The Long Haul: Healing the Wounds of War

I consider it a singular honor to have the opportunity to introduce Dr. Shay. I can think of no more fitting speaker to begin our Association's Soldiers and Veterans Initiative introduced by our president, Prudy Gourguechon. I believe you will find Dr. Shay's work fascinating, and his personal story as moving as those he writes about. Dr. Shay.

It really is a great pleasure to be here. Dr. Pyles's enormously generous introduction has given me a license to tell you some of the rather sweet story—I hope you're moved in that sense—of how these two Homeric books on war and returning from war came to be. I've also discovered that there's a “man bites dog” newsworthiness to my improbable career.

I went to work for the VA in 1987 expecting to do something utterly, utterly different. I was expecting to re-open the experimental neuropathology laboratory that I had had at Mass General Hospital, and the veterans kidnapped me. They saw something in me that I for sure didn't see in myself, and they redirected my life by at least 90 degrees. And I thank them for it. Another way that the veterans redirected me is that I have learned over 20 years that while they are a very contentious bunch who will argue about anything, the one thing that they are absolutely unified on is they don't want other young kids wrecked the way they were wrecked. And so it is the veterans who have set my feet on the missionary path. I describe that when I speak with active duty folks as a missionary from the veterans I serve. They don't want other young kids wrecked the way they were wrecked, so listen up.

The Essential Triad: Cohesion, Leadership, and Training

Now I'll give you a one-breath summary of preventive psychiatry in military organizations, and it really is one breath although I may expand some sentences and make it two breaths. But when you hear these three simple things I want you to know that it is a vast issue in practice and very heavy lifting for the military services. So here's the pitch.

There are three things that protect the mind and spirit of the people we send into a fight, and those three things are first, cohesion, which is positive qualities of community in the face-to-face unit; second, expert ethical and properly supported leadership; and then third, prolonged cumulative and highly realistic training for what they actually have to do and face. Do those things and do what it takes to improve cohesion, leadership, and training and avoid doing those things that wreck them.

But the story that I started to tell you was how I stumbled into saying some new things about Homer's epics. During my first year at the VA Day Treatment Center in Boston in a program for Vietnam combat veterans who were angry, abusive, demanding, narcissistic—gosh, they were wonderful people!—I realized that I was hearing fragments of the story of Achilles over and over again, sometimes the whole narrative sequence in the form Homer gave us in The Iliad. And in the same period I became painfully and embarrassedly aware that even in the VA where you would assume that everyone understood how to take a decent combat history that there were very, very few adequate combat histories in the clinical record. So I wrote a little paper that appeared in the Journal of Traumatic Stress. Basically what it said was if you want to take a decent combat history, remember the story of Achilles and you'll touch all the bases. I was proud of that. What a nifty teaching idea! Well, at the time my daughter was a freshman at Harvard College and taking Professor Gregory Nagy's course that the freshmen lovingly called Heroes for Zeroes. Gregory Nagy, I suppose it is fair to say, is the leading Homer scholar in the world, but maybe just to stick it to him I say one of the two or three leading Homer scholars in the world. He came to my apartment and said, “Would you expand this into a book for one of the series that I edit because this has never been said before.” “What?” All I said is that The Iliad really is about war and what matters in the heart of the soldier in war. “Never been said before,” said Nagy. Well, I can tell you that if Shay says that something is or is not in the corpus of Homeric criticism that and a nickel will get you a bowl of gum in the supermarket, but if Nagy says something is or is not in the corpus then you can go to the bank with it.

So, I cut out the general psychiatry part of my practice, kept the combat veterans program, rented a studio, and wrote Achilles in Vietnam. This was my one shot at immortality. If you write something decent about Homer, they will literally read it for centuries. It has been extraordinary what that book has done in the world and done for me, and veterans are kind enough to tell me what it has done for them. The second book, Odysseus in America was, of course, no accident, but I'm just your ordinary human critter and I went back to the same well where I got an adequate drink before. I tried to pull the same stunt with The Odyssey and you have to judge whether I pulled it off. It took a different approach because these literary works are very different. The Iliad is a tragedy; The Odyssey is a romance. The Iliad is a very straight ahead linear narrative; The Odyssey is a widely complex narrative structure with stories within stories within stories.

Maybe I pulled it off and maybe I didn't but it gave me an opportunity to do two things which I wanted to do. One was to be explicit, it was implicit in Achilles in Vietnam, but to be explicit in part three of Odysseus in America about the preventive agenda that you just heard. And the other was to make a point that this is not a partisan or ideological issue, and I made it by soliciting the jointly written foreword by a conservative Republican and a liberal Democrat, both of whom have credibility as veterans, “people who paid their dues” and “had seen the elephant.” I can tell you it was work getting them to agree on a common text.

Parallel Process and Social Trust

Having heard my rap on prevention, don't be surprised if you hear snatches of it coming back when I talk about the situation of trying to get things right in the clinic. Remember, my mantra is the positive qualities of community in the face-to-face unit which is, in military jargon, cohesion. In the clinic what we have to attend to is positive qualities of community among the veterans in the program and also, equally important, positive qualities of community in the clinical team. This is not intuitive. There are traditions very much built into the structure of American medicine and American psychiatry, and certainly psychoanalysis, that elevate the one-on-one dyadic relationship between a skilled, empathic, and engaged

clinician and a single person in pain or trouble. I'm here to tell you that is the belief of the people who founded that program at the VA 10 years before I arrived, and I came to embrace that belief, that recovery happens only in community. What I learned from both the experience and these folks who had it all figured out before I arrived, I just had the wisdom not to destroy it. As a new psychiatrist I would have had the power to destroy what they had created but I would not have had the power to create it myself. I wouldn't have known. The thing that they arrived at is that the minimum case of community is three. Now you may suspect me of playing some sort of logical game with you here, but it isn't. It is very practical clinical stuff working with this population. The key issue, the key barrier, to getting care of veterans with these severe psychological injuries is the issue of trust, the issue of their settled incapacity for social trust. They are not going to trust you on the basis of your credentials or your institutional position. That's my working definition of social trust in the treatment setting.

A stable trustworthy and safe environment of other veterans, in my view, is the royal road to recovery for veterans with psychological injuries.

Now trust is this explosive issue, especially with those patients, those veterans, who drive us utterly crazy, the ones who are enormous consumers of our energy, our worry, our hospital beds, our staff meeting time, prison cells, whatever resource you name; the key issue is that their capacity for social trust has been destroyed. Now what's left when social trust is destroyed is not a vacuum, it's not nothing. What's left is an active and potentially quite dangerous and firmly settled expectancy of harm, exploitation, or humiliation from every person and institution that they encounter. I confirmed the position that the people I learned from originally asserted, that recovery from this situation happens quite well in a stable and safe community of peers, peer veterans.

The Royal Road to Recovery

So, let's come back to this logical structure. Why is three the minimum case? Because community exists when each of this triad has the well-founded expectancy that when he or she is apart from the other two that the other two, first of all, remember his existence, and second of all, continue to care about this absent person's well-being and are not planning harm, exploitation, or humiliation. I say all this not because I think that individual therapeutic work is worthless. Far from it, just about every veteran in this program spent long periods in very helpful and valuable individual therapy, but it was always in the context of the group therapies and of the milieu. The holding environment for them was their peers, the trustworthy community of peers. A stable trustworthy and safe environment of other veterans, in my view, is the royal road to recovery for veterans with psychological injuries.

Now it is not as easy to pull off in the real world as for me to stand up here and say it. I need to point out to you some of the depressing downside. Number one is that cohesion, to use the military term, is simply a phenomenon of nature. It is neither intrinsically good nor intrinsically bad. It's a little like electricity. If it bakes your bread, it's great. If it electrocutes your daughter, it's horrible. Cohesion is much the same. Just as military small units can sometimes degenerate into criminal gangs, in the long history of the VA and vet centers occasional groups of veterans have formed criminal gangs in the context of the treatment setting. So there are deformities and degenerations of cohesion that these communities can undergo. It's critically important for the clinicians not to be so starry-eyed that they either get co-opted by a world view that says that this

misbehavior is good, right, just, and, in a way, cool and that clinicians intervene to stop destructive things that can arise in cohesive groups of trauma survivors. So it is not all sweetness and light and that's just an example. You have to be vigilant and sure that your team structure and trust within the team in the mental health workplace is doing its self-healing and self-critical work in keeping itself open to the larger ethical horizon. It's very easy to lose the ethical bubble under the enormous pressure that psychologically injured veterans place on us.

If I trash the diagnosis PTSD, it is because I regard it as badly out of focus, a rather accurate description of a very narrow and specific sort of fear syndrome if you wish, but it misses what actually wrecks the lives of veterans and their families and misdirects us in all kinds of bad ways.

There's a lot more to say about all of these things. I do hope that you will find a way to have a look at the chapter in the Saigh and Bremner textbook which is cited in your handout [Posttraumatic Stress Disorder: A Comprehensive Text, 1998]. I wrote that with my colleague, Jim Monroe, and it covers a lot more than I can cover today. I regret that because of intellectual property issues that chapter is not available on the Web, which is a drag.

