SERGEANT Bigman was a Ranger, and he lived up to his title and his name. The man was six-foot-six, solid muscle. He came into my offce looking angry and irritated to be there. He limped. I was more than a little scared, and I tried not to focus on the earlier words of my boss, Captain K.
“This is one of the best-trained killers on the planet. Everyone else in his unit was slaughtered, and he was captured and tortured by al-Qaeda for weeks. I don’t know how he escaped, and I suspect that the men who would have been there to actually see it are dead. He could snap your neck before anyone could get into your offce to save you. If that’s not enough to make you careful, remember that he’s a certified American hero, and every general on the West Coast is looking at what happens to him. So watch what you say.”
I started with hello.
He started with, “You know, I never believed in this PTSD stuff. I always thought it was a sorry excuse to get out of work, but I can’t sleep. My CO said I had to come and talk to you, so you have one hour, Sir.”
I offered him a chair in my cluttered offce, noting that even this exceptional man exhibited the familiar mix of irritability restrained by military discipline. The PTSD of which he spoke was post traumatic stress disorder, an affiction the military was trying to get a grip on in the face of ongoing wars in Iraq and Afghanistan. I was one of the Navy’s newest-minted so-called experts in the field. I had recently completed a psychiatry residency and, by virtue of having an extra doctorate in stress research, had been placed in charge of a program that tried to push the edges of what we could do for this disorder.
“Your commanding offcer can’t actually order you to come here,” I said. “There are very specific rules for that. You can only be compelled to seek treatment if you are judged to be a danger to yourself or others, and I’ve not been informed of anything of the like.”
“So I can go if I want to?”
He stayed anyway, at least for the hour, plus one more. I’d been given extra time with him because he was, as Captain K had indicated, a certified hero. You could read that from the medals on his chest: a Silver Star, Purple Heart, and, recently awarded, the Distinguished Service Cross, decoration second only to the Congressional Medal of Honor. So far, they hadn’t handed out that last celestial honor, no matter the acts of valor. On this man’s chest, you could see indications of the most noteworthy actions of any Soldier serving. In his eyes, you could see more. This was a true hero and truly human. This was a strong man in pain.
Sergeant Bigman stands out in my mind because he was emblematic of a generation of Service Members—Soldiers, Sailors, Airmen, and Marines—who ended up in my offce. He was not the only tough guy to suffer with post traumatic stress disorder. There were many others, some Special Forces supermen like him, others frail from old wounds reopened by the strains of military service. Most were people like you and me, neither tough nor brittle, who had found themselves with terrible events stuck in their heads that dominated their lives.
The military did what it could for these injured men and women. Some people have the impression that PTSD is an incurable tragedy, a mental scar that generals and admirals choose to ignore because it is a battle that cannot be seen and thus could not be won. I can’t testify forthe entire system, but I will say that at my medical center that wasn’the case. I saw that we could make a difference. Many people got better, went back to their lives, and were stronger for it. But not all.
I never found out the full details of what haunted Sergeant Bigman the mountains of Afghanistan, although I asked. Avoidance is the second part of PTSD. You re-experience a trauma, and try to avoid it, try to think about it, but running from yourself only makes the memories stronger. As psychiatrists, we try to break that cycle of avoidance, sometimes we push too hard. Maybe I pushed him away.
“I can’t talk about it, not now, not ever,” he said, tears brimming the edge of his scarred face.
He did tell me about growing up rough and hard. Like many sufferers of PTSD, the war was not the beginning of his trauma. His father beaten him and his brother when they were children, telling them would make them strong. It had at least pushed them together. He joined the military as an infantry grunt, his brother as a medic. Both ended up in Special Operations. They had saved each other many times. The action that resulted in his capture was not his first time in combat, not his time killing or seeing friends die.
“This was worse,” he said. “But I didn’t think this would happen me. I was supposed to be stronger than that.”
The sergeant had many things going for him that were supposedly protective against PTSD. He was well trained. He had good support from his brother and from his friends. I particularly liked that he was only tough but also smart. He had earned a college degree before enlisting, and now he had letters of acceptance from several law schools his term of service was up.
“Why didn’t you go in as an offcer if you already had a college degree?” I asked.
That had been my own path. The military had brought me in as a Navy lieutenant, the third step up in the offcer ranks, straight out of medical school. A college degree usually buys you at least the of ensign. I couldn’t quite fathom why Bigman would have purposefully passed up that advantage.
He practically growled his answer. “In Special Operations, officers don’t get sh_t for action. I wanted to actually do something.”
In retrospect, my question had been a mistake. I had insulted his calling, the way that I sometimes felt civilian doctors disdained our volunteer military. Even within the brotherhood of arms, there are often chasms of understanding and respect. In the same way that I was reading his face and his uniform, he had been testing me. And on my own meagerly decorated uniform, the only award was not for serving in combat but rather for publishing academic research. To a man who valued action, I had made myself an outsider.
To Sergeant Bigman everyone had become an outsider. His brother, his fellow Rangers, his country all still loved him. We all wanted to treat him like a hero. But to him, the only people whose respect he wanted, the only people who truly knew his pain, were dead. Some of them, the enemy who had bested him for a time, were slain by his hands. He was struggling not only with PTSD but also with grief, with depression, and with trying to carry the weight of heroism when he felt empty inside.
He had not rejected help altogether. Bigman had avoided alcohol or acting on his anger, traps into which many in his position have fallen. He had befriended a Vietnam Veteran who explained that PTSD was nothing about which to be ashamed. Sergeant Bigman didn’t quite believe this, but he did listen. He had even gone so far as to seek out a psychologist whom he had met in survival training school. The psychologist didn’t specialize in PTSD, but he was competent and caring. He taught Bigman relaxation techniques and worked with him closely for several months. When the nightmares and flashbacks stubbornly refused to fade, the psychologist suggested to the company commander that perhaps Sergeant Bigman could be given dispensation to travel to Naval Medical Center San Diego, where scientists and physicians were trying out new technologies to help this ancient affiction of war.
Having lost any credibility as a fellow in arms, I tried my best to play up my geek skills. I explained the history of PTSD to Sergeant Bigman, what we had learned about its origins and treatment over the years. I told him what we knew about the underlying biology, but that biology alone was not enough to mend a broken soul. I described how healing the psychological wounds of war involves medicine, psychology, and the fabric of society around us.
“In many ways, PTSD is a normal reaction,” I said. “But normal doesn’t always mean healthy. It is normal to bleed if you are shot, but that doesn’t mean that we should wait forever for a clot to form if you are gushing from the femoral artery. You need medical treatment.”
I explained that at this facility in particular we were advancing new work involving virtual reality and other treatments that were making a difference. We had learned what tended to work and what approaches were best avoided. I told him that, even though his story was sure to be unique, I had seen many cases of PTSD. There was nothing here that could not be overcome. I was very optimistic.
I never saw him again.
I started this book thinking that I was writing it for Sergeant Bigman or at least for the others like him, the ones who got away or never came in the first place. I wanted to describe how people with PTSD and other psychological wounds of war can be healed. If people knew this, it seemed like it would help. I wanted a second shot at it. Maybe he, and those like him, would read this. Maybe they would come back.
Later, I realized that writing was also a form of therapy for me. I was waiting to go to Iraq. If someone like Bigman could be broken by war, what chance did I have of returning mentally unscathed? The book took on new meaning, and new chapters formed as I journeyed toward deployment. On another level, I thought I was writing for other doctors. Psychologists and psychiatrists were interested in the discussions. I wanted to write these thoughts down and to educate the next generation of caregivers. I wanted to make sure that we didn’t overlook our past. But there are plenty of books for doctors, enough ways to remember. It is harder to forget.
Sergeant Bigman taught me many things. That isn’t his real name, of course, and his story, like all those in this book, has been jumbled and disguised in the writing to protect patient privacy. But it was never really only about him, and it was never just about me.
This book is a collection of what I call psychiatric fables, stories that have a message. My own experiences with science and technology are interspersed with the wisdom and experience of others who have been on the front lines of war and treatment. We will travel back and forth between the battlefield, the ivory tower, and the home front. There are stories from patients, doctors, Service Members, chaplains, family members, neuroscientists, and others. As I gathered information, I appreciated how much I was learning from the process. In the end, I realized that these stories were not about patients or doctors or even
friends and family members. They are about war and about healing and about hope. They are about all of us.
Dr. Streeter in the Virtual Reality Simulator
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