We finished the session by reviewing my transition to the VA.
“I’m excited for you,” Cher said. “You’ll do fine with the therapists there.”
“I don’t know that I’m excited, but I am open and I know I can adapt.”
“And that’s a positive sign of healing. That’s the soldier in you.”
I nodded and smiled just a bit. “I think you’re right,” I said. “I figured something out last week. I know I’ll never practice medicine again. I’ve known it for quite some time.”
I told her what I had known to be true and discovered and rediscovered so many times in therapy. I had felt the weight of it ever since my brain surgery and had pushed back and refused to accept it. But in that one definitive statement, I told the truth and let it flow unrestrained and saying it made it somehow less oppressive, as if I could see it as a doctor with some clinical distance.
“That’s been very difficult for you. Do you know why?”
“I wasn’t prepared for the loss. I was afraid of facing it. I felt like I didn’t have anything else.”
“Do you have anything else?”
“I don’t know yet, but I know it’s not medicine or the Army. I’ve decided that even if you were to sign something permitting me to return, it would be unethical. I can’t put myself in a position to harm patients. That’s a line that I cannot cross.”
We talked about my decision and the ethics of it, the weight and finality of it. Cher told me that it was the kind of decision that many patients never made, but that my willingness to accept my limitations would ultimately help me live with them and move forward. She reviewed some of the high points of therapy and my progress.
“When you consider all the things you’ve done in your career and all the places you’ve been, you have had a truly remarkable life. That’s not something a stroke can take from you.”
“When you say it like that, I can almost feel what you’re saying.”
“Almost?”
“I have a sense of it—that it’s true. I’ve done a lot with my career, but it’s hard looking back and seeing it come to an end the way it did. But I don’t want to dwell in that mind-set. I want to keep moving.”
“And that’s more a sign of healing than any test we could give you. It tells me you’re going to do more than be a stroke survivor.”
The VA in Iowa City was an older brick hospital built in the 1950s across the street from the University Hospital. Its hallways on some patient floors had dated vinyl flooring and the rooms seemed cramped. Part of my reluctance to go to the VA was its reputation. I had heard from other soldiers that care was slow and some of the doctors seemed uncaring. Residents in training from the University rotated in the VA under the supervision of staff doctors. Some of the residents were excellent; others lacked knowledge and sensitivity. The VA had so many patients requiring mental health services, including neuropsychology, that those services were relocated to a separate clinic facility in Coralville, about three miles away.
In August, the first provider I met at the VA in Coralville was Harvard-trained neuropsychologist Mike Hall, PhD. His office shelves held a collection of academic texts in neuroscience and behavioral science. The mandatory neuropsychologist’s plastic brain models sat on the top shelf. As he spoke and interacted with me in that first meeting, I decided he was a type A personality, atypical for a provider in mental and behavioral sciences and very different from what I had expected. He spoke to me like we were two clinicians conferring on a case, not that I was a colleague, but more that he recognized my capacity to understand clinical language. He was still the neuropsychologist and I was still the patient—that was clear—but it was also clear that my background as a physician made our provider-patient relationship different.
After we talked and familiarized ourselves with each other, Dr. Hall ordered a battery of neuro-cognitive tests that would pinpoint specific deficits. Some of them were the same tests I had taken at the University Hospital. He also referred me to a VA psychologist for a PTSD evaluation. He scheduled the tests and evaluations for the following week. The tests reaffirmed multiple stroke deficits and proved positive for PTSD.
The PTSD diagnosis, while not a total surprise, did make me curious, because I felt my war dreams and startle responses had settled down since I had returned home from Iraq. The VA psychologist, Heather, also a PhD, who was relatively new in the mental health department, discussed the scope and ongoing nature of traumatizing war experiences. She projected an interest in soldiers and in PTSD and she was sincere and kind, but when she spoke about war and trauma, it seemed to me she did so from the vantage point of a textbook or a VA seminar on treating soldiers.
“Let’s discuss the criteria for PTSD,” she began. “There is a traumatic event, recurrent memories, nightmares, avoidance, and a list of changes in mood or thinking.” I imagined her giving a lecture.
I didn’t need a lecture or a primer. I knew the criteria on the list. I had lived the criteria on the list, real-time, in combat. Fair or not, I dismissed her talk as lacking the real bite of combat experience and trauma. She had never been to war; I had. She had never been a trauma doctor. I had seen the emotional and physical trauma of combat.
Despite my initial misgivings, Heather impressed me as a therapist who genuinely cared for veterans and their causes. Still, I judged the tests for PTSD little more than voodoo because of their reliance on patient self-reporting. I also criticized the diagnostic criteria as being much too broad to yield any reasonable specificity for the diagnosis. There were no concrete lab tests or CT or MRI criteria. If the psychologist said you had it, you had it, period. To me, the diagnosis lacked clinical objectivity. I didn’t deny that it was real and that soldiers experienced it, but I battled against it with a military frame of mind, the toughness/weakness paradigm: soldiers are tough; PTSD is a sign of mental weakness. Consequently, I distrusted the diagnosis because I did not fully understand how behavioral and emotional actions, so functional in combat, could become so dysfunctional at home. I hated the term “PTSD” because of its overwrought emphasis on the word “disorder” and its implied status of emotional incompetence.
Heather continued to work with me even though I was reluctant to open up. She doggedly pointed out that I showed the signs and symptoms and pestered me about different aspects of reliving and avoidance, hypervigilance and irritability, violent dreams and nightmares.
“Tell me about one of your dreams or recurrent thoughts,” she said in one of the early sessions.
She was a spy. I could not let her see my secrets. “I don’t really want to go into it,” I replied coldly.
“Why not?”
“Too violent, maybe.”
She pushed and prodded. “Maybe? Can you be more specific or descriptive?”
“Well, it might be more like, I don’t know, something out of Dante’s Inferno, something hellish or evil.”
“Can you describe what you saw that makes you feel that way?”
Psychologists were always probing how I felt about things and sometimes I wanted to scream, “Shitty! I feel shitty or inhuman, dammit!” But I never did, because I knew that was what they wanted to hear, and saying it would only prove their point, that I felt something deep and dirty and horrible that I never wanted to surface. So instead I just said I felt sad. And I did, but that was the small of it.
I feigned confusion. “Describe what I saw?”
“Yes. Describe the surroundings or the person or the incident that makes you think of hellish things,” she said.
I wanted to just get through the session without delving into my wartime psyche or the patients I remembered, but part of me wanted to shock her, maybe as a way of saying I knew more than she did about trauma. I picked a case I remembered often.
“Okay. I saw this soldier—well, not actually the soldier. I just saw his empty Kevlar helmet, and it had a hole in it from a rocket-powered grenade. That was all I had left to look at—the helmet. The rest of him
went inside a body bag. So his Kevlar was burned and frayed where the grenade hit it, and the char of the helmet stunk and the inside of it was greasy and it still had a chin strap attached. Is that what you mean?”
“Yes, that’s what I mean. Was that the worst thing you saw?”
“No, but it is one that keeps coming back in dreams.”
“Could you draw me a picture of the helmet?”
I thought she was nuts. I had plenty of pictures in my mind; why draw one?
“No, I don’t think I can. I can’t draw very well.”
“I’m going to give you some paper and a pencil. Just make an outline,” she said.
And so the session went. Images and memories. Horrific memories and a crude drawing of a soldier’s helmet with a hole in it. I gave it to her and she kept it in my file, but I didn’t want it there, touching my other pages. I wanted to get rid of it. Out of my recall and dreams, out of my brain.
—
A few days later, I met Gina, a VA speech and language therapist who worked with veterans needing a wide variety of therapy for issues related to speech or language or cognition or all three. Her department saw older and younger veterans alike; ones with throat cancer, some with head injuries, others with PTSD, and veterans like me with cognitive stroke deficits. Gina, like Dr. Hall, treated me not as a colleague but with the appropriate recognition for my medical knowledge so I felt like I was part of my own therapy team—which, if I had thought about it, I was. Her personality didn’t fit my stereotypic image of a therapist. I imagined her as sort of maudlin or mega-serious or always poised to dig into the secret feelings about my stroke or make me take brain tests to show how much I had lost. She was anything but what I had imagined. She took a practical and more lighthearted approach to therapy, one that allowed me to fumble an exercise and not take it so hard. I felt at ease with her because she was obviously smart and experienced in her field, but also because she had mastered the art of working therapy so it wasn’t so weighty and intangible.
“Okay, Dr. Kerstetter, our first task is working with some numbers. Do what you can, and we’ll repeat the exercise and chart your progress.”
“I’m bad at numbers.”
“That’s okay. You’ll get better over time.”
Better over time. Those words helped me believe I could go beyond the therapeutic plateau that cornered me up against a wall like the crazed mob that cornered the Elephant Man. It gave me hope that if I cried out loud enough, my limits might dissolve and I could push further.
With Gina, there was never the question of my being able to complete a specific task, only the idea that I would try and that I would show incremental progress. Every exercise and every session focused on the very practical goal of improving functionality. The exercises meant nothing if at the end of therapy they did not help me become more functional in some aspect of cognition or life skills. In the beginning therapy sessions, we focused on exercises that used number and letter sequences. I put them in proper order or tried to recall numbers and letters from different lists. I grouped color-coded words together. I forgot my instructions in the middle of an exercise and Gina would simply stop me and review the instructions.
“That’s okay,” she would say in her soft clinical voice. Forgetting was forgivable. Imperfection pulled me one step closer to perfection. The universe did not come crashing in on my brain if I bungled, simply because there was no such thing as bungling. An exercise was an exercise; it helped improve my brain. I repeated the exercises in our sessions and eventually we saw improvements in accuracy and speed. One week led to the next, one new dendrite touched another, one at a time, and my memory and sequencing and focus began to improve.
Gina was patient. I was impatient. I compared my speed and complexity in recovery to the kinds of tasks I used to do in emergency medicine.
“That’s not a fair comparison,” Gina would say. “Don’t beat yourself up by measuring your progress against how you used to do things.”
“But I feel stupid and slow.”
“Your intelligence has not changed, only the speed and access to information.”
And when she assured me that I was still a doctor with stores of knowledge and experience, I wanted to work harder and recover more function.
—
I alternated psychology and cognitive therapy, so I rarely had them the same day. I needed the time in between to recover and think, especially as it related to the more emotionally traumatic sessions of PTSD therapy. I still struggled with the diagnosis and with the whole approach of confrontational therapy. After sessions, I always felt drained and wanted to distance myself from the sessions. About a month or so into therapy, Heather asked me specific questions about my dreams.
“Do you ever wake with night terrors or thrash around in bed?” She was prying again. I felt the hard edges of her question.
“Rarely,” I answered. “I had more of that when I first returned from Iraq.”
“And what about the dream wakes you? It is always the same one?”
“It’s usually the same one. An enemy is attacking me and we fight, hand-to-hand. I kick or punch with my fists and that’s what wakes me up. Sometimes I roll around and get caught in the sheets. That always gets me riled up, because it feels like someone is grabbing me and sometimes I yell out and scare my wife.”
“Have you ever hurt yourself or your wife in a dream?” she asked bluntly.
I didn’t want to go down that path. I wanted to shade my answer without having to violate the truth substantially. I felt I had earned the right to keep some things to myself.
“Not really. I did kick the wall by the side of the bed a few times, but other than a bruise, I was all right.”
“How often does that happen?”
“Rarely anymore. It’s mostly gone.”
She raised her eyebrows and tilted her head just a tad. “Completely gone?”
“Not a hundred percent, but I’m fine. My dreams are mostly okay.”
Heather wanted to keep digging, but I wanted to move on. Dreams were dreams. Nothing could be done to erase the ones that had already occurred, and nothing could prevent a nightmare from slipping through a mental crack now and then. I tried to change the subject, but she was a spy. Prying. Probing. Questioning. Her pestering questions threatened to grab hold of my secrets and make them public. Those secrets were mine; I could not let them out.
“How does your wife react when you have your worst dreams?”
“Well, sometimes she has to wake me up, but that was more when I first came home. Like I said, my dreams are okay now.”
“Does she still have to wake you?”
“Rarely. Only once in a great while, and then I go back to sleep.”
“Do you talk to her about the dreams?”
“Yes, just to give her an idea, so she’s not scared.”
The dream talk went on for more than I wanted it to, and when we got to the end of the session, Heather said she felt like there was more. There was, but I wasn’t going to say anything, and she was making me mad with all her psychobabble questions. Exposing my dreams and nightmares contained its own kind of creeping vulnerability, so I decided to hold the worst of my nightmares to myself.
—
In my morning routines, I continued aquatherapy with an arthritis swim group. Ray, one of the leaders, was a Vietnam veteran and a former Army Ranger. We joked around in the pool and sometimes went out for coffee afterward. At coffee one day, he asked me how my VA therapy was going. I told him about my psychologist and the skullduggery of talking about dreams and war and PTSD. Ray was a shoot-from-the-hip sort of veteran and he would blurt out things that made complete sense but were often embarrassing or politically incorrect.
“Sounds like the VA thinks you’re crazy, like me,” he said, loud enough so the tables next to us could hear. That’s just what I had wanted, my therapy as coffee talk for the other tables. He went on to tell me of his own VA psych experience and how he told the psy
chologist about his fits of nightmares when he first got back from Vietnam.
“Hell, yes,” he said. “I almost strangled my wife several times. I thought she was sneaking under the wire to kill me, so I choked her before she got the chance. I don’t know how she survived that first year back.”
We both made light of it, as if to make it less serious, but he made his dreams sound so real. The enemy sneaking in to get him. His thrashing in bed, the night sweats, the absolute terror, and his yelling and fighting in bed. He said he was glad he locked up his guns or he might have shot his wife that first year back. I didn’t know what to think. He wasn’t trying to trivialize the experience or trying to play psychologist. He was more or less neutral or clinical, as if the incidents were unfortunate but natural consequences of war and nothing to be ashamed of. He said the North Vietnamese soldiers were always sneaking under the wire and infiltrating the camps, and that his greatest fear was getting knifed as he slept. He asked me if I ever had dreams like those. I said I did, then changed the subject.
—
In Iraq, enemy insurgents didn’t crawl under a wire into our camps. Instead, they laid out roadside IEDs and beheaded people in front of video cams. They tortured and dragged captured soldiers through the streets, then burned their bodies and left the corpses hanging from bridges or tied them to a post for everybody to see. My greatest fear was being captured and beheaded. My nightmares centered on my arms being pulled out of their sockets and being marched in front of a camera with a black hood on my head, screaming as an insurgent took a knife to my neck. And when I dreamed them, I could feel the pain in my shoulders. The endings always escalated into a hand-to-hand fight where I thrashed in bed and got tangled in the sheets, and when the blankets rubbed against my neck, I attacked in a rage. I clenched my fists and punched at will. I kicked and clawed and screamed until I got my hands on my enemy’s neck and pressed on his trachea, which I knew was vulnerable. On the other side of my nightmare, Collin screamed and cried as she took the brunt of my war-fed panic. I kicked and kneed and punched her with a closed fist, and I didn’t stop until she woke me up. Once, according to her, I got her in a chokehold and she panicked. When I finally woke to her screams, I felt fear and sorrow and shame. And I wanted to hide myself or run away so I couldn’t hurt her.
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