Tag: PTSD

The Adaptive Role of Anger: Anger Has a Voice in Military Service and Suicide Risk

John was a Navy Seal who had seen more than his fair share of war. He saw and did things that I’ll spare my readers – not to protect John, but (just as he would want) to protect my readers from even imagining things human beings aren’t meant to see. One day in session, he was cataloguing various things that recently had him agitated: the politics in his unit (that only seem to disappear when in the immediate throes of war), his ex-wife seemingly trying to turn his daughters against him, and his home remodeling contractors stealing meat out of his freezer.

When John talked about the politics in his unit, he seemed despondent – sad and indignant – that brothers and sisters in arms could so easily get caught up in seemingly trivial matters when back home in the United States – that they could turn on each other. In fact, John had just been given minor disciplinary action for being “disrespectful” to a higher-ranking officer. John spoke about the differences between being a military member downrange (when all that mattered was life and limb) and being a military member stateside (where everyone was presumably safe). John said it’s simpler downrange, because the rules are easier and intuitive: Don’t get killed. Don’t let your allies get killed. Downrange, no one has time to worry about who did or didn’t say ‘hello’ to them that morning in an appropriately enthusiastic fashion. When life is for all intents and purposes ‘safe,’ the rules become more complicated. In safety, people have the luxury of behaving badly.

John was equally despondent when he talked about his daughters. They were now old enough to assert to the courts whether or not they wanted to go on visitations with him, and he was convinced that their mother was brainwashing them to hate him. He didn’t want to put his daughters in the middle of things, so he felt unable to fight back. He was scared of not seeing them. He was hurt by their distance. He felt powerless to do anything about it, and the pain was bigger than he could put words to.

But when John talked about the contractors stealing meat from his freezer, he was enraged – incensed! He was furious that they would violate his personal space by taking from him, and he verbalized thoughts of violence in response to them casually taking his hard-earned money. He railed about his stolen meat for at least 20 solid minutes. I watched as his face turned red and veins bulged in his neck.

When he finally exhausted himself and fell quiet, I briefly remained quiet too. Then I pointed out to him that, despite the gravity of his career being threatened by disciplinary action and despite the gravity of his relationship with his daughters being threatened, he exuded the most anger about his stolen meat. He sat back, and a look of surprise crossed his face. “You’re right, doc. I think that after dealing with everything else, I just can’t handle one more thing.”

He was partially right. The stress he carried around on his shoulders did indeed give him less patience for the routine stressors (stolen meat or otherwise) of life. His stress was leaking out everywhere. But there was more to it than exacerbation.

John was a moralistic man. He believed in doing what he believed was right, and he believed in exercising uncompromised integrity in following his moral compass. Despite lifelong hardship, he stayed the course…refusing to allow the hardships of the world steer him away from what he believed was right.

John was raised on trauma – an alcoholic, abusive father and submissive, victimized mother. He went to war – witnessing, exacting, and touching human death and suffering. He survived a toxic marriage – an unfaithful and verbally abusive wife who used the children to control him. Yet he persisted – white knuckling through with a tiny belief that there was order in the world and good, moralled people whom he just hadn’t met yet. He couldn’t survive without these beliefs, as his beliefs were the very thing that gave him a breath of hope and a reason to keep trying.

When his career was threatened (after everything he sacrificed) and when his daughters seemed to be turning against him, he couldn’t fully compute this information and the overwhelming landslide of feelings behind it. His brain wouldn’t let him…because it threatened his very reason for continuing to live. His brain protected him from the gravity of these events, and he froze in response.

The theft of the meat, on the other hand, was safe to feel. It was safe because petty theft isn’t super high on the hierarchy of bad human behavior. Petty theft sucks. It doesn’t feel good, and it’s mighty inconvenient. But it’s not murder, kidnapping, or any of the higher order wrongdoings that John’s survival couldn’t handle. His brain could let him feel petty theft, because petty theft didn’t squarely make him ask himself, “What’s the point of living?”

And so he raged and railed against it…indignant and dripping with disgust.

Had John acted out his rage on the sticky-fingered contractors, the news headline would’ve read something like this: Local military member bludgeons contractors for stealing rump roasts from his freezer. And just like that, he would’ve disappeared into cultural stereotypes as another unhinged troop.

On the societal level, we say that veteran suicides are important to us. We donate to veteran causes. We thank people for their service. We make puppy-dog faces when we hear that one of our troops or veterans are suffering after war. We spend millions on social media blasts and campaigns designed to educate the end-user about risks and warning signs. But does any of this really work? And how are we proving that it works? Or is it possible that we’re just hemorrhaging time and money on suicide prevention tactics that are ineffectual and only actually serve to make us feel like we’re doing something?

Is anyone meaningfully asking service members or veterans what they think of the PSAs and programs we spend millions for?

Who do you picture when you think of a veteran who’s at risk for suicide? If you picture the sad, mopey Eeyore, you might be wrong. And being wrong in this equation can be fatal.

While the at-risk veterans who demonstrate Eeyore-like behaviors do exist, at-risk veterans are just as often the angry, irrational, short-tempered hot-heads that inadvertently (or advertently, as it were) push people away through their aggressive behaviors. They’re the guy at work who punches a wall in response to the slightest inconvenience. They’re the woman that’s stoic and repels her coworkers’ attempts to befriend her. They’re the guy who gets in the face of the person who stole their parking space in a store parking lot. They’re the woman that a boss evaluates as “defiant and difficult to correct.” They’re the guy that bludgeons contractors over meat.

At-risk veterans and service members are often over-flowing with bitterness, frustration, and emotions that they don’t know how to manage, and these emotions are most safely converted to anger, as anger can feel safe. Anger doesn’t make a trauma survivor feel vulnerable, which is critical. I have yet to meet at at-risk veteran or service member who wasn’t repulsed at the idea of feeling vulnerable. They’ve had more than their fair share of feeling vulnerable, and in their life experience, vulnerability leads to death and mayhem. Vulnerability must be avoided at all costs. So anger is safer. Anger is the emotional and behavioral equivalent of standing tall and waving your arms to ward off a mountain lion. Even if you feel like a small and fleshy snack, your survival is optimized by making yourself appear big and bold. It’s the human way of showing that – even if you’re going to lose in the end – you’re not going down without a fight. And isn’t that central in the Warrior Ethos? “…I will never accept defeat, I will never quit…”

While I was still in the uniform, I tried to shift the suicide prevention message such that people would take a second look at their angry counterparts (e.g., https://www.kirtland.af.mil/News/Article-Display/Article/817278/tap-into-your-empathy-says-suicide-prevention-program-manager/). Alas, that message always seemed to get buried under a pile of the status quo.

As long as we ignore and reject this message, we aren’t truly moving towards changing our country’s devastating veteran suicide problem. And by not doing that, we’re failing at adequately caring for the people who sacrifice their lives for our way of life.

In clinical work, it’s exceptionally rare that I meet an at-risk veteran or service member who hasn’t had or doesn’t have “anger problems.” One patient in particular comes to mind; we’ll call him Fred. (Yes, I intentionally use blasé fake names.) When Fred first came to the military mental health clinic, he told the mental health technician that he was there because of “anger.” Fred also noted that he had a PTSD diagnosis from a different facility, but that he wasn’t willing to have that be the focus of treatment, as he had “been there, done that.” He was emphatic that he was unwilling to do “worksheets and repetition therapy,” because they didn’t work. So the technician asked me to take Fred (even though I was over-capacity and wasn’t supposed to be taking new patients).

Fred was a piece of work. He reported that both his commander and wife had incessantly complained about his temper and attitude, but he didn’t think he had a problem. “I’m just here to appease them. The real problem, if you ask me, is that people don’t like to hear the truth, and I’m not willing to change what I say just because it might hurt their feelings.” Fred and I arm-wrestled every time he came in. Sometimes, I’d win the match by the end of the session, and I’d get all naively hopeful that we had hit a pivot point. But then he’d come back next time – all yoked up and ready to wrestle again. The struggle was real. He was a pain in my ass…and I told him that. (Not gonna lie: I think his amusement at irritating me was part of what kept him coming back.)

Somewhere along the way, I completed my contract, separated from service, and opened my private practice in the network. Fred was allowed to continue work with me here. One day, I received a random email from his wife thanking me for helping him so much. She said he was like a different man. Fred arrived for his next session – yoked up and ready to wrestle – and I told him that his wife outed him. “What the hell?!” I asked him. “You never told me that things were changing out there.” He smirked and then confirmed that he had been getting positive feedback (both at home and work) about his improved demeanor and functioning. And then we finally hit a pivot point…

Some sessions later, Fred admitted to me that he had once had a gun in his mouth. He told me about years on end where he struggled to keep going and often believed he couldn’t tolerate the pain he carried daily. At his own pace, he started talking to me about where he had been, what he had seen, and who he had lost. (Even Fred will tell you that he still wrestles me sometimes, but maybe that’s just when he needs to get out some safe anger and bitterness to cope with his world.)

To adequately serve and help our service members and veterans – and prevent their untimely demise – we (as a profession and a populace) need to learn to see and orient to their anger in a different way. We need to learn that their anger is hard-learned, that it serves a purpose, and that (in the context of their experiences) it’s adaptive. Only then will we have any creditability with them or will they feel seen. That’s step one.

And then we need to help them strategically and adaptively turn down the volume on their anger, but that’s a different topic for a different day…

Joye L. Henrie, PhD

 March 2019

(Photo credit: Military OneSource https://public.militaryonesource.mil/health-and-wellness/managing-stress?content_id=282360)

The Invisible Creep of PTSD: How Trauma Changes the Way You Experience the World

A long-term patient of mine (who we’ll call Michael) is a combat medic with multiple combat deployments under his belt. When he started treatment with me, he already carried a Posttraumatic Stress Disorder (PTSD) diagnosis – a diagnosis that was spot-on. After we had been working together for several months, Michael was clearly agitated when he came in for his scheduled follow-up. He explained that he had gone into a well-known big box store to return an item. In comedically colorful language, he explained that another driver almost t-boned him on his way to the store, people were walking uncomfortably close to his car in the store’s parking lot, and he crossed paths with some questionable-looking characters as he walked into the store.

By the time he reached the greeter’s podium, he was perspiring and tight-chested. The greeter apparently blew him off, but when Michael attempted to walk past the greeter, the greeter stopped Michael by grabbing him by the shoulder. At this precise moment, approximately 82 of Michael’s brain cells imploded. He went into a blind rage – screaming in the greeter’s face and threatening to annihilate him.

“I’m losing it, doc,” Michael said to me – not even attempting to hide his fear.

Michael’s story is a common story among my military patients with PTSD. And yet, they all think they’re “crazy” or “losing it.” In psychology, it’s common for providers to say, “It’s a normal response to an abnormal situation,” and unbeknownst to folks with PTSD, it’s their daily reality.

It’s like this: The average person walks around with a subconscious threat-management radar operating at all times. If they’re having a picnic in the forest and a bear approaches them, they immediately spring into action and run (or whatever it is you do if you’re unfortunate enough to come face-to-face with a bear). They don’t sit and think, “Hmm. I wonder if that fury mammal will chew on my head?” This is the basis of fight/flight/freeze. Our radar detects threat, and we respond. It’s the same if we’re walking along a city sidewalk and a car comes careening toward us or if we’re standing in a bank when a masked man with a gun yells for everyone to get on the floor.

The threat-management radar of the average person is set at a specificity level to immediately detect clear and overt threat – like the radar-equivalent of a missile.

A person with PTSD, however, has the sensitivity of their threat-management radar turned up as high as it will go. They’re no longer just detecting missiles. They’re detecting mosquitos.

