Healing Combat Trauma

More Numbers to Remember: 3 Then, 7 Now

A newspaper article reports today, "In the Vietnam war, for every soldier killed, three came home wounded. In Iraq, for every soldier killed, seven come home wounded." Those are some substantial numbers...and I wonder if they're even accounting for PTSD in them, which is often considered an "invisible wound," and one which shows up usually after the fact.  The numbers could be even that much higher...

Roughly 5,000 killed to date -- 35,000 wounded (by that estimate) -- and for every veteran, another 50 people who he or she affects (see Fred Gusman comment about that, which we blogged about earlier -- linked here).  If we add the number killed and the number wounded together, then multiply the 50 each veteran affects directly in his or her life, that's 2 million Americans affected by veterans' sacrifices.

Upcoming Seminar on Warrior Health: PTSD, Depression and TBI

The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., presents:

A Center for Deployment Psychology Training Program:

"Addressing the Psychological Health of Warriors and Their Families: PTSD, Depression and TBI."

When: Mon 22 Jun 2009 through Fri 26 Jun 2009.

Where: The Cheyenne Mountain Resort, Colorado Springs, Colorado.

What: This intensive course, which is comprised of 4 modules, will train civilian mental health providers to better address the behavioral health needs of military personnel and their family members throughout the deployment cycle.

Who: The intended audience is civilian mental health providers who provide behavioral health care to the military population or military family members, including veterans and their loved ones.  This training is NOT intended for active duty military providers, but rather for civilian or private practice/community providers.

Supported by: Fort Carson Soldier Readiness Center, National Organization on Disability, Operation TBI Freedom and Regis University.

For more information about this upcoming seminar or to register online, click here.

The Real Meaning of Memorial Day: Remembering the Sacrifice

For the real meaning of Memorial Day, remembering the sacrifices that have been made, there's a powerful essay written by a trauma surgeon in Iraq about the tragic death of one Marine he treated that might be worth your while to read.  Beware: it's completely gruesome, and spares no detail, though is done respectfully.  And it has an even doubly tragic ending (you'll have to read it to see what it is.) If you have been to war, you might not need to read this -- you're already plenty in touch with what carnage and sacrifice are all about.  If you haven't been, though, it might be a little more eye-opening about what those who serve go through and ultimately sacrifice.

The most impressive part of the story to me, besides the great care the trauma surgeon takes with every battlefield injury, is his love and respect for those he's working for -- and on, a love and respect shared by everyone involved in the course of his workday.  The sheer magnitude of what they go through, and its power to numb the human heart and psyche, is astronomical.  The fact that they fight through for it not to numb them is even more remarkable.  It's a complex human reaction, best expressed by the doctor himself, but it's also summed up centuries ago in the following quote, which we've used before on this blog:

"Anyone who looks with anguish on evils so great must acknowledge the tragedy of it all; and if anyone experiences them without anguish, his condition is even more tragic, since he remains serene by losing his humanity." -- Augustine of Hippo, quoted in One Bullet Away: The Making of a Marine Officer, by Nathaniel Fick.

If you want to read a gory but powerful reflection on the true cost of sacrifice, read "A War Surgeon's Perspective on Memorial Day," by John P. Pryor, M.D., quoted in full on the blog, The Kitchen Table. The reflection is linked here.  It's well worth reading, though completely sobering and sad.

Editor's note: For more material along the same lines, there's an OEF/OIF memoir by another doctor who served, "On Call in Hell: A Doctor's Iraq War Story," by Cdr. Richard Jadick, which is linked here.

A Harvard Study Confirms More Combat Exposure = More PTSD

The Atlantic magazine this month has a story about the Grant Study, a longitudinal study which followed 268 "Harvard Men," from the classes of '42, '43 and '44, from their sophomore year in college, through for the next 42 years.  The Grant Study men, those who are still alive, are now in their 80s, and approaching death. It wasn't the purpose of the study, but because so many of the men served in World War II, the study was able to comment that, among other things:

"More than 80 percent of the Grant Study men served in World War II, a fact that allowed (the study's administrator) Vaillant to study the effect of combat. The men who survived heavy fighting developed more chronic physical illnesses and died sooner than those who saw little or no combat, he found. And “severity of trauma is the best predictor of who is likely to develop PTSD.” (This may sound obvious, but it countered the claim that post-traumatic stress disorder was just the manifestation of pre-existing troubles.)

The full story, called "What makes us happy," by Joshua Wolf Shenk, is linked here.

Abraham Lincoln on Sacrifice, Loss and Grief

"It is with deep, heartfelt regret and sadness that I write this letter. My words seem inadequate at a time like this so I will quote a letter Abraham Lincoln wrote Mrs. Bixby, who had lost five sons in the Civil War:

"I feel how weak and fruitless must be any word of mine which should attempt to beguile you from the grief of a loss so overwhelming. But I cannot refrain from tendering you the consolation that may be found in the thanks of the Republic they died to save.

I pray that our Heavenly Father may assuage the anguish of your bereavement, and leave you only the cherished memory of the loved and lost, and the solemn pride that must be yours to have laid so costly a sacrifice upon the altar of freedom.

Yours, very sincerely and respectfully,

A. Lincoln"

-- From a wonderful tribute written by Matt Farwell, 10th Mountain Division, Afghanistan, over the loss of his brother soldier, Army Sgt. Carlie M. Lee III, this past week. RIP, Sgt. Lee.

Hanging Tight to the Narrative, to Pull You Out of Hell...

