War Heros: A Poem

War Heroes

As taught by 500 veterans who have been tormented by their war.
Part 1 How to know you are a war hero
(pick some from the list below)

Believe you didn’t do enough
Believe the real heroes are dead
Have pride in what you did
Despise what you did
Not give a shit about what you did

Believe you should have died
Think you must figure out the secret reason you didn’t die
Be angry at the people who weren’t there
Think of everything you can to keep your kids from going
Love anyone else for going
Think you only did what you had to do
Think you didn’t have to do everything you did
Think this is not how heroes think and feel

Part II How to get over being a war hero

Grieve everything and everyone you lost
Grieve all the yous you think you could have been
Go through the grief until you recognize the impossibility of the other selves

Learn we have an obligation to find serenity
Learn that nobody in their right mind needs you to suffer anymore
Learn that living your life well is the only way to honor the dead
Learn that trying to carry other people’s pain would be an insult, if insults could exist
Stop pretending you are not going to die

Learn that knowing something once is not enough, we must keep coming back to it
We don’t pray once

Part III Where you learned the definition of the word hero

Maybe when you were a kid you learned to look up to someone as a hero
You thought that person had all the answers, all the power, all the skill, and none of your kind of fear
Then you grew up, but still never noticed
that the hero didn’t feel what you thought he felt

Now we know that the courageous are scared,
and the skillful aren’t always courageous

Part IV Summary

There was a new recruit from Maine
who thought he would earn him some fame.
He got in the fight,
and Lord it got tight,
but you better not call him a hero because now he knows
it is much more complex than that, and besides all the heroes are dead

Howard Lipke
(1/6/16 version)

Don’t I Have the Right to Be Angry? A Podcast Interview

Podcast from the University of Buffalo School of Social Work

Listen to a 35 minute interview with Howard Lipke conducted by Dr. Nancy Smyth, dean of the School of Social Work. The basics and history of the development of the HEArt program are discussed, as are research, general ideas about anger prevention work and clinical practice with combat veterans.

Episode 180 – Dr. Howard Lipke: HEArt for Veterans: Identifying the Hidden Emotion. (2015, November 23). inSocialWork® Podcast Series. [Audio Podcast] Retrieved from http://www.insocialwork.org/episode.asp?ep=180

 

On Stigma

Below are two paragraphs from a paper on stigma, especially as it applies to veterans. (Actually there are two papers, one addressed to veterans and one more academically written for MH professionals) In the second paragraph it is suggested that if vets, or anyone with trauma related “symptoms,” is going to get down on themselves they should at least “Get it right.” which is the name of the academically oriented paper these quotes come from.

That stigma (being marked or believing one is marked as disgraced) is a primary barrier to veterans seeking help to overcome the destructive psychological effects of trauma is one of those cultural phenomena which is easy to see, widely acknowledged, and also supported by research (Hoge et al 2004) . As is often pointed out, the stigma has two manifestations, (e.g., Corrigan, 2004) the belief by others that the need for psychological help is a sign of essential inferiority, and the same belief held by the self. Both are important with the self-stigma clearly most damaging.

 Stigma terms

  1. Current stigma term: Crazy Vet 

More accurate term: Stuck Transferer

This is the stigma associated with re-experiencing symptoms. “Stuck Transferer” refers to the idea that flashbacks and reliving nightmares are a manifestation of unprocessed memory. In Horowitz’s terms (1976) memory has not moved (transferred) from short term to long term storage. In the version presented to veterans this is called moving from “reliving” to “historical” or “intellectual” memory.

 

The Definition of EMDR

Let’s start with a fairly circumscribed mild point. We need a new definition of EMDR, one that does not begin with “…evidence based …” or “…successful outcomes well documented …”, as occur in EMDRIA’s official definition. Those aren’t phrases you find in a definition, you find them in an evaluation or a press release. In addition, “evidence based” suggests that EMDR was developed from research demonstrating the effectiveness of its various aspects. It wasn’t, but more on that later.

I have a definition in which more is different from EMDRIA’s than just the absence of self praise. I don’t think my proposal is perfect, but so far it is the least bad one I know of. It should also be mentioned that a version of the one below was submitted to EMDRIA during the latest development of the EMDR definition and it was rejected. But, that doesn’t mean the discussion should be over, or that someone could not use mine if they needed one that focused on essential features.

And, here it is: Eye Movement Desensitization and Reprocessing (EMDR) is a method of psychotherapy in which aspects of a target associative network (usually a troubling memory) including visual images, thoughts, feeling, emotions, are identified, as are a preferred thought about the self when target memory is active. The believability of the preferred thought is rated, as is the level of distress felt as the troubling memory is activated before initiated eye movement.

With the painful aspects of the problem memory again brought to awareness, the client is asked to free associate while moving her or his eyes following the therapist lead, in a repeated pattern for a period of time, determined by client response, but usually about 30 seconds. After the set of eye movement, the client is asked to report on the current content of consciousness, and then eye movement is reinitiated. This pattern is repeated until distress associated with the target network is resolved, and, hopefully, adaptive associations are connected to the targeted event. In its most complete form all aspects of the target memory(ies) are addressed, including related past events and possible future situations which may elicit related psychopathological responses.

Therapist comments between sets of eye movement are limited to brief instructions, unless the client is not progressing by either becoming aware of new material or not having decreased distress. In these cases a variety of interventions, many typical of other methods of psychotherapy may be made before eye movements are resumed.

There are many variations to specific aspects of the above activities, including on what the client is supposed to try to keep in mind as em begins. These variations are determined by client response, experience and research.

As in standard psychotherapy practice negotiation of treatment contract, client evaluation, history taking, building of rapport, explanation of method, and development of stress management strategies are part of treatment.

And now a short dictionary/elevator definition:

EMDR (Eye Movement Desensitization and Reprocessing) – a method of psychotherapy which usually involves recalling a troubling experience and engaging in therapist led repetitive back and forth eye movements or other sensory/motor activity. The rest is commentary.

I was just kidding about the commentary part. This subtle reference to Rabbi Hillel’s effort to explain his religion while standing on one leg obviously doesn’t belong in a definition. However, it should also note that Rabbi Hillel is reputed to have also suggested that the commentary should be studied.

Response to a potential objection:

I can foresee objection to the phrase: “including on what the client is supposed to try to keep in mind as eye movement begins”. The allowance of the loosening of the protocol comes from clinical practice. Let’s say before the first set of eye movement, when the therapist asks the client to put in mind a picture of the worst part of the target memory, the client has an immediate strong emotional reaction, and the therapist then begins the eye movement. Since the client has already been prepared for eye movement at this point most experienced therapists I have asked would just begin it. Would this not be EMDR because most of the Assessment phase was skipped over?

There will never be a fully satisfactory definition of EMDR, and this is a problem with almost all terms in the mental health field including such basic terms as “mental health” and “psychotherapy”. So we have to pick compromises that are most useful and least problematic.

Understanding Psychological Trauma Through Literature (draft)

As a psychology graduate student, in the 1970’s, I came across an edited volume, The Abnormal Personality Through Literature, by Alan A. and Sue Smart Stone (1966), which presented long passages of great works of fiction to describe psychiatric syndromes and psychotherapeutics. I thought it a great idea then, and still do. The work you are reading attempts to apply their method more specifically, to just the destructive psychological effects of trauma and efforts to overcome them. The other variations from Stone and Stone include the use of shorter passages, and comments on changes in the way trauma has been recognized over the years, since it has been officially acknowledged in the Diagnostic and Statistical Manual (DSM) as the official United States standard.

A reasonably clean rough draft:

Thinking and Feeling About Forgiveness

This is a paper based on work with combat veterans over many years and addresses some of the most difficult and painful concerns people can have, the difficulty of which is magnified by involvement in war. It includes discussion of forgiveness of others and the self, with the decision to forgive, not all or nothing, and not a foregone conclusion.

Recently the phrase “moral injury” has been applied to some of the issues addressed in this paper.  While I’m glad the moral and emotional reactions to participating in combat are being  more fully considered by psychologists who used to only talk about the fear related to traumatic experiences, I’m not sure that the injury metaphor is most useful way to consider them. The term moral injury appears to be about what is already considered when we talk about guilt. Guilt people feel related to trauma, whether  it seems justified to others or not, or necessary or not, has already been subject of much psychotherapeutic work, written about for a long long time and undoubtedly considered even longer.

Integrating EMDR into Clinical Work

The attached paper is especially for new EMDR practitioners. It indicates that I practice at  the North Chicago VA Medical Center. I still do a little work there, but it is now called the Captain James S. Lovell Federal Heath Care Center.

Brochure: For War Vets and Family

The brochure For War Veterans & Family: On Combat Exposure was written in late 2008 for veterans and their family members who were connected to the Stress Disorder Treatment Unit (SDTU) at what was then the North Chicago VA Medical Center, and is now the Lovell Federal Health Care Center. Although there were many educational materials available on the psychological effects of combat (e.g. National Center for PTSD internet resources available at: http://www.ptsd.va.gov/public/) these appeared to focus on describing PTSD symptoms, attempting to normalize them, and encouraging treatment. They certainly met a need, however, their focus on diagnosis and symptoms failed to address essential issues that would help to clarify a reasonable understanding of how the effects of combat related stress might occur, and what paths might lead toward relieving  them. The standard approach also did not answer many of the questions that had arisen over the years from veterans and family members.

In an effort to meet these needs work began on the brochure. As was the process with many of the clinical materials developed for the SDTU, after a first draft was completed by staff it was presented to groups consisting of residents and some alumni outpatients of the SDTU program. Their feedback was incorporated into subsequent drafts. This process continued until there were two consecutive groups who found no objections to the material. The brochure was then made available to veterans and family members in its completed form.

EMDR Clinician Survey

In 1992 an extensive survey was sent to the 1200 clinicians Francine Shapiro had trained asking about their clinical experience with EMDR. EMDR was new and it would take a while before many randomized controlled studies would be available (actually there were very few RTCs of method of therapy for the effects of trauma then), so it seemed important that there be information available about the effects of EMDR from independent sources . In addition there was the important, and not often seen, establishment of a body of clinical “lore” that would be based on a systematic collection of data, not just the passing on of clinical impressions, which is/was a common way clinicians receive our information. So, here is the survey, only ever published in the now out of print first edition of Shapiro’s basic text, Eye Movement Desensitization and Reprocessing (1995).

Fighting the Last War: On Courage and Wisdom

This paper comes out of discussions of issues addressed in meetings with combat veterans in the Stress Disorder Treatment Unit at North Chicago VAMC, now named The Captain James A. Lovell Federal Health Care Center.

The Short Version:

The main psychological challenge while in combat is to, minute by minute, find courage to overcome fear and pain. The main challenge of civilian life is to find wisdom to define and meet long term goals. Knowing this is a big step toward overcoming the problems which come with mistaking civilian challenges for combat challenges. 

The Long Version: