ODYSSEUS IN AMERICA
There are two good books stemming from the Viet Nam war that explore the combat experience and its effect on human character. The first is Achilles in Viet Nam and the second, the subject of this note, Odysseus in America, by Dr. Jonathon Shay. Being a fan of Greek mythology, I remain inspired by the insight the Odyssey brings—used as a tool by Dr. Shay— to our contemporary world with a focus on Post Traumatic Stress Disorder (PTSD). I will review the major points of the book and expand with the notion that PTSD is not just a problem found in combat veterans. It is one of few psychological diagnoses (assuming you don’t believe we all carry a psychological diagnosis) that any one of us could acquire ie it happens to “normal” people — you get this this without being psychologically “weak” or “crazy.”
The Odyssey takes place after a long war (ten years….) and Odysseus who was such a hero in my mind as a child, is displayed in this book’s analysis as the prototype of a damaged veteran—along with his fellow vets. He is one of the victors; he is clever and resourceful. He is damaged. How so? It seems, you can be intelligent and resourceful AND damaged.
He heads for home with his booty, his ships and men. Along the way, they raid—they were well practiced in the necessary skills and had become a lifestyle. This behavior is aggressive and reckless—-a characteristic of some with PTSD— and a price is paid—he loses good men and ships. They come to the land of the Lotus Eaters—-a metaphor for substance abuse and his men lose their drive, their motivation to return home to the lives they had before the war. He remains disciplined—he tricks and corrals them and they move on. They confront the Cyclops and while Odysseus deserves credit for outsmarting the Cyclops, he cannot refrain from taunting him as they make their escape; this taunting reflects both risk taking and an oversized ego. His crew and Odysseus pay for it as by identifying himself, he becomes the target of Poseidon whose son was the now-blinded Cyclops.
You need Poseidon on your side if you are sailing home.
He is able to obtain help from the God of Winds, but no longer trusting his men, he will not divulge the contents of a bag given to him by that God to secure a safe trip. When, too weary to stay awake guarding the bag, his crew, angry at the distrust and secretiveness, take it and open it just as they are in sight of Ithica; they release of the winds held in by the bag and are driven away in a storm— again, with loss. Distrust is tied to PTSD in the returning veteran with this condition.
He takes risks on selecting a not-so-safe course and loses all his ships but for one. He lands on the island of Circe where his men are turned to swine and he is seduced by a witch using sex and drugs to keep men in line. Misogeny and drug use……He escapes and has a chance to see his old comrades in Hades where he is unsettled with their tidings—he has survivor’s guilt. He passes the sirens who sing that they KNOW everything about the war and what really happened. What veteran doesn’t want that? What veteran actually gets that?
If they could get it, would it solve their problems?
I have always struggled with the mind-body dichotomy ie the notion that the body is a machine and the mind, some sort of ghost that animates it. Common belief and medical practice have long treated them as two separate things. But consider a burn or a deep cut— healing depends on the health of the tissue and the organism’s overall health starting out before the injury. This is relatively easy to do when examining the leg of an old diabetic who smokes or NFL athlete in their prime. It is harder to do with an angry veteran who struck a social worker or a police officer. Healing a physical or psychological wound requires a treatment plan and a specific environment: the diabetic leg is treated with positional advice, dressings, antibiotics, surgery sometimes, and check ups. The patient with PTSD? The resources and a plan are often not clear or available. Most of us can look at an obvious leg wound and understand that it is dangerous with a need for treatment. Psychological injuries are not as clear when viewed with the naked eye. There are many who are skeptical about the veteran with PTSD have a real “thing.” All they see is the bad behavior and most of us have a simple recipe for what should be done in that setting.
Dr. Shay points out that not all veterans who experienced adverse events suffer equally. Those who were psychologically resilient will do better than those who were not. He does not define psychological resiliency (but we all know it when we see it!). For combat veterans, some “have the stuff” that allows them to suffer and find long term success— sometimes amazingly so (Max Cleveland) and others not so clearly (Lewis Puller). He paints a picture of the therapist in a group session trying to limit the conversation between the Marine and the Army veteran who compete over who suffered more……..nothing good comes of such a conversation—the resilience of each individual leads to a different outcome even with shared experiences. With so much suffering and different manifestation of behavior, what are the common threads and how does that inform treatment options?
Referencing his experience with Viet Nam veterans, Dr. Shay notes that sometimes PTSD affects a person’s character and damages “social trust.” With this, a person cannot flourish or live a full life. This is what people (veterans) with complex PTSD face. He explores this further—how does he define social trust? It is the trust that power (specifically, the VA, the Government, the local police officer) will correlate with “what’s right.”
When you lose that trust, you adapt a psychologically defensive posture:
You mobilize to fend of physical or psychological attacks.
You mobilize to fend of humiliation.
You mobilize to avoid being exploited.
You figure out how others are trying to trick you.
What are the symptoms when this happens (specific psychological observations)?
He characterizes them: apathy and demoralization, self loathing, loss of self-respect and initiative, raw vulnerability, social withdrawal, irritability, hypochondriasis, suggestibility—blind obedience or radicalization to a cause, risk taking, grandiosity, coercive demands for respect, rage at slights, coercive attempts to dominate, and apocalyptic ecstasy.
In my medical world, I would reflexively recommend a trial of medication for some of these symptoms and counseling. It is straightforward. He points out that given the root cause, these are band aids; you need more. Healing in this setting with this population requires:
Sobriety
Safety
Self care
He developed models in the Philadelphia VA to provide this framework in addition to the traditional approaches of the psychiatric department. He saw some successes. He had resources. This is a useful framework for all of us to consider in the broader world where the resources have not been as rich.
Stepping back, I wonder if our society in the United States (not to mention that in Russia, Hungary, Mexico, etc) does not suffer some systemic PTSD given the symptoms he lists, and the recommended treatment approach.
I came to appreciate in my practice that patients on narcotics for chronic pain were often asked by psychiatrist certain detailed questions about their past—questions I did not initially see as relevant to the medical condition I was treating. From this I learned that by asking, unrelated to the cause of headaches, neuropathic pain, or chronic back pain, open question about some life changing trauma, a near death experience or rape for example, would soon find the tears flowing. The concept of PTSD and psychiatric resilience echoed from these books in people I saw in the day to day in a community practice.
There is an acknowledgement over years that childhood experiences relate to psychiatric resiliency, (which is hard to measure) and outcomes: odds of completing education, drug use, managing to find and keep gainful employment not to mention close emotional relationships. Going back to Dr. Shay’s observation that given the same experience, two veterans can react and adjust quite differently, consider the framework of ACES (Adverse Childhood Experiences). The questionnaire lays out the background being examined— and the more positive responses, the more likely the person has problems coping with life—civilian and military.
What are the ACES exactly?
Before your 18th birthday:
Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or act in a way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or ever hit you so hard that you had marks or were injured?
Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or attempt or actually have oral, anal, or vaginal intercourse with you?
Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Were your parents ever separated or divorced?
Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Did a household member go to prison?
The veteran with a high ACES score might be more likely to suffer combat related PTSD than the veteran who had a low Aces score. Other factors may be in play. I would argue that the inner city young adult or poverty-stricken rurally raised young adult would show the same profile of PTSD in the face of car accidents, run-ins with the law, gang violence, or near death experiences. Their resilience and reaction to a psychological injury of this type is as relevant as the status of circulation in a leg with an infection.
In my lifetime, there has been a dramatic change in our nation’s degrees of sobriety, safety, and self care. These themes resonate with every election. They are in the news. They are reflected in movie and TV shows. The lack of a dominant culture that supports a reality where sobriety, safety, and self care can be practically supported lends itself to the chaos we see every night on TV or our cell phones.
Dr. Shay points out that we are successful as a species because we evolved in communities that in the end are all powerful against much of what nature has thrown against us —-because of our ability to form community. Our brains are tied to social communities and the rules that bind—“we live in relation to culturally constructed moral codes”—Dr. Shay’s ultimate message: OUR SOCIAL LIVES REMODEL OUR BRAINS; RESTORATION OF DAMAGED PSYCHES AND THE CAPACITY FOR TRUST ONLY HAPPENS IN COMMUNITY. Community in this sense is interactive and with a focus on improvement.
How many of us have that?
Related to this sense of community in our heterogenous and large society, is seeking community on a smaller scale with healing damaged psyches in mind. Malcolm X advocated for this—he even got a contribution from the American Nazi Party leader and was OK with that as he saw the needed prescription was not to be found in the larger American Society. Mormons have done this historically and after great deprivations, have demonstrated the power of it.
My interest in systems of care comes up against this all the time. Vaccinations are front and center. I have found historically, that people against vaccines generally, have a belief system in alternative views of body function and health than that for which I trained. My role supporting a large and complicated system (let’s call it modern Western medicine) automatically made me suspect to those who already had a smaller community supporting a different belief system. That smaller community allows for personal advocacy and identity you don’t get seeing your doctor once a year. That one-on-one advocacy by a known friend or acquaintance over and over seems more truthful and authentic psychologically, regardless of national recommendations or statistical analyses demonstrating “truth” at least as we know it today…….
We live in a low trust society. That adds fuel to the fire for each and every one of us coping with the world.
BONUS : The concept of ACES was anticipated before formal psychiatric recognition: From West Side Story:
1957 BROADWAY LYRICS
Dear kindly Sergeant Krupke,
You gotta understand:
It's just our bringin' upke
That gets us out of hand.
Our mothers all are junkies,
Our fathers all are drunks.
ACTION AND JETS
Golly Moses, natcherly we're punks!
Gee, Officer Krupke, we're very upset;
We never had the love that ev'ry child oughta get.
We ain't no delinquents,
We're misunderstood.
Deep down inside us there is good!
ACTION
There is good!
ALL
There is good, there is good,
There is untapped good.
Like inside, the worst of us is good.
SNOWBOY
(Spoken) That's a touchin' good story.
ACTION
(Spoken) Lemme tell it to the world!
SNOWBOY
Just tell it to the judge.
ACTION
Dear kindly Judge, your Honor,
My parents treat me rough.
With all their marijuana,
They won't give me a puff.
They didn't wanna have me,
But somehow I was had.
Leapin' lizards, that's why I'm so bad!
DIESEL
(As Judge) Right!
Officer Krupke, you're really a square.
This boy don't need a judge, he needs a [sic] analyst's care!
It's just his neurosis that oughta be curbed.
He's psychologically disturbed!
ACTION
I'm disturbed!
ALL
We're disturbed, we're disturbed,
We're the most disturbed,
Like we're psychologically disturbed.
DIESEL
(Spoken, as Judge) In the opinion on this court, this child is depraved on account he ain't had a normal home.
ACTION
(Spoken) Hey, I'm depraved on account I'm deprived.
DIESEL
So take him to a headshrinker.
ACTION (Sings)
My father is a bastard,
My ma's an S.O.B.
My grandpa's always plastered,
My grandma pushes tea.
My sister wears a mustache,
My brother wears a dress.
Goodness gracious, that's why I'm a mess!
A-RAB (As Psychiatrist)
Yes!
Officer Krupke, you're really a slob.
This boy don't need a doctor, just a good honest job.
Society's played him a terrible trick,
And sociologically he's sick!
ACTION
I am sick!
ALL
We are sick, we are sick,
We are sick, sick, sick,
Like we're sociologically sick!
A-RAB
In my opinion, this child don't need to have his head shrunk at all. Juvenile delinquency is purely a social disease.
ACTION (spoken)
Hey, I got a social disease!
A-RAB (spoken)
So take him to a social worker!
ACTION
Dear kindly social worker,
They say go earn a buck.
Like be a soda jerker,
Which means like be a schmuck.
It's not I'm anti-social,
I'm only anti-work.
Gloryosky, that's why I'm a jerk!
BABY JOHN (As Social Worker)
Eek!
Officer Krupke, you've done it again.
This boy don't need a job, he needs a year in the pen.
It ain't just a question of misunderstood—
Deep down inside him, he's no good!
ACTION
I'm no good!
ALL
We're no good, we're no good!
We're no earthly good,
Like the best of us is no damn good!
DIESEL (As Judge)
The trouble is he's crazy.
A-RAB (As Psychiatrist)
The trouble is he drinks.
BABY JOHN (As Social Worker)
The trouble is he's lazy.
DIESEL
The trouble is he stinks.
A-RAB
The trouble is he's growing.
BABY JOHN
The trouble is he's grown.
ALL
Krupke, we got troubles of our own!
Gee, Officer Krupke,
We're down on our knees,
'Cause no one wants a fellow with a social disease.
Gee, Officer Krupke,
What are we to do?
Gee, Officer Krupke,
Krup you!
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