More Tyler Boudreau, from "Packing Inferno: The Unmaking of a Marine," on why he writes:

"They say war is hell, but I say it’s the foyer to hell.  I say that a lot.  I say coming home is hell, and hell ain’t got no coordinates.  You can’t find it on the charts, because there are no charts.  Hell is no place at all, so when you’re there – you’re nowhere -- you’re lost.  The narrative, that’s your chart, your own story.  There are guy who come home from war and live fifty years without a narrative, fifty years lost. They don’t know their own story, never have, and never will.  But they’re moving amidst the text every day, and every long night without even realizing it.  They’re out there beyond the wire, trudging through the sentences, tangled in the verbs, suffocating on the adjectives, wrecked by the names.

They live inside the narrative like a cell, and their only escape is to understand its dimensions.  Once you get it, maybe you can start tearing down the walls.  Every soldier’s mind is different.  There is no single code to break.  It’s ever-changing.  I don’t have a recipe, but there’s one thing I do know, and that is the power of the narrative.  Put the story together.  Understand the story.  Ask questions of the story; make it answer you.  Make it.  You don’t take no for an answer.  You keep building that narrative until the answer comes around.  That’s the low road out of hell."

Okay, the low road out of hell: Maybe. It's not the first time someone's thought that telling their story -- just getting the words down on paper -- would have curative powers.  Read another Marine captain, Nate Fick's, essay for Powells, the great used book store in Portland, Oregon, about why he wrote "One Bullet Away: The Making of a Marine Officer."  See other veterans from other eras -- for example Claude Anshin Thomas, who wrote At Hell's Gate: a Soldier's Journey from War to Peace -- as they grapple with the narrative, to pull themselves to safety -- or sanity.  See and feel the way they fight for it, with every breath, with every word on the page. The same goes for the veterans who are the authors and the poets in Maxine Hong Kingston's anthology, Veterans of War, Veterans of Peace. Many,  many people feel...that this way lies redemption.

Or does it?

A little over a year ago, I was "gifted" with a narrative worthy of a Charles Dickens, if Charles Dickens had been to war.  Forty years the combat veteran had spent, trying to crack his own case (of severe, combat-induced PTSD), trying to get it all down on paper.  To make sense of it for himself, to make sense of it for his family.  And 40 years is not an insignificant amount of time.  He followed the narrative, all right; he clung to it like a rope.  But you know what?  All it did is lead him to the precipice of healing.  It wasn't even the precipice itself. What it did do was, in a way, detail the exhausting of his options, and get him in touch with the many things he'd tried -- including, in his case, religion -- so that he could he could continue the search, this time going even deeper.

Ironically, and we had several conversations about this -- he never finished the narrative, even after 40 years.  He didn't finish it, and he couldn't finish it -- we eventually agreed because it was his LIFE, and there was no real need to sum that up as though it was already over, because it wasn't.  It, and he, were still very much "a work in progress." And there weren't any simple answers, that would put everything into perspective.  Not for the combat veteran, not for his family either.  It was a pretty good narrative of what he endured, and the sense he was able to make of it.  But it was not in any way curative, though getting it down on paper was powerful, and compelling, and both moved his readers -- and himself.  It moved his readers (including his family) towards empathy, or a better, deeper understanding of what he'd gone through.  And it moved himself to continue going after the true prize, which was healing -- not just setting down what he had experienced.  IF writing were truly curative, we'd see more mentally unbalanced, yet otherwise fabulous authors experience "the cure."  (And one has only to think of the great Virginia Woolf, her pockets loaded with rocks, headed into the water to drown herself, to reflect on the apparent wisdom encoded in that statement.) What writing is, or can be, is deeply cathartic.  What it isn't, is the actual "cure."

Feel Like Just a Number / War's Psychic Toll

The New York Times has a good op-ed piece today by Bob Herbert, entitled "War's Psychic Toll," linked here.

One point he makes, in the wake of the shooting deaths at Camp Liberty, is that:

"The fallout from the psychic stress of the wars in Iraq and Afghanistan has been vast, but there was no reason for its destructive effects to have surprised anyone. There was plenty of evidence that this would be an enormous problem. Speaking of Iraq back in 2004, Dr. Stephen C. Joseph, who had been an assistant secretary of defense during the Clinton administration, said, “I have a very strong sense that the mental health consequences are going to be the medical story of this war.”

He also further clarifies a point that a number of people have been making over the last several years, which is that an all-volunteer military concentrates the inevitable "psychic toll" of warfare into too few combatants on our side.  Herbert writes:

"Because we have chosen not to share the sacrifices of the wars in Iraq and Afghanistan, the terrible burden of these conflicts is being shouldered by an obscenely small portion of the population. Since this warrior class is so small, the same troops have to be sent into the war zones for tour after harrowing tour.

As the tours mount up, so do the mental health problems. Combat is crazy-making to start with. Multiple tours are recipes for complete meltdowns."

We've already seen, in previous blog posts, how more combat => more opportunities for PTSD. The relationship is direct.

At some point, with the same people serving multiple deployments, being injured becomes a numbers game.  And increasingly servicemembers who keep going back, if they've managed to avert injury so far, become concerned that their luck can't hold out forever.

A Recon Marine, with multiple deployments under his belt -- some would say, the toughest of the tough -- headed back to Afghanistan on Monday.  "I'm scared," he told his friends and family, unashamedly.  War is a dangerous game, and multiple deployments wreaks havoc on those who go, and those who stay behind and wait.

---
In the old Bob Seger song about working on an assembly line, "Feel like just a number," he sang, "I feel like just another / Spoke in a great big wheel / Like a tiny blade of grass / In a great big field."  Seger insists he's gonna "cruise out of this city / Head down to the sea / Gonna shout out at the ocean / Hey its me!" "I feel like a stranger / A stranger in this land," he sings.  "I feel like a number / But I'm not a number / I'm not a number -- Dammit, I'm a man! / I said, I'm a man."

