Healing Combat Trauma

"I Had My Hard Lessons in Life" - Ambrose Bierce, Literary Poster Boy for TBI and PTSD

It's getting hard for me to think of Ambrose Bierce as anything but the quintessential, though unrealized, poster boy for PTSD (and secondarily, TBI) from the Civil War era -- in addition to his stature as a journalist and writer of quite macabre short stories...and the funny-as-hell classic, "The Devil's Dictionary."  

(The painting pictured, too, shows Bierce with the human skull he allegedly kept on his writing desk "for inspiration".)

The more I read about Bierce, the more his symptoms jump off the page -- really consistent, too, with the extreme amounts of combat trauma he experienced.

More on that later, as it comes up, but here's an item from an unrelated book I've just been reading, which mentions Bierce's "mentorship" of another San Francisco-based writer, George Sterling.

"This was Sterling's first lesson.  Many more followed.  Bierce...obliged him to visit the city morgue, where he bribed an attendant to display bodies for them to "strengthen the spirit."  When Sterling had to rush from the place and vomit in the gutter after viewing the corpose of a drowned man, Bierce said, "Don't be embarrassed...When I was eighteen, I had to go out and bury soldiers and horses who had been lying in the sun for a week.  I had my hard lessons in life, too."

---

That passage is followed by another in the same book, where a different San Francisco writer -- Jack London -- reinterprets Bierce's fixation with death to the same young writer, George Sterling:

"They walked up Grant Avenue and Sterling told London about the evening that Bierce had dragged him around the city, ending up at the morgue.

"That figures," London snorted.  "Bierce is fascinated with death because he detests life.  He's afraid of it, I think.  He doesn't want to live in the real world. Anyway, I'm not taking you to any damned morgues tonight.."

-- Source: Realms of Gold: The Colorful Writers of San Francisco, 1850-1950, by George Rathmell.

Another intepretation of course is that perhaps Bierce had seen "too much" of the real world... and was still trying to put the pieces together, for himself, even decades later.

Teddy Roosevelt on Veterans - Give 'Em a Square Deal, Afterwards, for Serving

A quotable quote from the 26th president of the United States, who served as a legendary Rough Rider during the Spanish-American War, and also as an Assistant Secretary of the Navy:

"A man who is good enough to shed his blood for his country is good enough to be given a square deal afterwards. More than that no man is entitled to, and less than that no man shall have."

The Danger of Incomplete Mourning: "Unable to Achieve the Catharsis of Grief"

Deep within the William Styron memoir, "Darkness Visible," which we blogged about recently, here, is this observation of his about what might have precipitated his own depression.  Because it touches on things we've covered over and over again on this blog, it seemed very worth mentioning -- as well as quite profound:

The morbid condition proceeded, I have come to believe, from my beginning years – from my father, who battled the gorgon for much of his lifetime, and had been hospitalized in my boyhood after a depression spiraling downward that in retrospect I saw greatly resembled mine.  The genetic roots of depression seem now to be beyond controversy.  But I’m persuaded that an even more significant factor was the death of my mother when I was thirteen; this disorder and early sorrow – the death or disappearance of a parent, especially a mother, before or during puberty – appears repeatedly in the literature on depression as a trauma sometimes likely to create nearly irreparable emotional havoc. 

 

The danger is especially apparent if the young person is affected by what has been termed “incomplete mourning” – has, in effect, been unable to achieve the catharsis of grief, and so carries within himself in later years an insufferable burden of which rage and guilt, and not only damned-up sorrow, are a part, and become the potential seeds of self-destruction.

From Darkness Visible: A Memoir of Madness, by William Styron.

Making Darkness Visible - One Author (and Former Marine's) Attempt

I read the classic Darkness Visible: A Memoir of Madness, by William Styron, the other night.  It's a quick but melancholy read and takes about an hour. (What I didn't realize at the time, and it's completely tangential to his story, which is really about a four year bout the well-known author had with clinical depression, and the closeness he felt to suicide, is that Styron was a former Marine.)  Styron died of pneumonia in 2006, at 81 years old.