Blowing Up the DSM

Now, I am going to move onto something that is available on the Web and as someone who is given to ranting, I am offering you the invitation to read the rant that I did at the National Academy of Sciences Institute of Medicine (IOM) panel on the “Scientific Merit and Clinical Utility of the Diagnostic Construct PTSD.” If I trash the diagnosis PTSD, it is because I regard it as badly out of focus, a rather accurate description of a very narrow and specific sort of fear syndrome if you wish, but it misses what actually wrecks the lives of veterans and their families and misdirects us in all kinds of bad ways. I worked hard on this rant and it's my best shot at blowing up the DSM and I hope you will download it from the Web. What I want to mention here is only some of the objections to the diagnosis.

Starting right off with the word “disorder” and you will hear in this my mission to the armed forces. Now people do differ on whether words really are important or whether they are just a superficial crust on the reality that everyone can touch, so what's the difference. Well, in military forces disorder is stigmatizing in itself. Why is that? If you're injured in the service of your country, that's entirely honorable and there's a long tradition of being able to continue with your military career with distinction after you have recovered from your injury. Eric Shinseki, Obama's cabinet nominee for Veterans Affairs, used to be army chief of staff and he still has a prosthetic foot, having lost it to a mine when he was a company grade officer in Vietnam. He continued to the rank of four stars and to chief of staff and he was a fine officer and had a distinguished career. On the other hand, if you fall ill, get a disease, malady, or disorder, in military service it is not dishonorable but let's face it, it's unlucky. And who the hell wants to share a fighting hole with an unlucky soldier or marine. It's stigmatizing on the face of it.

I have been agitating for years to replace the word with one drawn from the semantic range of injury and wound. Psychological injury is the simple locution that I prefer but it's certainly not the only possible one. It has the advantage of removing a totally gratuitous stigma and, no less important, it shifts the perspective of a lot of players on the matter of complications of the primary injury. I really want to get everybody thinking like a trauma surgeon rather than an internist. If you're a trauma surgeon, you're thinking about complications right from the first moment. In fact, you're thinking about identifying and preventing them even before you do anything else. If an infantryman has an arm blown off in a flash, and just a reminder this is part of my perverse run in the rant at the IOM, we don't speak of this person as suffering from “MAD,” missing arm disorder. It's ludicrous, and I submit that only habituation and professional acculturation prevent us from finding post-traumatic stress disorder just as ludicrous. It's an injury. So back to this unfortunate soldier.

When the trauma surgeon encounters this infantryman, he or she, the surgeon, is thinking first of all about controlling hemorrhage which kills people fast and controlling infection which kills them more slowly. These are the two main complications of ballistic and blast injuries. Obviously the medic out in the field has been thinking about these complications, the soldier's buddies, and if he is able the soldier himself. The validity of this way of thinking does not rely on the injury being as extreme as a total traumatic amputation of the limb.

Adaptation and Physioneurosis

Now in the mental health arena I have advocated that we think of the primary psychological injury as the persistence into civilian life or into life in garrison as the persistence of absolutely valid adaptations that kept you alive in a situation where other human beings were trying to kill you. And doing a damn good job of it because the person to your right, the person to your left were dying or being maimed by the enemy's action. These are serious adaptations and they're as much in the physiology as in the mind and Abram Kardiner referred to combat neurosis as a physioneurosis to emphasize this. But it's also in the social connection which we witness as the incredible bonding of people who fight side by side. The primary injury is the persistence of these adaptations into civilian life or life in garrison. The adaptation occurs in the brain, the mind, the social, and the cultural because we're just one critter.

Just as an aside, I know that some will bridle at applying the word “injury” to the bonds of absolute obligation that arise between combat buddies but ask military and veteran families about this. Ask direct leaders in garrison about this and ask them if these virtuous adaptations in combat do not sometimes become disabilities when put into play in civilian or garrison life. This is awkward and uncomfortable. We don't like to think of virtues as disabilities, but I submit that it's an accurate and actionable understanding. But it's not real comfortable.

I'm speaking as someone who has done a lot of work with the military forces but as a clinician I've only worked with veterans who were injured years ago. And on that basis I have come to the conclusion that the primary injury rarely wrecks a veteran's life and this is part of my gripe with PTSD. PTSD is not a bad summary of the persistence of valid adaptations. Just like the primary injury, that traumatic amputation, just like that is rarely with today's military medicine fatal to the infantryman, but the complications can be; just like that complications of primary psychological injury can be disastrous and fatal, and I regard suicide as a complication of combat trauma. Even lesser complications than suicide can totally wreck the capacity for a flourishing human life, not only of the veteran, but the whole family, sometimes their workplace, sometimes their local community. And I, and many historians, believe that the pathogen burden, to use a public health term, of un-healed combat trauma and the complications of combat trauma contributed mightily to the destruction of the Weimar Republic in Germany in the 1920s…

Editor's Note: Shay's talk did not end here; this excerpt may inspire readers to read his self-described “rant” at , and to read his work. After Shay's talk there was some time for questions and comments from the audience, which were as moving and riveting as the talk itself. A good number of psychoanalysts reflected on their own wartime and military experiences.