I recall a conversation with another Marine, who between tours of Vietnam, had a premonition that he wouldn't survive his second tour.  What worried him even more than the dream was that everyone he knew who'd had a dream like that, and shared it with his buddies, subsequently was killed.  This Marine talked it over with his dad, a heavily-decorated Army officer, who told him, in sort, to buck it up and suck it up and go back -- because if he didn't, he'd be running from every other experience like this in his life.  Well, the premonition had a lot of weight to it -- he was shot multiple times and almost died, and took years to recover from his injuries. So we know that the Recon Marine in today's story, headed back to Afghanistan, does have something to be worried about -- even if he hasn't had a dream like this.

Ultimately, whether he and servicemembers like him think of themselves as "just a number" in the larger war machine or not, their more pressing concern, with multiple deployments in harm's way, is whether this time their number is going to be up.  And let's hope it won't be.  But of course, for society at large -- who stays behind -- the broader public health worry is that even if these warriors come home relatively "unscathed" -- in body, more likely than in mind -- their struggle with dealing with the after-effects of combat will just have begun.

Editor's note: To listen to the Bob Seger song mentioned above, on YouTube, click here.

Puget Sound Veterans Hospital Tries Meditation for PTSD

The Seattle Times reports in today's paper that a veterans hospital in the Seattle area is trying a version of mindfulness meditation for combat veterans with PTSD.  The article is called, "Seattle hospital teaches meditation to troubled vets," by Michelle Ma.  The eight-week course, which has been held for a year, has proved to be of some value to veterans, and current plans are to study the effects more in-depth. 

The article in the Seattle Times is linked here.

For links to other posts we've done about mind-body medicine, including meditation, and PTSD, click here.

Upcoming Seminar: War and the Soul, with Edward Tick, Ph.D.

An upcoming seminar that may be of interest to readers is Edward Tick, Ph.D.'s week-long "War and the Soul: Healing Post-traumatic Stress Disorder," put on by the New England Educational Institute, and hosted at Eastham, on Cape Cod, Massachusetts.

(As a Cape native I can say, that's an extremely popular place in the summertime -- make your reservations for accommodations early, if you're considering going.)

From the brochure:

Edward Tick, Ph.D., is Founding Director and Senior Clinician of Soldier’s Heart: Veterans’ Safe Return Programs. Honored for his groundbreaking work in the holistic and community-based healing of veterans and Post-traumatic Stress Disorder (PTSD), Dr. Tick has been a psychotherapist for 33 years, specializing in working with veterans since the 1970s. He is the author of Sacred Mountain, The Practice Of Dream Healing, The Golden Tortoise, and the award-winning book, War and the Soul.

 Dr. Tick is an internationally recognized expert on veterans, PTSD, and the psychology of military-related issues and has conducted training at Walter Reed Army Medical Center and other Department of Defense facilities. He lectures throughout the world and leads semi-annual international educational, healing and reconciliation journeys to Vietnam and Greece. Dr. Tick specializes in using psycho-spiritual, cross-cultural, and international reconciliation practices to bring healing to veterans, communities and nations recovering from the traumas of war and violence.

Click this link for more information, or to register.

The schedule for the seminar, also from the brochure:

Symposium Schedule:

Monday:

• The universal dimensions of the war experience;
• Introductory stories from veterans of several wars;
• What we mean by the soul and its place in psychotherapy and healing;
• What war does to the soul;

Tuesday:

• Post-traumatic Stress Disorder from Vietnam to all wars;
• World history of PTSD;
• Mythology and PTSD;
• Warriorhood: Archetypal, cross-cultural and historical perspectives;
• The Hero's Journey, Initiation, and the Warrior's Path;

Wednesday:

• A holistic understanding of Post-traumatic Stress Disorder;
• Stress and anxiety disorder;
• Identity crisis;
• Interrupted initiation;
• Social disorder;
• Attachment disorder;
• Soul wound;

Thursday:

• Traditional and cross-cultural models and practices for healing from war;
• Purification and cleansing of the warrior;
• The healing power of storytelling;
• Restitution in the family and nation;
• Initiation as a warrior;

Friday:

• Healing beyond the therapy hour;
• Unique spiritual dimensions of healing from war;
• Healing through spirit principles and practices;
• Healing in the community;
• International healing;
• Spiritual vision regarding war and its healing.

PTSD, Suicide and the Primary Importance of ... Sleep

There's a great article in today's San Antonio Express-News by Sig Christenson, called "War Lingers, GI Suicides Rise."  (The article is linked here.)

It quotes my favorite, retired Veterans Affairs psychiatrist, Jonathan Shay, M.D., Ph.D., and it quotes him on, among other things, the absolute primary importance of SLEEP, which we've talked about many times on the blog before. (Click here for a link to those posts, many quoting Shay himself.)

Quoting Christenson's article, from today:

"The armed services' high operational tempo for the past decade definitely is part of the problem, said (Jonathan) Shay (M.D., Ph.D.). Though alcohol abuse “is a major risk factor,” he said the military's rapid training and deployment cycles short-change troops on the one critical ingredient to good physical and mental health: sleep.

“I've been agitating for years the importance of getting truly realistic policy on sleep,” Shay said. “This is a slow slog because it is so contrary to the macho culture and so contrary to the self-sacrificial culture, which sees self-care like sleep as self-indulgence.”