In an obituary printed about Styron on Martha's Vineyard, where he had a home, the following information about his military service is revealed:

Following high school [Styron] joined the reserve officer training program for the United States Marine Corps, and enrolled at Davidson College. He was unhappy there and through the Marines transferred to Duke University in June of 1943. In October of 1944 he was called to active duty and in late July 1945 was commissioned a second lieutenant. He was assigned to participate in the invasion of Japan; a month later the atomic bomb attacks forced the surrender of Japan and he was discharged. ... In 1955 he published The Long March, originally a novella about his experiences in the U.S. Marine Corps.

The same obituaryalso makes clear the trajectory that led to Styron's depression, and the resultant book that introduced this highly personal experience of the author's to the American public:

[Styron] drank heavily and smoked cigars until the summer of his 60th birthday in 1985, when he decided that alcohol no longer agreed with him and gave it up. But the abstinence triggered mood disorders which required medication, and the drugs in turn brought on a deep, enduring and suicidal depression that required him to be hospitalized for more than two months. The experience prompted him to write Darkness Visible: a Memoir of Madness, after he had recovered.

The book earned Mr. Styron a whole new set of followers. "I think it causes people to realize two things," he told the Gazette in an interview in 2001. "That this is a pain that afflicts a lot of people; it's universal and if I could describe it in this way and people could relate to it, it meant they weren't alone; and the second thing - almost as important or more important - is stressing the truth that people can get well, and that it's not by any means fatal."

Styron's book is interesting, to a degree, mostly because of his prominence as an author at the time he wrote it, and because it is so uniquely personal: One person telling the story of his own descent into "madness." I wasn't a complete fan: it's a little hard to keep reading how marvelous Styron's life was, yet how unhappy he was within it -- true though that might be.  And the entire book, while short, is one continuous slog through the same miserable territory, until his case finally improves towards the end (mostly thanks to hospitalization, it would seem.)

However, there are some intersting parts.  One is near the beginning, where he quotes the French writer Albert Camus, "There is but one truly serious philosophical problem, and that is suicide."  In Styron's hands, the problem becomes more physiological than philosophical.  He tries to put off suicide, while coping with his depression -- but first, cataloging his depression fairly exhaustively for the reader (or himself, it's never too clear.)  He covers some standard themes, such as how self-medication with alcohol kept his demons at bay for years, until he cold turkey gave up drinking, and watched his depression take on form and substance.  He explains how the common response of depression is to be more interested in injuring self than others (small comfort, that).  And he mentions the unique aspect we discuss here from time to time, about how psychological pain can manifest as, or at least be accompanied by, physical pain.  In Styron's words, about his own case:

"What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain.  But it is not an immediately identifiable pain, like that of a broken limb.  It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room.  And because no breeze stirs this cauldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion." 

(Hmmmn.)

Styron indulges in one of the book's only tiny moments of humor when he describes the loss of his libido, which he says happened pretty much as soon as the depression settled in.  Describing a conversation with a doctor he felt 'just didn't get it,' Styron writes:

"...I wondered if he seriously thought that this juiceless and ravaged semi-invalid with the shuffle and the ancient wheeze woke up each morning from his [sleeping pill-induced] sleep eager for carnal fun."

Styron helpfully delineates his personal symptoms and by so doing, provides an example for others about what depression can look and feel like.  He describes his sensations of pain, his loss of libido, his weakness, his weak and distant voice that made him sound much older than his years, etc.

He also describes his troubling experience with several doctors (he calls them "careless") who overprescribed medications to him, including sleeping pills, at levels that were dangerous and could have provoked suicidal thoughts. It's unclear whether Styron ever considering a malpractice lawsuit against these doctors, but what he describes doesn't sound good -- and it sounds like he just took it in stride and was thankful he wasn't harmed, but didn't pursue any further action.  Ironically, eventually it's medication that helps him get well, once he is hospitalized.  Before he commits himself, however, he reaches the end of his rope and contemplates suicide.  When he finally realizes how sick he is, he heads for the hospital, and, there removed from other distractions, is able to (in his opinion) concentrate on his cure.From other things I've read since, it sounds like Styron continued to battle depression off and on for the rest of his life, and probably had struggled with it for many years beforehand, also.  At no point in the book is there any indication about his military service having an effect, pro or con, on his depression.  In fact, it sounds like his depression was both genetic and environmental -- but had nothing to do with being a Marine.

By page 84, the last page of the short book, there is finally a ray of at least faint light.  Styron is getting better, and he sums up -- neatly mentioning Dante, the subject of a previous post here on this blog:

For those who have dwelt in depression's dark wood, and known its inexplicable agony, their return from the abyss is not unlike the ascent of the poet [Dante], trudging upward an upward out of hell's black depths and at last emerging into what he saw as "the shining world."  There, whoever has been restored to health has almost always been restored to the capacity for serenity and joy, and this may be indemnity enough for having endured the despair beyond despair."

And then he concludes with a quote from Dante, mirroring the optimism that is finally able to see in his own situation:

"E quindi uscimmo a riveder le stelle.

And so we came forth, and once again beheld the stars."

Editor's note: If you want to read more about Styron's later work, referencing this book as well, there's a good article from 2003 in the Guardian, linked here.

Sarah Haley - Psychiatric Social Worker, PTSD Pioneer, Friend of Veterans

Gerald Nicosia's book Home to War: A History of the Vietnam Veterans' Movement, is fascinating reading, if only to keep in mind the wisdom of the George Santayana quote, "If we do not learn from the mistakes of history, we are doomed to repeat them."  Nicosia goes into much detail about how the PTSD diagnosis was first determined and included into the DSM, and along the way he paints the picture of many of the key participants, including Sarah Haley, in first treating Vietnam veterans for combat trauma and the resultant PTSD.

Whenever we look at history like this, it becomes apparent that whoever is impressive today in this work owes so much to pioneers like Haley (who Nicosia discusses) and Lawrence Kolb, M.D. (who Nicosia oddly does not).  "Standing on the shoulders of giants" is the semi-cliched expression about what present practitioners owe as a debt to the pioneers of the past, and it is certainly true about Haley's work: she was a true giant.

Here I'm going to excerpt, with Nicosia's permission, parts of the many passages about her work so you can see three important things: what her background was, which gave her a special compassion for the truth the veterans first presented with; the extent of her rapport with and trust established with the veterans themselves, which allowed her to help them; and some of her more intuitive leaps about what PTSD really meant from the lives of veterans with whom she consulted.  What a truly remarkable person; and what a shame she's no longer with us, so that we can continue to benefit from her truly outstanding work with veterans.  (Few of these quotes are continuous; most skip around from important part to important part, with the gap indicated by the ellipses)

Haley's background:

"It was a woman .. a psychiatric social worker named Sarah Haley, in the big VA outpatient clinic in Boston, whose research into veterans’ stress disorder literally blew the existing psychiatric definitions to pieces and began to put a whole new definition on the map.

"Sarah Haley [initially] seemed the least likely person in the world to make waves…

Her friends all warned her that the VA’s psychiatry program was “fifth-rate,” that she would find herself treating ‘chronic schizophrenia and passive-dependent men with bleeding ulcers,’ and that her career would surely go down the tubes.  But despite the fact that she entered upon her new VA job with the meagerest of expectations, she couldn’t help being ‘shocked at the low caliber of the general run-of-the-mill health person there.’  As she recalls, ‘These were not mental health people that you would want anybody in your family to get near.’"

 

Haley's first astounding discoveries:

"One day, a young man in a highly agitated state was brought into the clinic by his parents.  He had only been home from Vietnam for three days, and his parents had no idea what to do with him.  He was having total body tremors and exhibiting ‘startle response’ every few minutes.  If a car backfired or a door slammed, he would dive under the nearest table.  After much rambling, the young man told her he had been at a place called My Lai, that terrible things had happened there, but that it was difficult to piece it together.  He was confused and experiencing a lot of amnesia, but he did remember seeing the bodies of women and children and vomiting into the bushes.  He also remembered that he could not shoot anybody himself, that he had thrown his gun down.  The American soldiers who did the killing had sought to intimated him and the others who didn’t shoot: ‘If you ever tell anybody, we’ll come get you.  Or we may come get you anyway.’

 

…

"Indeed, any other intake worker might have dismissed [this recent Vietnam veteran] as delusional, but Haley had reason to believe him.

(Her father had been on special operations with the OSS in North Africa during World War II, a self-admitted ‘assassin for the government.’  He had told her about seeing a truckload of German prisoners who were led out and made to kneel in front of a ditch, where an American officer shot each one of them methodically in the back of the head.  Then the Americans dumped their bodies in the ditch and shoveled it over.  Thus Haley, as she puts it, had “no illusions about war.”)

 

How Haley worked with veterans and understood their particular trauma:

"Haley had nothing to go on but a big hunch, but she decided to follow it.  It seemed to hear that a lot of mental health professionals – especially those at the Boston VA clinic – had great difficulty in listening to the recital of trauma: as a defense, they either disbelieved it off the bat, turning it into the less threatening notion of “delusion,” or else withdrew from the patient as quickly as possible so as not to have to hear more about it. 

 

The other horn of this troubling dilemma was that the traumatized person, especially if he was a Vietnam veteran, would almost never come in and spill his guts to a perfect stranger.  Trauma patients need to establish trust with a therapist, and the Vietnam veterans coming into the VA clinic were never being given the chance to do this.  It was by the merest lucky chance that the My Lai veteran had seen something in Sarah Haley that made him believe he could confide in her, thereby opening the door not only to his own dark secrets, but also to possible help for a whole generation of trauma victims.

Haley perceived correctly that the reason the My Lai vet could not remember all the details of his trauma was that much of the most painful material had been repressed.  In the coming years, she would encounter the same phenomenon in hundreds of Vietnam veterans, some of whom could only recall five or six months of their 12- or 13-month tours of duty.

 

More insights into how Haley worked with veterans, and uniquely modified the approach for dealing with combat trauma:

"She further realized that the stuff was eating away at them would have to be brought slowly and steadily to the surface – that there were no quick fixes, like ‘5 mg. Stelazine daily.’  Equally ineffective, she would soon discover, was ‘the sort of non-authentic treatment’ where the professional would talk about family issues or other daily matters that were troubling the patient, but never bother asking about the existence of trauma in his past; for if the professional didn’t ask, the trauma victim would seldom bring it up on his own. Haley was aghast to learn, for example, that an analyst friend of hers had “successfully” treated a Vietnam veteran solely on the basis of working through the rivalry with his father and never even asked the veteran about his [combat experience.]

"Most of the Vietnam veterans Haley found were coming in to see a VA psychiatrist merely so that they could get their next month’s supply of Valium.  Haley would go to the psychiatrists and inquire whether they had ever asked these veterans about their Vietnam experience; the usual reply from the shrinks was that they had stopped asking because the veterans didn’t want to talk about it.  Haley was flabbergasted that none of the VA psychiatrists – with the exception of two notable women, Lillian Rodriguez and Constance Hartwell – evinced any interest in learning the cause of the tremendous anxiety for which they were blithely prescribing shelves of medication.

Unique problems to Vietnam veterans that Haley noted:

"During those first few years at the VA, Haley encountered a great many vets who talked about participation in atrocities.  she found most of them to be ‘terribly guilty, feeling unclean, and not worthy to be back in the world.’

…

 

"… Instead of hearing, “Doc, I have a bellyache,’ or “Doc, I’m seeing visions,” or “Doc, I’m terribly depressed,” what Haley would hear time after time was, “Doc, I think I’m a murderer… I slaughtered innocent civilians.”

 

And finally, Haley's substantial impact: