”
PTSD can make you feel totally out of control. By choosing to take new actions which have worked for others, you can regain that sense that you are in charge of your life.
Home life problems: The final topic I want to cover are some of the things I noticed in my family. Bob did things that really made me mad and I told him so a lot. Family members, friends, and even therapists can believe if you just did what they told you, you would be over it. Since the essence of trauma is your powerlessness to prevent it, most veterans need to regain a sense of control in their lives. This makes telling them what to do, even if you are right, counter-productive and ineffective, especially if you are constantly doing it. How do I know? I did it for years. Suggestions, on the other hand, can be quite useful, especially if explained as, “This has helped others. It might be awkward at first, but you might try it?”
For veterans of war, home life also creates triggers which cause major problems in the family without anyone realizing why.
Being asked to do things can get you killed in war, yet not doing common everyday things that your spouse asks you to do can cause a lot of resentment. Ask yourself, “Will taking out the garbage get me killed?” If not, maybe you can help out. Bob also says that common everyday things seem so unimportant when you come home from war, why bother? (Is the garbage shooting? No. Then don’t worry about it.)
Taking orders can also get you killed, so if your spouse gets demanding or bossy, resistance may become even stronger. Spouses resent this, too, because they usually get bossy when they are desperate for help.
Not following orders can also get you killed. Since you have the experience of war, you may find yourself ordering your family around and expecting instant obedience as if you were in the field. This can cause problems and resentments. No one likes to be ordered around.
Lateness can get you killed, so you may react strongly to it.
Mistakes can get you killed, but the way children (and grownups) learn is through mistakes, so they are not all fatal. You can remind yourself of this.
Emotions can get you killed. You have probably become quite numb to survive, but if you react to the normal emotions of your nearest and dearest as if they are trying to get you killed it usually causes problems.
People in your family may also seem like sissies with a lot of whiney problems, and after what you’ve been through you simply want them to shut up and focus on survival. Most people find that demeaning and unkind.
You want to keep them safe by making them strong so you may yell at them and try to toughen them up physically and emotionally. Most people hate that.
You may even envy these spoiled brats who have everything compared to you or to the people you were trying to help in other countries. It rarely helps to point that out.
So in dealing with family issues, you can ask yourself some questions:
1. Is it going to get me killed? Usually taking out the trash or washing the dishes won’t.
2. It is not life or death like stuff in Iraq/Afghanistan, so it may not be important to me, but is it important to my family member or friend? Can I be of help? It is rarely helpful to point out to them that in your scale of things, this is petty bullshit.
3. Do I want my kids to live like the kids I saw in Iraq or Afghanistan? Or do I want them to have an appreciation for what they have and to reach out to help those kids who have less? It is more effective to teach by example than by yelling.
Another problem that develops with PTSD as it becomes chronic is depleted cortisol. When people are flooded with adrenaline during combat (or arguments), a hormone called cortisol calms you down afterwards. Studies on Vietnam veterans with chronic PTSD show that instead of having chronically high levels of cortisol, they have depleted cortisol, not enough cortisol to calm down after they get hyperaroused. For me this explains a lot of the anger problems in veterans. They get angry easily because a killing rage can keep you alive and fighting in combat, but turning off the anger once it is on is really difficult. Not only is cortisol depleted, but in the middle of an argument, if your heartbeat is over 175 beats per minute, no one is home in your frontal lobes where you listen to reason! The forebrain has been hijacked, so you can’t understand your spouse’s arguments. When this happens, it is best to remove yourself from the source of your anger.
The purpose of this article is to give you information that will help you decide to heal whatever post-war reactions you may be having. It is not easy, but if you want to feel less alienated, it is possible. Recovering from war is not for the faint of heart. Bob and I wish you well.

Patience Mason is the wife of Vietnam helicopter pilot, Robert Mason, whose memoir of that war, Chickenhawk, was a bestseller. Her book, Recovering from the War, has been helpful to family members and veterans of all wars. Her website is Bob’s is (He has pictures.)

You may download a number of free articles at as well as ordering the book, Recovering from the War. I also sell two books for kids, Why Is Daddy Like He Is? and Why Is Mommy Like She Is?, several pamphlets, After the War: For the Wives of All Veterans, The War at Home, and An Expalnation of PTSD for 12 Steppers: When I get sober, I feel crazy), and the collected Post-Traumatic Gazette.

Sunday, May 6, 2007

Irritability and outbursts of anger

It can save your life to be able to go from fine into a killing rage in nanoseconds. The capacity is built into our brains. Anger is a normal response when people try to kill you and your friends. It is a normal response to the privations of war, the f*ck-ups by higher ups who are not risking thier lives, the job of killing, the fear of dying. Anger helps you feel powerful. It has a lot of survival value while you are at war.
Anger can become your biggest problem after you get home, driving away your friends and family, isolating you so you can't get the help you need to process what you have been through. It can make you dangerous and unreasonable self-righteous and cruel. If you develop chronic PTSD, your cortisol levels will be depleted so you can't calm down once you are angry, and while you are angry, your heartbeat may get above 175 beats per minute which means your brain is not operating either, so no one can reason with you.
If you have been to war and are now constantly angry, that is a symptom of PTSD. You may not like to hear that, but you have been, quite naturally, affected by the war. Many generations of veterans have lost family and friends because of this symptom, and it is not your family nor your friends fault. They could behave perfectly and you would still be pissed off. Nothing they do will prevent that, because this anger is welling up in you due to your experiences, and you need to process those experiences with an experienced therapist, or work a 4th step with a sponsor in AA/NA or some other 12 step program (In the 4th step you start by listing your resentments, the fun part, and then you look at your part...), or start meditating so you can see your anger as an emotion and not THE TRUTH about what is going on.
Handling your anger is your responsibility.
You need to learn to walk away, and your spouse needs to learn to let you. You need to learn how to let go of anger, seeing the emotion beneath it, like feeling disrespected, blamed, guilty, or afraid you won't get what you want. Steven Stosny's HEALS technique is the most effective antidote to anger that I know of. It is an acronym
Healing (see the letters flashing in neon, which takes you out of the angry space)
Explain (to yourself what the underlying feeling is, from disrespected down to worthless and feel that feeling for a few seconds-like an inocualtion, so you can tolerate the painful feeling without flying off the handle, which gets easier with practice)
Apply compassion to yourself: Of course it hurts to feel disrespected or worthless, so I need to have compassion for my pain, and to respect myself or value myself, give myself an antidote to the pain which fits the particular kind of pain I am feeling
Love yourself. If this sounds selfish, loving yourself means you will be able to love others and feel compassion for them too.
Solve the problem. Anything you say or do that does not involve yelling or other outbursts of anger is much more likely to solve the problem. When you are not angry, your thinking is clearer and your solutions are better.
Stosny has written a book for people in emotionally abusive situations, and blowing up at your nearest and dearest is emotional abuse, called You Don't Have To Take It Anymore which contains a boot camp for the person who is doing all the yelling and name calling and criticizing. If you are doing that, the book will help you.
You have to think about what kind of a partner and parent you want to be and commit to that. Was your plan to emotionally abuse your family and friends? Probably not. There is a type of therapy which is used at some VA hospitals called Acceptance and Committment Therapy (ACT). You accept that you have been affected by war (or if you have been diagnosed with PTSD, by that) and you commit to learning how to be the type of spouse and parent you always wanted to be. You learn basic un-training, which means how to take time for yourself so you are not blowing up all the time, how to handle your anger, how to let other people make mistakes (it is how they learn), be human, etc.
You have to commit to your own healing and to being fair to your family, even though what happened to you and your friends in war WAS NOT FAIR. None of them deserved to die. You don't deserve to have PTSD. That is the truth. But you do deserve to recover, no matter what you did or didn't do, saw or didn't see, you deserve to recover and to have a good life.

Saturday, May 5, 2007

One cure for reexperiencing (intrusive thoughts, nightmares, flashbacks)

I just got a copy of "Toward the Flame," by Hervey Allen, a memoir of WWI. I mostly read memoirs because I don't care what the historians say. I want to hear what happened to the people, the soldiers...
Being the good girl that I am, I started with the preface to the original edition (1925) and the preface to this edition (an illustrated 1933 edition which came out after he wrote a bestseller, Anthony Adverse). This is what he wrote:
"After returning home in 1919, I found myself much troubled at night by memories of the war and often unable to sleep. It occurred to me then that I might rid myself of my subjective war by trying to make it objective in writing. Taking in hand the material mentioned above [letters from the front and the hospital], and adding to it what I still so vividly remembered, I whipped the whole into shape without any thought at the time of publishing it. The medicine worked, although perhaps the style of the utterance suffered." Toward the Flame, Hervey Allen, University of Nebraska Press, Lincoln, 2003, xxiv.
This is what happened to Bob also, When he wrote and rewrote Chickenhawk. He didn't realize it had happened until a couple of years ago when he was giving a workshop on writing about war and one of the participants shared this story. When this guy got back from Vietnam, he started going to community college. For his English class, he had to write a personal journal. He got an F on the first one because it wasn't personal enough (Numb??) so he thought, "Fuck her.(Irritability and outbursts of anger??) I'll make it personal. I'll write one of my nightmares (re-experiencing)." So he did. The teacher, bless her, simply corrected it and handed it back to be re-written. This happened several times until she was satisfied and then he rewrote it a couple of more times to make it completely accurate just for his own satisfaction. And then he noticed he was not having the nightmare any more.
When he heard this story, Bob realized that after he finished Chickenhawk, his nightmares also stopped, and he stopped thinking about the war everyday...
There is actually a scientific explanation for this. Much of the information about the traumatic events in your war is stored in the reptile part of your brain (hippocampus, amagdayla, other funny names) in the form of fragments of non verbal memory (sounds, scenes, smells, words, emotions, etc). They often trigger flashbacks, intrusive thoughts, nightmares and hyperaroused bodily states. People are designed to form narrative memories. It is what the whole front part of the brain does, and through the process of verbalizing those fragmented incidents, you can move them out of the part of the brain that causes reexperiencing up into a normal narrative memory, which might be painful, but won't entail involuntary re-experiencing. Therapy, if you get to talk about what happened, can do this too. That is why they want you to talk. But sometimes therapists don't want to hear, or don't want you to feel bad, so they cut short parts of the story. It can also be very hard to remember some parts of it if you feel ashamed of something you did–or didn't–do. So if writing it out doesn't seem to do the job, look deeper.
An example of this: a woman who was raped who was so afraid the guy would kill her and so desperate to get it over with that she moved her body as if it was good for her. In therapy, she didn't even remember this, it was so shameful in her eyes, but when she read my prayer for trauma survivors, which says "Help me to love myself no matter what happened to me or what I did to survive," she remebered, and after that, no more intrusive memories!
Here are the affirmation, prayer and expanded serenity prayer I wrote for veterans:

Affirmation for Veterans with PTSD
I’m _____________ and I’m ____ years old.
I am home from the war. I can feel safe here.
I live in ____________________.
I live with _____________________________, and _________cares about me.
I can feel sadness and despair and fear and anger and guilt.
I can cry and those who love me will still care for me.
I need to have these feelings so I can let them go.
Each time they come up, I can use them as evidence that I need to do whatever it takes to take care of myself.
I can ask for and recieve help.

Prayer for Veterans with PTSD
Higher Power,
I know that it’s not within the harmony of the universe that I be healed from the trauma of my experiences in the war without pain.
Help me through the pain. Surround me with the golden light of healing, fill me with the white light of peace and love. Help me to bear the pain as I go through these memories. Help me to cry. Help me to remember. Help me to love myself no matter what happened to me or what I did to survive. Amen.