Let's recap some absolute basics about sleep:

• It's absolutely necessary for mind and body healing, and down regulation of bodily systems;
• It's vital for decision-making and mental health. Studies on drivers who operate on lack of sleep of sleep show that it impairs functioning to the level of alcohol intoxification.
• It's hard to get in a war zone, for any number of reasons: from the operations that go on for days and nights at a time, to the noises of combat, etc.;
• It's hard to get after combat, thanks to nightmares, hypervigilance and arousal, and often the desire to avoid sleep (which brings on intrusive memories, nightmares, night sweats, and the like);
• Chronic lack of sleep impairs mental, physical and emotional health;
• And yet without adequate, nightly sleep -- how is healing going to take place?

There's a great story told about beloved Marine veteran, Travis Twiggs, who we've written about in other contexts.  Apparently his nickname was "War Pig," and it was given to him during a tour of duty at Guantánamo Bay, where after being up for umpteen hours straight, and finally getting a break, he had fallen into such a heavy sleep that he couldn't be roused, and a passing a general had stuck over his sleeping form a sign that said, “Here Lies the Mighty War Pig.”

I know another hardcore combat veteran and former Marine who came with me once to a program that was designed to help people learn how to sleep better.  He bitched and moaned while we were there, quite a bit, about how this wasn't really suited to combat veterans like himself, but whatever -- he persevered, and tried what they had to offer.  The next day, after he flew home, I worried about him because I hadn't heard how he was doing. A day later, he called me back. "I came home and slept for 31 hours straight," he said.  "I hadn't been able to sleep more than two hours at a time since before I left for Vietnam." So my guess is that the method was of some help to him ;-) But imagine not sleeping for more than two hours at a time?  How well would you be able to heal?

Editor's note: Read the rest of the articles we've included about sleep, from previous posts, linked here.

When the Darkness Has Fallen...Just Me, in the Wake of Battle

I've been reading Tyler Boudreau's "Packing Inferno: the Unmaking of a Marine."  Probably a wise choice, in light of the news recently about combat stress and how servicemembers do and don't tolerate it.  I was drawn to reading Boudreau's book because I'd read several of his essays recently, and pretty much felt like they didn't go far enough -- and I was trying to understand the backstory.  His backstory, that is.  And how better to do that, than to actually read his book.  Boudreau comes across well, as he earnestly attempts to untangle the ordeal of his experience, both serving and (more to our point), coming home.  Within the first ten pages of the book, he's already described his PTSD, and it's a nice, succinct, almost poetic expression, which will help others who don't quite understand it yet.  Here it is, in Boudreau's own words:

"I’m hemmed into the night.  My brain has come to prefer the darkness.  I can’t say with any certainty if this is a product of never sleeping – that is, if it’s just a bad habit I’ve got to break – or if there’s something else going on, like the systematic avoidance of those bloody dreams.  I told the doc I wasn’t sleeping when I got home, and he glanced (up) casually from his desk and said, “That’s normal.  It’ll pass.”

Normal, he said.  When I told him I was just about jumping out of my skin every time I heard a loud noise, he said that was normal, too.  Normal, as in commonplace, as opposed to, say, pathological, like it would have been abnormal not to jump out of my skin.  It’s what they expected from me.  They figured I was in good working order, I guess.

Then they blew off my rage with the same line. “Everybody’s got that,” they said.  I wonder if they’d call me normal now, with all that I’ve got to say.  Three years later, my heart was still pounding, I was still raging, and I still wasn’t sleeping.  I was up, thinking about the war.  I finally told myself it’s like a bad back or a trick knee; you just learn to live with it and you walk. on.  So as I’m walking on, night after night when the darkness has fallen, and the rest of the world is silent, I go looking for my narrative."

(The narrative is something we've talked about earlier, here, and in Boudreau's case, we'll also talk about again -- but later, in another post.)  Suffice it to say, he finishes the foregoing description with a very potent, and poignant, explanation of who he is right now:

"The Marine Corps made a schizophrenic out of me, figuratively speaking.  I used to have only one voice, one point of view.  All right, so I’ve got a new perspective now. It happens.  But it’s not like I changed my mind.  My mind changed.  It split, two, three, and four ways over.  Now there are voices coming at me from all sides.  There’s no coherence to them, and no clear distinction either.  There’s the angry voice, and there’s the broken-hearted one.  There is the tender me and the savage.  And of course, there is the Marine.  There will always be the Marine, standing tall inside me, speaking smartly about values and patriotism.  There there’s all the rest of me, the part of me that was left over when I left the Corps.  He has no name, no identity, or credentials, or skills.  He has no title or rank.  He has no cause.  He is just me in the wake of battle."

With these words, both simple and profound, Boudreau expresses many, many combat veterans' experiences, that they will often spend decades trying to come to terms with, often failing, sometimes succeeding, and sometimes also killing themselves, in a forlorn attempt to, ultimately, attempt to bring resolution to that exact conflict.  Not the external one, in which they were involved as a warrior; but the internal one, with the battle that continues to rage, that they often feel they cannot escape.  Good for Boudreau for putting words to his experience, so that others -- veterans and the public at large -- can relate.

Editor's note: Boudreau's book, "Packing Inferno: the Unmaking of a Marine," is linked here.

Combat Veterans, PTSD and Acupuncture

We've written about acupuncture before on this blog, in posts linked here. And an article in the current issue of "Acupuncture Today" magazine (May, 2009) discusses -- tangentially -- the use of acupuncture for PTSD.  It especially emphasizes the costs savings, particularly when used as a form of pain control (a typical use of traditional acupuncture, known as TCM). Here's a story, though, that shows the human side of acupuncture's worth for a combat veteran.

Recently I met a Marine who was part of a wounded warriors unit.  I won't say who he was or where he was located, to protect his privacy, but he had completed several hazardous deployments in Iraq and had come back to the Marine base to continue his service. I happened to learn that he sampled a few modalities from the "complementary and alternative medicine" spectrum we've discussed on this blog before, and one of the therapies he'd tried was acupuncture.  I happened to catch him in an unguarded moment, when he had his mind on other things (what amount to pain control, at the time) and I asked him to describe his experience, because I wasn't sure who he'd seen or what type of acupuncture it had been.  He described that he'd been interested in checking it out, but that the commanding officer  had considered it to be some form of "voodoo," so was pretty much against it.  But there was one acupuncturist from the town near the base who was willing to come on base and offer it, and do that for free.  So that removed some of the initial barriers to trying it, and the commander okayed it.  With those circumstances in mind, I asked him what his experience was like.  This is what he said:

"After she stuck me (needled me), I went back out to my truck, and I just sat there, for about an hour and a half, just GLOWING (his words.)."  His eyes moistened briefly as he said, "I realized it was the first time I had felt happy in two and a half years," he volunteered, continuing, "I had forgotten what it was it like to feel real joy."

I couldn't leave well enough alone -- I had to track down the acupuncturist he'd seen.  I figured out who she was, called her up, she answered the phone, we identified him as the patient in question, and then had a brief conversation about what he'd shared.  She told me she had goosebumps from hearing the story, which she hadn't known before, and added, "this is why we do what we do."

With all the lip service -- and, one hopes, quite a bit more than that -- these days being paid to treating combat veterans in more comprehensive ways that meet their needs better, I hope ancient methods will merit due consideration.  When I remember this short conversation with the very much moved Marine, it's hard not to appreciate its merits. Neatly, there are several types of acupuncture -- one which specializes in addiction treatment, one which focuses on treating body, mind and spirit, and a general, all-pupose form (along with many others).  With many offerings to choose from, and increasingly more research to support its efficacy, acupuncture truly deserves a place at the table in treating the hidden wounds of combat veterans.  I have only to remember the glow in this Marine's retelling of his experience to remember why.

Travis Twiggs: The Un-Happy One Year Anniversary of Combat PTSD's Perhaps Most Visible Death

Just a brief note to mention, it was one year ago today that Travis Twiggs passed from this earth, by his own hand, the veritable poster boy of combat-based PTSD.  It also marks his brother Willard's passing, who left this earth with Travis, apparently by Travis' hand.  It's an absolute tragedy, for any number of reasons -- from the family members and friends the Twiggs brothers leave behind -- to the fact that Travis, personally, was making an impact as a Marine who broke the code of silence, so to speak, and spoke openly about his PTSD.  Twiggs wrote about his ordeal in the January, 2008 issue of the Marine Corps Gazette, in an article that has been widely circulated, and is still available on the Web.

Travis Twiggs' suffering was something that really stood out to me -- perhaps because of his very willingness to speak openly about his struggles, something Marines.Just.Don't.Do.  We actually broke the news of his death on this blog, before the mainstream media had reported on it -- and in fact, the early reports were wrong on the facts but widely repeated, making the damage that much more painful.  (He and his brother were reputed to be hardened criminals, for example, which they were not, although they had been -- at the last -- involved in a carjacking, as part of their initially ill-fated but ultimately successful desire to end their lives.  In fact, Twiggs was a much-decorated Marine with multiple combat tours behind him, who had recently met the president, and whose Marines (and his family) deeply loved him.  His brother, Willard, was well-loved as well.  A year later, not a day goes by that people don't find this site out of a search they're doing for Travis or Willard; and in the days after their death, searches for Willard were almost as popular as those for Travis, though Willard was obviously shyer and less well known. And these tragedies were not the only ones the Twiggs family suffered in a very short amount of time: their beloved grandmother also passed away within days of the Twiggs' brothers' deaths. Hard, hard times for the Twiggs' family, and for all those who loved Travis and Willard.

It's hard to explain my own involvement in this saga except to say, I had a bad feeling about how Travis was really doing, without even knowing him, just based on reading what he wrote, and how it didn't seem to add up.  So the month before, without realizing he'd already been confined to an inpatient PTSD program at Bethesda Naval Hospital, and was therefore unable to answer, I repeatedly tried to get ahold of him and/or the Marine Corps Gazette, which had published his somewhat optimistic article months before.  When neither would reply, I started to really worry that something was amiss.  Then when the first news reports came out of the National Park Service about the "armed, tattooed and dangerous" Twiggs brothers, involved in a carjacking, I just knew it had to be Travis, and that things had somehow gone terribly wrong. Hoping to offset the "bad news" (and mistaken news" about who Twiggs really was -- not a lifelong criminal, but a decorated Marine, who everyone loved, who'd struggled mightily with PTSD -- I went out on a limb, and wrote, as I realized he was dying, what became a "PTSD obituary" to this at the time unknown Marine, who'd undoubtedly died from the consequences of his uncured, but not untreated PTSD.

In the days that followed, as I waited for any national attention to be focused on his case -- none was -- the blog here received heavy, heavy traffic, as those who loved Travis and his brother came to essentially pay their respects, much as I had tried to myself, and also tried to come to terms with the brothers' passing.  Over time, various reporters kicked into gear and started covering the Twiggs' story in lengthy pieces. (I had to put the "use with attribution" notice up on this blog when one reporter spent, no joke, 40 hours mining this site, without acknowledging where he got his information.  Ugh.) Richard Ruelas wrote about the saga for the Arizona Republic (the brothers had died in Arizona), Bill Finnegan's at the New Yorker magazine, and there was a two-part series in the New Orleans-based Times Picayune. CNN, to its discredit, never once mentioned the brothers' passing.  I think once they missed the initial window, it was too embarrassing to catch up, but to this day, they never have, whereas pretty much everyone else has had something to say about it -- or them.

While many, many aspects of being the one to break this story -- on a blog, not in a newspaper or a wire service -- have been exceedingly frustrating, I'll spare you my angst on that one.  The blessings have also been there -- getting to "meet" online and sometimes in person, some of the key players in the brothers' lives, and have them express their appreciation for what I did to help to humanize their brothers, while the rest of the print world was essentially doing the opposite (at least initially). I'm still concerned for how Travis' wife, now his widow, Kellee, to whom the news of Travis' whereabouts and obviously his death, came about as a shock, as well as for the Twiggs' parents, whose loss of two sons at once is just incalculable.

In the New Age-y world, people do talk about being careful about what your intention is, and how your intention will carry the day.  Without going into what "intention" means, overmuch, it can be simplified to say, whatever the vision is of an outcome, that you carry in your heart, or that you express to the world.  In this case, it was very, very clear.  Back exactly a year ago today, as Travis Twiggs and his brother were in their last moments, and time was running out, I wanted the world to NEVER FORGET who Travis Twiggs was, and what the legacy of unresolved PTSD looks like.  If ever there were a poster child for PTSD, it was Travis Twiggs.  He took the first step when he told the world his secret in that powerful, much-read article in the Marine Corps Gazette, when he broke the silence for his Marines, and the rest of OEF/OIF veterans.  What I held in my heart that day -- despite the professional disappointments that may have followed -- was that when people thought of PTSD, they would think of Travis Twiggs.  And given that his legacy is still very much alive, one year later, I do believe that intention accomplished exactly what it was supposed to.

As Twiggs himself said, he was willing to come forward and talk about what he went through, because he wanted no other soldier, sailor, airman or Marine to suffer like he had -- in silence.  With his death, and that of his brother, unfortunately for the much-beloved Twiggs brothers, but mercifully for the rest of us -- it's a conversation we will all keep having.  RIP, Travis and Willard Twiggs. You are not forgotten.

---

Editor's note: The original blog entries about Travis Twiggs from a year ago are: "One Marine Reflects on His Battle with PTSD," linked here (before his death); "PTSD -- "The War Within" -- Claims Another Victim," linked here; "RIP Travis N. Twiggs, USMC PTSD Sufferer," linked here; "The Ballad of Travis Twiggs," linked here; "Travis Twiggs' Suicide - Only Questions Remain," linked here; "The PTSD Obituary for Travis Twiggs," linked here; "Bleeding Green with PTSD," linked here; "Twiggs' Wife: 'The PTSD Drove Him Crazy'," linked here; "The Tragic Last Days of Travis 'T-Bo' Twiggs," linked here; "Travis Twiggs' Widow, Kellee, Puts a Human Face on the Suffering of PTSD," linked here;and, finally, "SSgt. Travis Twiggs - Well-Loved U.S. Marine and Hurting PTSD Hero - the Update," linked here.

After Combat: Looking for Health in a Handful of Pills?

From a week ago: The Savannah Morning News had an excellent article, by Pamela E. Walck, called "One soldier's struggle: Sgt. fights anger, treatment system," linked here. (There's also video, but it's not as on target as the article is.)

Sergeant John Jones, now part of the Warrior Transition Unit at Fort Stewart, Georgia, is the subject of the article, and by any standard he has a lot on his plate.

He was deployed with the 3rd Infantry Division's  2nd Brigade's 1st Battalion, 30th Infantry as a gunner, serving his second combat tour at age 29, when he was injured by an IED blast in July of 2007.  Less than six months later, doctors also discovered a brain tumor, and operated.  Since then, though the difficulties you could anticipate from those incidents alone would be enough for one person to cope with, there's been more. Symptoms of PTSD, trouble with authority both on and off the base, difficulty sleeping, the sense in Jone's own words that his personality is not what it was before, a (fortunately) failed suicide attempt, etc.  Really a painful story, of what sounds like a good man, having trouble coping with the after-effects of his injuries. The one peace in his life appears to be a rented cabin, where he goes for solace (and to fish!), yet is in danger of being taken away from him.

Walck does a great job reporting the story, and not settling for just the usual details. Through her work and Jones' own words, you're drawn into the story of what amounts to really a typically "wounded warrior." And while you find yourself pulling for Jones to survive and thrive, you can't help noticing that the "hope" held out for him is not much more than a handful of pills. Who he feels like he's lost, in his words -- echoing that of so many other combat vets with PTSD -- is "the old John," who he's now all but lost entirely. How he's going to get that guy back... is unfortunately anybody's guess. (As an additional difficulty, it's unclear whether his brain injury is making his behavioral issues worse -- it's likely that it is.) In the meantime, we can hope for peace and a healthy solution for Sgt. John Jones -- but for those who want a broader-than-usual, fully-developed "portrait" of one wounded warrior, struggling with the ravages of combat and PTSD, be sure to go here and read his story.

"I Have PTSD," But "I Am Not PTSD"

This conversation goes back a while ago with a combat veteran of the Vietnam era, who has been trying various therapeutic methods for addressing his decades-long case of severe PTSD, and finding, by degrees, some actual and substantial relief.

Over the past few months, as his situation has greatly improved, aspects of his PSTD have fallen away, symptom-by-symptom.  But lest this lead you to believe that such progress, or success, is all "positive" -- the reality is, it doesn't always feel that way to the veteran, who has become habituated to seeing the world through the context of their having PTSD.  PTSD, of course, affects virtually every important aspect of their lives: from how social they are, to relations with their family, to how they can hold a job, how much pain they are in on a daily basis, how much stress they can manage, and how many medications (with their attendant side-effects) they take.  Psychological symptoms, physical symptoms, even "social" symptoms: they're all there.