Why? PTSD is, as its name states, a trauma-based disorder. It is the result of exposure to a trauma event that threatens life or limb, and the research suggests that exposures to multiple traumatic events exponentially potentiates the development of full-blown PTSD. Subsequent to these traumatic events, the person’s thoughts and beliefs about the world, themselves, and others changes. They may come to believe that the world isn’t a safe place or that people can’t be trusted or that if only they had done X, the trauma wouldn’t have occurred.

These changes lead and/or run parallel to hypervigilance (i.e., hyper-awareness of and hyper-sensitivity to one’s surroundings and its changes, and exaggerated reactions designed to manage one’s surroundings and its changes). In other words, the person with PTSD is likely to study people in their environment, notice exits (aka: escape routes), want full visibility of their surroundings, notice and investigate noises of unknown origins, etc. This is their radar operating in the hyper-sensitive mode. They’re detecting mosquitos and interpreting benign stimuli (e.g., noise, movement) as potentially threatening.

And their history tells them that they need to be ready to respond, because nonresponse can be the difference between life and death.

Now, this super-human radar setting may be periodically useful to a law enforcement officer…or a person sitting in a movie theater who hears the sound of a shotgun being cocked. But it can lead to malfunction in daily living – at a big box store, at work, sitting at home. This person’s responses to common situations are often disproportionate to the actual threat probability. People around them might view them as over-reacting or may start tip-toeing around the person’s “temper.”

The tragedy of this is that the individual with PTSD – as well as their friends, family, and colleagues – often have no idea what’s really going on, which results in the individual with PTSD feeling “other”…disenfranchised from society…standing on the outside looking in.

And let me assure you: living a life with a threat-management radar set on high sensitivity is exhausting (and unpleasant). This, unfortunately – but understandably, leads many individuals with PTSD to seek relief from the constant barrage of noise and movement and threat – whether through substance use, ‘leaning into’ threat by engaging in risky, adrenaline-fueled behaviors, or any other behavior that soothes them and allows their mind to escape and rest.

I explained all of this to Michael, and he was dumbfounded that someone could put words to a reality he’s been trapped in for years. I told him that it’s important that he starts taking mental inventories of the various stimuli coming at him at any given time – the radio blaring, the drivers cutting him off, the firetrucks blasting by with their sirens on, his son trying to talk to him, etc. Michael needs to not only take a conscious inventory of incoming stimuli, but he needs to actively manage stimuli (e.g., turn off the radio, tell his son he’ll talk to him when they get home). And on the days that he doesn’t succeed at his stimuli inventory or managing incoming stimuli, he needs to make conscious decisions about what he can and can’t adaptively do at the moment. (For example, by the time Michael walked in the big box store and encountered the greeter, he was already perspiring and tight-chested. It was unlikely that he was going to handle any other hiccups well.)

To be clear, I’m not suggesting outright avoidance, as avoidance can be the death-spiral of PTSD. Rather, what I’m suggesting is that strategic adaptations are not only wise, but can ensure maintained functionality. I’d rather Michael start going to a different, calmer big box store than end up in jail for assault or murder. I’d rather that another of my patients sets limits with his wife on when he can or can’t adaptively have a conversation, as opposed to ending up a divorced alcoholic and absent father.

Today, Michael is working on taking continuous mental inventories of his surroundings, setting limits when feeling overwhelmed, communicating these needs and strategies to his loved ones, and not seeing every situation or person as a threat. Michael is still a work in progress, but ‘progress’ is the operative word. Michael doesn’t spend as much time today perseverating on beliefs that he’s “crazy” or beliefs that he should forever be alone to protect others from his “crazy.” The world may still feel like a threatening place to Michael, but now he understands and can articulate why – which makes him feel a little more in control of his world. At his last appointment, Michael told me that he started opening his blinds every day, that he hung up motivational posters in his home gym, that he got a flower for his house, that he started having light saber wars with his son, and that he started dating a woman – despite nagging (but increasingly quieter) beliefs that she’ll eventually reject his “crazy.” Michael is now living – one little step at a time, but by god, he’s living.

Joye Henrie, PhD

September 2017

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