Serenity Prayer:Grant me the serenity to accept the things I cannot change: the war, what heppened to me and what I did or didn't do, and that what happened was traumatic no matter how effectively I have stuffed it.
Courage to change the things I can: my attitude towards my symptoms—help me to accept them as a normal response to war and evidence that I need to take care of myself by talking about what happened to me with a safe person and getting whatever help I need; my actions—I no longer have to blow up, drug, deny or repress my symptoms. I can accept them as evidence of how much I have been through; my reactions—instead of freaking out, blowing up, or trying to repress what I feel, I can focus on the symptom, whether it is numbness, anger, a painful emotion or memory, dream or flashback, or a physical reaction, feel what I feel, go through and have the pain and learn whatever it is that my Higher Power wants me to learn. Then I can share about the effects of trauma on people. Finally I can change how I see these symptoms—as normal responses to trauma which helped me survive and will help me recover even if they are painful.
And the wisdom to know the difference: help me to be willing to accept that I survived something terrible, and that I can learn from it and heal if I look outside my own head for help, and that I deserve to heal.

Please feel free to change the wording in whatever way works for you. I suggest keeping copies of this with you for those moments when you feel overwhelmed with feelings that you don’t want to have.
REMEMBER: It is okay to feel bad. You can’t heal what you don’t feel.
Patience Press PO Box 1517, High Springs Fl, 32655

Friday, May 4, 2007

Is PTSD normal after War?

Yes, it is. Right after a single trauma, according to one study, everyone gets all the symptoms of PTSD. Some of them seem to heal, so it is a disorder of healing. Our society seems to be set up especially to prevent healing from trauma. Everyone wants you to be over it in a week. I remember hearing a woman who barely got out of the Trade towers on 9/11 saying a week later that her friends were asking her why she was still upset. After all, she lived.
It is illegal in this country to feel pain. We are all supposed to be fine. FINE is an acronym to some of us: F**cked up, Insecure, Neurotic, and Egotistical, which fits those people who think "It wouldn't have affected me/didn't affect me/shouldn't have affected you."
All the symptoms of PTSD start out as survival skills which are built into the brains of all of us. No one is exempt. Those who seem to have been exempt, like John Wayne or Rambo, actually sat out their wars and were never exposed to combat.
The first survival skill set is called "symptoms of increased arousal not present before the trauma" by the diagnostic criteria. One problem with this is that if they were present before the trauma, it probably means you were traumatized earlier. Beatings, emotional abuse, neglect, sexual abuse, when these happen to a kid, they are more traumatic, not less, and kids react by becoming very wary and very fast. This makes them better soldiers. It is what basic training is designed to reinforce because these behaviors will keep you alive. The first PTSD symptom/survival skill is an effective (not "exaggerated," EFFECTIVE) startle response. Others include irritability and outbursts of anger, inability to fall or stay asleep, hypervigilance, and "inability to concentrate" which is actually the inability to concentrate on anything that is not survival information. These keep you alive. This is the fight/flight/freeze capacity, built into all of us that enables us to react before thought. Our brains are designed to scan for danger and react instantaneously. Since this capacity is based in what they used to call "the reptile brain" in High School science, it doesn't speak English (that's in the frontal lobes, the last part of the brain to develop) and can't tell time, so you can tell yourself you are home and it is over, but the message does not get through to this part of the brain for a long, long time, sometimes never.
The second survival skill set is called numbing and avoidance. Our brains are designed to pay attention to threats, which means extraneous stuff like emotions go into a box. The brain is also designed to rapidly adapt to whatever is going on, which means the first dead person is very upsetting, the second, not so much, and by the third, you may be numb as a stump. This keeps you able to keep fighting and doing your job, saving yourself and others. (In medicine, this is called professionalism). Trauma/combat happens so fast that you can't take it all in, so you may forget all or part of some particualrly horrific incident, which is your brain's way of protecting you. Unfortunately those details remain in the emotional/non verbal parts of the brain and may cause you a bunch of trouble later. Once you have been in combat, you may not be expecting to live long. You know, on the most basic level that life can end in an instant. You've seen it. You will also probably feel like other people can not understand, that you are different, so you get detached and estranged from people. Part of this is because after your buddies are killed, you protect yourself by not attaching to new guys, but it is also a reality you are going to face for the rest of your life. Your brain has been changed by combat. And OTHER PEOPLE CAN NOT UNDERSTAND WHAT YOU HAVE BEEN THROUGH. I learned this when I came out of the movie Platoon and said to my husband, "That was so awful!" He looked at me, almost puzzled, and finally said, "It's worse when it's real." That statement hit me hard and I realized I will never know. I may want to understand, but if I am honest, I know I can't. On top of this people say such shitty things to combat vets, "Did you kill anyone?" "Why aren't you over it yet?" etc. that you know they don't understand. Then you start to avoid things that remind you of the trauma. You avoid thoughts and feelings that remind you of the war, so if you were happy and your squad got hit, you may decide you will never be happy again. If you feel it was your fault, you may decide you will never be wrong or feel guilty again, which will make you self-righteous and argumentative and critical of others. If you love your buddies who died (and soldiers in combat are closer to their buddies than anyone) you may decide never to love anyone again. Next you avoid activities and situations that remind you of the trauma: driving, cookouts (burning flesh), crowds (bigger target), sports involving blood (hunting, football), movies, reunions, etc. Avoidance behaviors are survival skills in that they help you avoid triggers which can cause strange embarrassing behavior. And triggers can have children and grandchildren, so that if a car backfired while you were watching kids play, and you hit the dirt, the sound of kids playing can become a trigger too... The progression of triggers can get you to a point where you can't leave the house. Avoidance is also a survival skill because it keep you from feeling a depth of pain that most people cannot imagine, a depth of pain that is quite illegal in America, the land of the fine. Once you are numb, it is much easier to stay numb. The commonest way to do this is alcohol, although almost any substance (drugs, food, booze, etc) or behavior (sex, gambling, internet, religion, shopping, TV, workaholism) will do.
Unfortunately your brain also wants to figure out what happened, so you will also start re-experiencing the trauma. This is what brought PTSD to the attention of shrinks who were determined not to see it back in the 60's and 70's (the American Psychiatric Association's denial and delusion period) so they think it is a wierd reexperiecing disorder with associated wierd behaviors. I'm lucky in that I knew my husband before he went, and after I found out there was such a thing as PTSD, I began to look at why these symptoms developed and how it would happen under the hammer of war. That is why I see PTSD as normal, meeting the need to survive built into all of us. BTW, others who think like me include John Briere, PhD and Sandra Bloom, MD, and some of the ideas I have mentioned here came from their work.
I have not been able to blog for a couple of months because of my rage at the REMF's who started this war, please note, WITHOUT LISTENING TO THE GENERALS!!!, and are now presiding over the mistreatment of PTSD, sending people back into the war on medications, and the mistreatment of our returning veterans, and giving bonuses to VA managers...
However, I think the most helpful thing I can do for our returning vets and our vets who are being re-triggered by this miserable cluster-f**k is to blog about my take on PTSD as a normal response to war. If you take nothing else away form my blog, remeber it is NORMAL TO BE AFFECTED BY WAR. NORMAL. NORMAL. NORMAL.
More tomorrow.

Monday, January 8, 2007

VA Gilgamesh Cartoon Insults VA Doctors

I actually need to say that the cartoon version of the Gilgamesh story is aimed at VA doctors, and if I were them I would be insulted. Most of the doctors and nurses I have met at the VA in recent years have been polite, concerned and helpful, nothing like the cartoon of Doctor U. or the way it was for Vietnam Vets in the 60's and 70's.
What angers me is that someone was paid to make this insulting information-free, misinformed (the paralysis before combat...what is that? Are they trying to mention conversion reactions when someone in the field for the duration would become paralyzed??? or blind??? in both World Wars???). And Gilgamesh is dirty and unshaven which proves he has PTSD??? NOT! Most people with PTSD are working a job and killing themselves to look FINE... (although I know at some VA compensation exams if you don't show up dirty and unshaved, you will be denied, that is the compensations system, not the treatment people).
How much did it cost?
Who approved it?
Who made it?
Let them all lose their jobs, and use the money for information which will actually help the doctors do a better job, or inform the patients about PTSD. This cartoon does neither.

A waste of money
This is probably the stupidest waste of VA money I have seen in a long time. If you take the time to watch it, you will be amazed by the self-centered, self-absorbed doctor, the incredibly stupid jokes, the lame attempts to be reassuring, the absolute lack of empathy. I mean it is pathetic.
Actually it may also be accurate. There's a frightening thought.
I followed some of the links at the end.
The scariest was on
"Intensive, three-week, multi-disciplinary treatment program for patients with deployment-related stress, Post Traumatic Stress Disorder (PTSD) and/or difficulties adjusting to re-deployment" [my italics] So they are sending people with PTSD BACK, which is completely unethical. It is well known from Israeli studies that combat vets with PTSD in one war or deployment get it worse in the next one.
Another frightening line towards the bottom of the description of what sounds like it might be a worthwhile program if it weren't used to send people with PTSD back, is "The individual's command must approve program attendance." So the numb ("It didn't affect me") or clueless (no combat experience) CO has to approve a medical decision, instead of the medical staff. Do CO's approve all other medical decisions? Are CO's the new insurance company representatives in the military structure?
Anyone who has studied the Vietnam War, or any other war, as I have, knows there are always officers who will sacrifice their own men so they look good. They should not be in the position to do this to men and women with PTSD.

Sunday, January 7, 2007

Heart attacks and PTSD

Study: War Trauma May Raise Heart Risks

Associated Press Writer
I have no idea how to make that a link.
This is a really good study and about _______ time.
A few years ago, a famous psychiatrist [George Valliant, MD. I remembered!] whose name escapes me at the moment (Halfheimers, when you don't quite have altzheimers, or is it CRS... can't remember) did a study of all the WWII vets who had gone to Harvard. They had thorough medical histories of them when they got into Harvard, so they looked for PTSD in those who had seen combat. He, of course didn't find much (Ha ha. The old school) but he did find that by age 65 most of the WWII Harvard combat vets were either physically very ill or DEAD, which was incredible!
There have been other studies connecting PTSD with stress related diseases.
One of the earliest descriptions of PTSD, in Civil War veterans, was published in 1876. Dr. Da Costa described a set of heart symptoms and called them Soldier's Heart. My husband had this when he came back from Vietnam, but since it was old medicine, no one had ever heard of it, and they told him he could probably die of it anytime. Wonderful for a person diagnosed with "nervousness" since there was no diagnosis of PTSD at that time.
And when he had his last C&P exam a couple of years ago the young woman doctor didn't KNOW that no one was diagnosed with PTSD in 1968 because the Diagnostic and Statistical Manual II of the American Psychiatric Association had no such diagnosis. As a matter of fact, they had just discarded the "Gross Stress Reaction" of the first edition and decided, on no scientific evidence whatsoever, that if a trauma affected you for more than 6 months, you were screwed up before the trauma...
How could a person like that be doing compensation exams for the VA? Of course she was better than Umesh Mahtre, MD, who asked my husband how he was doing. Bob said "about the same." They talked about flying for a few minutes. We thought he was trying to put Bob at ease, but that was the end of the interview and his report was, "The patient reports no problems." He was famous among the local veterans for never seeing PTSD even when it was in his face.(If this has happened to you, the exam is "inadequate for compensation purposes" and you can immediately in writing ask for another exam on that basis.)
The VA compensation system (which is different from and separate from and, as far as I can see, IGNORES the doctors at the VA Hospitals and other treatment facilities) in many areas of the country does it's best to see that those who need help die before they get it, some of the deaths no doubt brought on by stress related heart attacks.
If you want to help, write your representative and senator and ask for more funding for treatment at the VA, and for forced retirement of any old hack in the VA Compensation system who routinely denies PTSD claims or denies them with insane criteria such as this one, which a friend of mine received: "Since you were an infantryman and seeing the death of a friend in combat is not outside the range of usual human experience for an infantryman, you do not have a traumatic stressor." Totally wrong, but he still may have his job...

Saturday, January 6, 2007


I subscribe to the Psychotherapy Networker e-newsleter and just read a great article by Nancy Errebo, Psy. D. about using EMDR with a returning vet. (This issue has 3 articles on PTSD.)
Two quotes struck me:
"while nightmares and flashbacks are very troublesome and painful, avoidance is by far the most dangerous aspect of PTSD-in fact, it maintains the fear and vigilance and the constant preoccupation with the war. "Avoidance also becomes a way of life," I said and described some veterans I know who'd spent many years avoiding almost everything and everybody in their largely unsuccessful attempts to stay calm. There's no healing without exposure to the memory and the emotions that go with it, I added." [my italics-Patience]
and also:
"the brain naturally tries to process trauma by reviewing experience, but the images and emotions are so vivid that nightmares and flashbacks result. So the opposite, also completely natural, tendency kicks in and the brain tries to avoid the pain by numbing the emotions. At this point, the information can't be processed, and the cycle just repeats over and over again-the natural healing process getting caught in a kind of gridlock. EMDR is designed to break the gridlock and keep the information processing system active so that healing can occur."
This article also mentions EFT, Emotionally Focused Therapy for couples, one of the therapies I think is stupendous. Dr. Errebo wrote an article on that: "EMDR and Emotionally Focused Couple Therapy for War Veteran Couples" in the Handbook of EMDR and Family Therapy Processes. I belong to the International Society for Traumatic Stress Studies, and often go to their conferences. I saw Susan Johnson, the developer of EFT, give a workshop on it, and it was simply wonderful.
A lot of VA's do offer EMDR these days, and it works for many people. Processing the trauma may only be the beginning of recovery, however, if you grew up in a home where there was a war between men and women. EFT offers the chance to make your home a sanctuary instead of a battleground. So does applying the principles of Al-anon to life with PTSD and I'm sure there are other effective therapies, but this is the one that I know about.
Another therapy that I attended a workshop on is ACT, Acceptance and Commitment Therapy. I felt that this was another one that I would like to see in every VA. If you Google "Steven C. Hayes" and "Sonja V. Batten" and "Acceptance and Commitment Therapy" you can find out more from the people who developed the concept. I think it pays to be an informed consumer of mental health and to speak up for what you feel would help you.
By the way, none of the devlopers of these therapies think their way is the only way. When a therapist tells you that their therapy should have worked, that's when instead of feeling like a failure, you need to find a new therapist. The failure is not you. It's different if they say "this doesn't seem to have helped you, so lets try and find something that will, perhaps with another therapist." That is honest, because people are best with techniques they know and love, as long as they don't imply that you failed.
Actually, I think I have to qualify that,too. If you try to do therapy while drunk, stoned, in a food coma, etc (all of which may be the PTSD symptom: efforts to avoid thoughts or feelings associated with the trauma) you can prevent your own healing. It is like the healing of any wound. Pain is involved. You went through hell and healing it will hurt. So you heal in small doses with help. But if you don't feel, you won't heal.
I often say it is good to be able to go in and out of the numbing at will, since the numbing is a survivor skill. But healing is something else, something beyond numbing. When you numb pain, you also numb joy...
And if your pain is intolerable, there are programs like Dialectical Behavioral Therapy, which teach you skills in tolerating painful emotions before you try to do trauma work. I don't know of a VA where they do that either, but I hope it will come.