And after a lifetime of identifying yourself as a "crazy, f*cked-up Vietnam vet," f'r instance, if that "identity" should start to fall away -- as you progress towards actual health and wholeness...mmmmnn, what do you replace it with?  Because there needs to be something.  Having relied on one identity for years (even decades) to manage life, and keep others at bay, suddenly that "crutch" or that "coping system" is no longer there.  And with all the other problematic pieces stripped away, piece by piece, what's actually left is a raw, brand new...baby. At least in terms of trying to cope with who you are in the world.  Amazing stuff.  And as great as it might be to get some symptom relief, and some ultra-positive life changes, at the same time...fear comes into play.  Who will I be without this shell I've learned to rest upon for so long?

Even the Bible talks about, in a slightly different context, how if you're going to sweep a place clean and remove all the demons, you have to immediately replace the empty space with something good, lest more demons come by (boy, the Bible is awful cheery; I'd forgotten...) and, finding the place vacant, immediately seek to fill it up with something "ten times worse" than what had been removed.  Mmmm. Lovely.  But the principle is a worthy one: If you're been relying on one thing, for a long, long time -- and you suddenly remove it -- you'd better find a way to be comfortable with the new self, because it's what's you have from here on out.

Having been privy to these struggles with one veteran as he walks his path, it's been surprising to me to see how "upsetting" the concept of healing can be -- initially upsetting, that is.  There's an old Tony Robbins line that human nature will do much more to avoid pain than they will to seek pleasure, and I think that comes in to play here, too. Change is painful; growth is painful; heck, even healing -- in that context only -- can be painful.  It's all new; it requires new skills; a new outlook; even new hope.  But ultimately, it's (obviously) the best way.  Most ironic of all is when the combat veteran, for example, has been the one to pursue the healing so radically -- and then when it starts to happen, in shock, he draws back, startled, as if realizing, ahhh, this is going to be my new life: how strange. I wonder if I recognize me in this at all.

Of course, over time, the progress coming in waves, as more methods are tried and proven useful, the experience gets better, and the veteran gets to be more at peace in his own skin.  Symptoms with which he has lived for decades start to abate, and be replaced by ... peace... and better experiences with himself, his family and loved ones. Overall, though the process is bumpy, the progress is sure.  There's no turning back: the combat veteran continues to WANT his healing, and his healing is happening.

And suddenly, the revelation, at least in his mind: "I have PTSD," he declares, decades into the fight, "but I am NOT PTSD."  Previously, of course, the unspoken assumption was that there was no distinction.  PTSD so consumed his life than in fact he WAS PTSD.  Now, he can say that he has it -- increasingly, even better, that he HAD it -- but that it is not him.  Wow.

Violence at Camp Liberty: Shocked, Maybe, but Not Surprised

 Allow a little venting of spleen here: The violence at Camp Liberty today in Iraq, where an American active duty servicemember allegedly opened fire on others at the stress clinic, a location where other servicemembers go for counseling, killing 5 at 2:00 p.m. local time -- if we're shocked that this happened, that's okay; but seriously, America-- why are we still "surprised"?!

Here's 10 reasons NOT to be surprised, though feel free to continue to be shocked:

