Odysseus in America

by Jonathan Shay

  • Self-loathing, a sense of unworthiness.

  • Loss of self-respect and initiative.

  • Pervasive “raw” vulnerability and feeling conspicuous.

  • Social withdrawal, irritability.

  • Hypochondriacal preoccupations, alternating with neglect of real ill health and injuries.

  • Suggestibility and blind obedience, which may turn into a fanatical “mission.”

  • Mortal risk taking to divine the status of one’s “luck.”

  • Danger seeking, fight seeking.

  • Claims to having been players in the single most important event in human history.

  • Grandiosity and entitlement.

  • Coercive demands for respect, honor, acknowledgment.

  • Rage at small slights, disappointment, lapses.

  • Coercive attempts to establish power dominance.

  • “Global” destructiveness of their fantasies, wishes, and, occasionally, behavior.

  • Apocalyptic ecstasy.

  Mental health professionals who have casually encountered combat veterans with complex PTSD often react negatively to the second half of this list and call it “narcissism.” They are frustrated and offended by such veterans’ insistence that they will deal only with “the head of the snake,” e.g., chief of service or medical center director. When clinicians use the term “narcissistic” to damn veterans who present themselves this way, it is as though the clinicians have utterly forgotten the importance of narcissism in any good life. The first half of the list is no less involved with narcissism (its deflation) than the second half (its inflation), but deflated narcissism generally draws more sympathetic labels, such as depression.

  Does Homers Odysseus give us a portrait of a pure form of post-traumatic character damage that is neither simple PTSD nor complex PTSD? Some political tyrants, some criminals, some artists, some religious leaders, appear to have only a giant thumos, with no symptoms of PTSD. Trauma can crush thumos or inflame it and cause it to swell into giant, tyrannical thumos. In the same person, deflated and inflated thumos can alternate, giving the appearance, descriptively, of bipolar affective disorder. In a fixed inflated state, giant thumos can produce a ranting megalomaniac such as Adolf Hitler or a quiet megalomaniac such as Osama bin Laden.23

  The earliest inventors of democratic politics invented equal citizen honor—isothumos— as the necessary psychological and social substructure for democracy.24 With it they built laws into their polis to provide trustworthy restraints on biē and mēetis, violence and fraud. The former was restrained by the law on hubris, and the latter by the strict accountability of magistrates, which made deceptive speech in public office very costly.25 Either extreme, thumos too weak to imagine a future, or bloated, violently or deceptively subjugating all to its concept of the future, is destructive to the democratic process. Severe trauma can produce both extremes. Severe trauma destroys democratic isothumos.

  Descriptively, the phenomena of damaged thumos draw in symptoms of many diagnoses in the DSM.26 The symptoms of PTSD have been called “protean.” Menelaus’ battle with the god Proteus, as told in the Odyssey, is an excellent metaphor for the veteran’s struggle with the symptoms of PTSD:

  But [Proteus’]

  tricks were not knocked out of him; far from it.

  First he took on a whiskered lion’s shape,

  a serpent then; a leopard; a great boar;

  then sousing water; then a tall green tree.

  Still we hung on, by hook or crook, through everything,

  until … [Proteus] saw defeat,

  (4:485ff, Fitzgerald)

  ARISTOTLE AGAIN—HUMAN IS POLITIKON ZŌON

  The human being is a bio-psycho-socio-cultural whole at every moment. This restates Aristotle’s zoological observation (Politics I:1:1252a3) that the human is the animal of the political community. Body, mind, society, culture are not separate “realities,” even less are they hierarchical “levels.” Our physical brains are biologically evolved to make us culture bearers and users; it is our biological nature to live in relation to culturally constructed moral codes; our social lives remodel our brains; cognitive assessments and their related emotional states influence bodily health; and so on. The very fact that we speak in terms of body, mind, society, and culture is only a reflection of the methodological and institutional history of the Western world. These terms are temporary guides to perception and communication. They are throwaways, not eternal realities existing beyond the Platonic veil. What I do at this moment of writing and what you do at this moment of reading is at one and the same instant, physiological, psychological, social, and cultural.

  Restoration of thumos and of the capacity for social trust happens only in community.

  This simple and seemingly innocent statement is actually quite subversive, because it casts doubt upon a great deal of what mental health professionals do (following the cultural and economic model of medicine), how they find their value in the world, how the mental health workplace is organized, and how power is used there. In fact, the overall effect of this simple statement is to push mental health professionals off of center stage in the drama of recovery from trauma, and to place them in the wings as stagehands.

  The next two chapters take us to two apparently unconnected settings: to the Department of Veterans Affairs outpatient clinic where I and my colleagues do our work, and to the Vietnam Veterans Memorial in Washington—known to many as the Vietnam Wall, or simply the Wall. We arrive at the Wall twice—once physically with the veterans in our program and once electronically via an Internet discussion group of Vietnam veterans and others as they communalize the shock of Lewis Puller’s suicide.

  17 From the Clinic to the Wall

  Fourteen years ago, in another lifetime, I went to work for the Veterans Administration in Boston, hoping to restart my neuroscience lab research. I had never served in the military and knew virtually nothing about veterans. I do not believe I had even heard the words PTSD or combat neurosis in the course of my clinical psychiatry training. I had completed that training in June 1980, with my mind already preoccupied with worries about a troubled family business, and was unaware of the publication that year of the third edition of the DSM, which reintroduced psychological injury into the diagnostic vocabulary of American psychiatry as Post-Traumatic Stress Disorder. For most of the decade I gave no thought to psychiatry and certainly none to the newly coined diagnosis of PTSD.1

  I started work as a general psychiatrist at the Day Treatment Center of the VA Clinic in Boston in November 1987, with my head full of research plans. Talk about being thrown into the deep end of the pool! Day Treatment was where chronically, severely ill veterans were offered support and intensive outpatient treatment, usually between hospitalizations. Out of the corner of my eye, so to speak, I became aware that within the Day Treatment Center was a specialized program for Vietnam combat veterans whom nobody else in the VA wanted anything to do with. Many had histories of violence—some had assaulted clinicians in the VA—and of incarceration. In mid-December, the Argentine psychiatrist and cofounder of this Vietnam combat vet program, Dr. Lillian Rodríguez, asked me to cover for her while she returned to Argentina for a long Christmas and New Year’s holiday with her family. I gulped anxiously and said sure. I joined the team meetings and community meetings of the Veterans Improvement Program—VIP, as it is called—and tried to make myself useful. January came and went and we received word that she was ill and that her return would be delayed. Over the weeks a steady stream of veterans in the program came down the hall to my office (a converted storage room) with what were purported to be medication questions or problems, and only in retrospect did I realize that I was being interviewed by these very intimidating men.

  Another month or so passed, and word came that Dr. Rodríguez had died at home of a recurrence of the breast cancer that had been treated some years before. My boss then (who is still my boss now) asked me if I would be willing to split cover
age of the VIP with another psychiatrist, seeing it as a hardship to be equitably shared. By this time, after those few months of training by the VIP team (three of whom are still on the team fourteen years later), I was astute enough to say no. Either I am the psychiatrist for all of VIP or for none of it. My boss looked ready to faint from relief that I was willing to take on the most intimidating patients2 in the whole clinic.

  These veterans saw something in me that I did not see in myself. I think initially it was the willingness to listen and to learn from them, and not to think I knew already. And listen I did, and listen, and listen. I also listened to the rest of the VIP team, which was then ten years old, and absorbed their experience and philosophy across the chasm of different disciplines and less fancy credentials. But it is mainly the veterans who have been my teachers. They have redirected my life, and I thank them for it. It has been a privilege to know many of them, men of very high rank in being, even if gaining little success in the civilian world. We devote ourselves to helping them achieve a better human life than before they came to us, and in this we generally succeed.3

  Not long after settling into VIP I noticed that I was hearing elements in the story that Homer told of Achilles in the Iliad. Over and over these elements recurred. I wrote a little paper for the Journal of Traumatic Stress pointing this out, thinking it was just a neat teaching piece: You want to take a combat history? Remember the story of Achilles and you’ll touch all the bases. I’ve told the story of how this paper got turned into Achilles in Vietnam: Combat Trauma and the Undoing of Character at the request of Harvard’s professor of Classical Greek literature, Greg Nagy, in the Introduction to that book.

  Most of what I know about trauma I have learned from the veterans. However, most of what I know about the treatment of trauma, I have learned from one of the founders of VIP, Dr. James Munroe.4 Anyone interested in the details of the VIP approach should consult our textbook chapter referred to in the notes. I only want to highlight a few points of our method here to set the scene for the annual VIP trip to the Vietnam Veterans Memorial.

  We foster and protect the conditions under which veterans can heal themselves and each other. The heart of our program is this understanding that veterans heal each other. Because we move mental health professionals off of center stage, veterans can bypass many of the obstacles blocking those with complex combat PTSD from getting help.

  If the stakes weren’t so serious, the usual collision between a combat veteran with complex PTSD and a mental health professional could be like the raunchy, cynical, irreverent soldiers humor of Aristophanes’ Greek comic theater:

  VA Doctor (singing): See my certificates, degrees, an’ diplomas—Look at every one, up to the last.

  Veteran: Trust you? Trust them! Stick ’em up your ass!

  Because their psychological injuries have destroyed social trust, the most severely injured veterans are least able to get and retain access to treatment. Complex PTSD destroys the key resource—trust—necessary for its successful treatment.5 So we have a paradox, or at least an impasse. The very thing that constitutes the difference between simple and complex PTSD—destruction of social trust—blocks the treatment of complex PTSD.

  The veterans have reason, based on their experience, to distrust credentials, institutional position, and abstract, universally applied procedures. These veterans have had the real experience of lives lost and people maimed when a person in a position of power “went by the book,” rather than first looking sharply at the particulars, and then applying the book to them with flexibility and good sense. (Aristotle: “The doctor cures a particular [i.e., not abstractly universal] man,” EN I.6,1097a13.) Most veterans will not insist that a therapist be a subject matter expert on every technical detail of the Vietnam War, but only that the therapist be willing to “listen.”

  During the Vietnam War, company and battalion commanders who resisted rotation out of dangerous command billets at the end of their six months were labeled as having “gone native,” that is, having developed more commitment to the troops than to the officer corps and to personal career advancement. This label was a career-ending stigma. Ironically, many instances that were called “going native” were efforts to fulfill ideals of military competence. Such officers would show reluctance to rotate to a rear area staff billet, because the six-month rotation policy guaranteed that no one in command of a company or battalion had the time to learn what they had to know to do the job well—in purely professional military terms.

  The veterans we treat, who were all enlisted men, treasure the memories of the officers who were more devoted to their substantive military tasks and to the men under their command than to the career system. More to the point clinically, any sign of careerism by a clinician is liable to be a traumatic trigger, bringing back memories of having been put in lethal danger to get body count—or worse, to fill out the denominator of a kill ratio, where the presence of American casualties was rated as positive evidence of the commanders “aggressiveness” and “balls.”

  These veterans’ worldview is based on an expectancy of exploitation for other people’s advancement. The urgency of fear lies behind the veterans’ need to know that we are working in VIP because we want to, because it gives us personal pleasure and satisfaction for its own sake.

  Expectancy of exploitation leads veterans to assume that we are only interested in them as vehicles to get a graduate degree, to write a book, or to earn VA salary money. In the last fourteen years, James Munroe did earn his doctorate,6 and I did publish a book—periods of intense anxiety followed both of these events, while veterans watched to see if we each would leave, having accomplished our “real” purpose in being there.

  Vietnam veterans experienced lethal incompetence at the hands of officers and bureaucrats who had all the right credentials but whose competency in passing through career progression schools did not equip them for the reality of war against an observant and resourceful human enemy who figured out how to turn every school solution into a death trap. The veterans insist that there is something personal that makes someone trustworthy as a combat leader or as a clinician. Our institutions treat professionals who have the same credentials as fungible—absolutely substitutable—for one another. The veterans reject this. Their trust is personal, nontransferable.

  Essential to this trust is the clinician’s willingness to listen to the particularity of the veteran’s own experience, and not treat them as subsumable examples of an abstract category of psychiatric or even PTSD patients.7 They don’t ask us to be universal experts, and will not trust a widely read clinician who is smug about his knowledge, and neither listens nor learns.

  Trust can only be earned, never assumed from job titles or degrees. In VIP we assume that veterans must test the trustworthiness of anyone claiming good intentions, particularly where power is involved. We don’t take offense when they test us.

  VIP has taught me how to work with crisis-ridden patients who have learned to survive through violence and intimidation. Amazingly, the veteran community in the Clinic provides both physical safety—the VIP veterans do not tolerate even the smallest threat against the team—as well as psychological safety.

  STAGES OF RECOVERY

  Among ourselves and in speaking with veterans we use the three-stage description of recovery developed by Judith Herman:8 Stage One, establishment of safety, sobriety, and self-care; Stage Two, trauma-centered work of constructing a personal narrative and of grieving; Stage Three, reconnecting with people, communities, ideals, and ambitions. Although we think and speak of these stages, the VIP is not programmatically built around them, and each veteran progresses at his own pace.

  I cannot emphasize too strongly that safety, sobriety, and self-care are the essential foundation upon which recovery is built. We are not an anything-goes therapeutic community that is infinitely “understanding” of drinking and drugging and wild behavior. There’s no way to skip safety, sobriety, and self-care and go right to the trauma, no
matter how logical the veteran’s claim: “Doc, Vietnam caused all that drinking, and drugging, and fucking people up. You fix the Vietnam stuff and I can stop all the rest.”9 Never happen, soldier!

  We work with the veteran, in Judith Herman’s words, starting with the body and moving outward, to help him lay down weapons, maintain sobriety, meet health and nutritional needs, terminate current violence as perpetrator and/or victim, and eliminate danger-seeking behaviors.

  While most VIP veterans are also in individual psychotherapy and request medications,10 the heart and soul of the program is its group therapies and the ideas and rituals of the VIP veteran community. The core idea is “You are not alone; you don’t have to go through it alone.” From the beginning, other veterans provide what military social scientist and historian Faris Kirkland and his Army colleagues11 called “substantive validation,” a knowledgeable audience (even if they were not in the same specific units or operations), to whom the veteran’s experience matters, and who are able to support him through the confusion, doubt, and self-criticism that seem intrinsic to having survived the chaos of battle. The team provides practical support for veterans to obtain their military records, unit diaries, and after-action reports when the situation demands. Surprisingly, this often provides the first “institutional validation” that the veterans have had, sometimes learning for the first time of awards and decorations for valor that they had earned, but had never been presented to them. In group therapies with Stage One veterans, we are active and educational as group leaders, assisting members in gaining authority over the pace of trauma disclosure, so it is safe. We seek the delicate balance between silencing the veteran and allowing him to become flooded with bodily sensations, emotions, and images by reliving the trauma, which only retraumatizes him. There are no theatrical cures where the veteran screams, vomits, bleeds, dies, and is reborn cleansed of the war. Recovery is much more like training for a marathon than a miracle faith healing.