1.    Tours are too long, putting considerable and unprecedented strain on the all-volunteer military. The AP reports, "The U.S. military is coping with a growing number of stress cases among soldiers in Iraq and Afghanistan - many of whom are on their third or fourth combat tours. Some studies suggest that about 15 percent of soldiers returning from Iraq suffer from some sort of emotional problems." The ones who initially deployed?  Strong and willing.  But as the tours wore on, how many stayed that way?  Certainly not everybody.
2.    Resources for stress management are inadequate, and there's often peer pressure not to make use or take advantage of them -- and then the broader question: what are we really offering to help soldiers heal?  Is there anything in the conventional medical world that's actually working? There's talk therapy and there's medication, and those who follow this topic in-depth know that there are problems with either or both of those approaches.  Anecdotally, of the three combat veterans whose lives I follow most closely, all three of whom had recently pronounced substantial healing  -- two of the three who relied on the most conventional approaches -- were re-hospitalized within the past month for psychiatric reasons, each within several weeks of pronouncing how much better they were doing, thanks to their course of treatment.  (The third combat veteran, who follows a less conventional path, is actually truly doing better -- or so it would currently seem.) When it comes to combat-based PTSD, the "cure," such as it is -- is a long way off -- particularly if we only look along conventional channels.
3.    Access to firearms is...ummm...not an issue: they're everywhere.  It's war, and we're armed to the teeth.  It's part of what we do.  But carrying a weapon in a stress clinic?  Doesn't seem on the face of it to be a wise safety choice;
4.    Workplace violence is a fact of civilian life, too: OSHA reports that homicide is the fourth leading cause of workplace fatalities. On an average workday, according to one site, "three people will be murdered on the job in the U.S."  Annually, "one million workers are assaulted, and more than 1,000 are murdered." Concerns are that half these cases go unreported, so the figures might even be doubled. Mondays, in fact -- today  when the Camp Liberty incident took place is a Monday, after all -- are a prime time for incidents to take place.  Something about people stewing about their real or imaginary mistreatment over the weekend, and coming back in and deciding to "do something about it."  Read the cases: Monday is often when disgruntled American workers, at the very least, choose to settle the score;
5.    Sleep deprivation is a chronic problem in the over-extended military.  As a technique for inducing symptoms along the spectrum from abject misery to forms of psychosis, it's effective enough that it's used (by the U.S.) as a form of torture, like waterboarding. Going without sleep, which the military chronically does, puts soldiers at risk on a regular basis.  Not that there are any easy answers to this, but that needs to be taken into account. Not sleeping is very dangerous to your health: and if to yours, by extension to those around you, too. Experts like veterans advocate Jonathan Shay, M.D., Ph.D. have long warned about the dangers of exhaustion and sleep-deprivation.  It's time to pay greater attention;
6.    Talking heads and pundits attempt to minimize the problem by saying, it's only the fifth case of soldiers killing one another since the war began but REALLY -- are they serious?!  How about adding the qualifier, "known" case -- as in, proven.  (Even the New York Times said, more accurately, "The killing of American troops by their fellow soldiers is infrequent, but not unheard of.") Think of the many cases of noncombat deaths in Iraq.  How many of these, because of insufficient, inadequate, or misguided investigations -- or cover-ups -- might turn out to be soldier upon soldier violence, if we but knew the facts? A percentage of the noncombat deaths are murders, not just accidents or suicide.
7.    Felony waivers. While many -- or most -- of the military may be fine and upstanding individuals -- better, in fact, than most of their less patriotric, more self-centered peers -- the reality is, as the war continues, an increasing few who have less savory backgrounds or mental states are being given waivers and allowed to join anyway -- then deployed with the rest of the troops, and put under the same types of strain, which perhaps they don't bear very well -- or as well as their peers;
8.    If recruiter suicides are up (and they are) -- recruiters being in a good position to know the true costs of going to war on the troops -- and suicide is effectively giving up on their being a solution to one's problems -- shouldn't  this ring some greater warning bell than it has, that perhaps we're asking people to do and to sacrifice, far beyond their actual ability to?
9.    We can't discount the fact that some people are just unbalanced -- and some of the ones who are, unavoidably, also serve in the military.  The last well-publicized statistic on the subject was that roughly 10% of the (overall) population suffers from mental illness. Some of these people are in the military, and under stresses and strains greater than most of us have ever endured, some will snap.  that in itself should not really...surprise us.  It's not a diss against the military: it's a fact of life. If anything their challenges are stronger than anyone else's.
10.  Interpersonal violence and suicide are both extreme versions of "lashing out" at what's perceived to be an unjust fate.  Domestic violence rates in the military ARE worthy of some "shock 'n awe" of their own.  During the same news cycle, where the Camp Liberty incident is being broadcast across all possible news outlets, other, equally horrendous incidents are also happening among servicemembers and veterans -- horrendous to the victims and their families, as well as to the families of those who commit the crimes. Here's an example of the same from today's news cycle, though it's all been pushed off the page by the greater prominence of the Baghdad story. The Colorado Springs Gazette reports that Thomas Woolly, 24, was arrested in the shooting death of a 19-year-old woman.  As the Gazette describes, "Woolly ... was a heavy machine gunner in the 4th Infantry Division's 2nd Battalion, 12th Infantry Regiment.  Members of the 500-soldier unit, nicknamed the Lethal Warriors, have been involved in stabbings, beatings, brawls, domestic violence, shootings, at least two attempted murders and four homicides in Colorado Springs. Another soldier who served with the unit in Iraq has been accused of murder in California. The unit has also been plagued by drug abuse and suicide..."

By bringing this up -- that this violence might be "shocking," but surely shouldn't be "surprising" -- it isn't intended to single out servicemembers or veterans as "bad" -- if anything, they're under abnormally large stressors.  It is to say, this stuff happens -- not always as well broadcast as when it happens in a group.  But it happens all the same. Forgetting even Iraq and Afghanistan for the moment -- across AMERICA -- do we honestly believe that fewer than five people -- including the servicemembers and veterans involved -- had their lives in actual, mortal danger from incidents like this? (In the Woolly incident above, for example, one woman was killed, but another one was injured, according to published reports.)

Again, if we were but able to "see" across the broad expanse of all the people this affects, and into all their homes and lives, even on one given day, I think we might be quite surprised to see the continuing emotional toll and strain that combat stress and its aftermath produces. Continuing to look at incidents like whatever happened at Camp Liberty today -- as the facts continue to come out, over time -- as "isolated" incidents, instead of a very visible part of the mostly in-visible spectrum of pain and suffering -- only allows us to stay in the dark on this topic a little longer than we should. 

For the health of servicemembers, veterans and their families, it's time to start admitting what a difficult problem we have: and one that takes more than lip service, and conventional modes of treatment, to "handle" and ultimately to "solve."

Students' Documentary on Veterans: "It's a Privilege to Hear Their Stories"

The Boston Globe has a GREAT front page story today called "Battling a Different Kind of War," by Peter Schworm. The subhead gives you a clue to the content: "military college students document the struggles veterans face when they return." The students in question are from Norwich University, in Northfield, Vermont, and the documentary, done entirely by students, talks to Iraq and Afghanistan veterans about their readjustment issues on returning home.  As such, it's both a truthful and a cautionary tale, for those on both sides of the camera.  Great job!

Let's hope the documentary soon will be available for viewing publicly, to further enhance all of our understanding of what combat veterans go through when they willingly go to war, and return -- hoping, but maybe not always able, to pick up their lives "right where they left off." Because the students involved are at a military college -- and some of them have already served their country -- they're probably a little more sensitive to some of the issues involved, and presenting a less-biased approach than those who are necessarily "for" or "against" military service.  From the sounds of the Globe article, everyone involved seemed pretty aware and respectful of the price that veterans pay to serve their country. (The quote in the title above was said by one of the filmmakers in the story...)

Editor's note: The Boston Globe article is linked here.