Crossings

by Jon Kerstetter

  In the next session with Heather, I decided to tell her about my pool buddy Ray and his traumatic nightmares. After a bit of her prodding, I leaked some parts about my dreams and how they became so vivid they distorted reality and how my wife became my enemy and I attacked her to survive. The secret was bare and open and the telling of it made me ashamed, but it also confirmed what we had both known and I was now facing.

  “Would you refer a soldier for PTSD counseling if they gave you that same clinical history?” Heather asked.

  I hesitated before I responded. “Yes, I would.”

  As I heard the logic of her question and my own short reply, I knew she was talking about me. And like the experience of finally admitting to my stroke and its consequences, admitting to PTSD and its sequelae gave me a sense of freedom and power to confront the whole truth of my injuries.

  Heather wanted to introduce me to therapeutic writing, not just journaling but writing a short piece about an incident that was recurrent in my thoughts or dreams. In the previous session I had thought I might be done with the whole describe-your-worst-scenarios approach. That part of therapy elicited gut-wrenching emotions and horrific memories. The “fun meter,” as I used to joke, stayed on zero for those sessions. I needed a break.

  “Can we do that next week?” I asked.

  Despite her lack of military experience, Heather displayed a mission-minded persistence that reminded me of a range sergeant: we were going to stick to the task until it was completed.

  “Yes, we can, but I want to get you started on some short reading from trauma patients so you get the sense of how this might be helpful.”

  “Okay, but I’m tired of bringing up these memories. No offense, but I feel like shit after some of our sessions.”

  I thought she would be offended, but she wasn’t. She remained professional and unfazed, like she had heard it before.

  “That’s natural. You’re processing the most difficult of human emotions and it’s not easy. If you can, tell me just in a few words what you might write about.”

  “If I had to pick one out of many, I would write about a postmortem identification of a soldier who was a colleague and friend. I had to identify him after a helicopter crash. I remember it all the time.”

  “That’s all we need for now. Just an idea, no more. And if you feel like writing about it, just write details as they come to mind. Don’t try to make sense of them; just write down anything that comes to mind, like a free-writing exercise.”

  I took the writing samples and over the next few days ignored them. Then, two days before my next session, I read them. Mostly they felt strained, as if the writers were trying to make a point but were at odds with writing short essays. There were four short articles. One described how a soldier had shot a dog in Iraq and how that affected the writer because the dog probably belonged to some Iraqi kid. The dog story made the most sense to me—not because I liked dogs, but because the writer connected how an incident of combat that had no bearing on war had a bearing on humanity.

  When Heather encouraged me to write about the helicopter crash, it was October 2008. Four years had passed since I performed the postmortem identification on Lieutenant Michaels and his copilot. I expected the time was enough to distance me from the traumatic context. It was not. Writing about the incident triggered vivid and horrific memories, including the smells and even the prickly skin sensations I had experienced. The writing exercises dragged on for a month and, in my own clinical judgment, did not help.

  Initially, I wrote at a table in a coffee shop. One paragraph or even one sentence took hours to write, each word stirring the deep emotions of that singular incident of war. Unavoidably, the hardest details brought me to weep, not for myself but for the soldiers I had cared for. I felt lost. Often, my struggle became so intense I left the restaurant and drove home where I sat alone in the basement trying to gain some distance from the memories. Sitting in the basement only made writing more difficult, as if the isolation concentrated my focus too much. For weeks, I repeated the same writing process.

  Heather thought if I could frame the crash in a different context, one that did not inevitably collapse into an emotional impasse, I might make some progress. I didn’t know how to do that so I tried approaching the writing as a clinician doing a medical investigation. Rather than forcing myself to expose hidden feelings and emotions attached to the crash, I simply described what I saw, writing only the objective findings of fact relevant to the postmortem identification. It was the same technique I had used in Iraq: focus on the objective nature of the findings; keep an emotional distance if you can. With that perspective, I found a paradoxical sense of freedom—in a sense, permission to explore the periphery of trauma. As I explored the edges, I was able to separate the facts of the incident from the emotion of the incident, creating a dual perspective where I finally understood that writing about a traumatic event was not equivalent to the event itself. That truth may have been self-evident to therapists, but to me, at my stage of healing, the distinction between what was real in combat and what was remembered at home became obscured by the diffusion of one reality into the other. Keeping them separate was not easy.

  That initial small understanding about the dual nature of trauma, real versus remembered, allowed me just enough space to compartmentalize my traumatic memories into specific blocks of time where they had limited emotional momentum. During that time I wrote objective notes to myself. The process was often difficult. On many days I could not write. On some days I wrote one line in five or ten minutes, then I stopped and sat and relived the details, often writing nothing for hours. I used to get angry and cuss at myself for not being able to write and think objectively. On occasion I would break out in spontaneous tears when writing at a coffee shop, and I would pretend I had something in my eyes and rub them red, then leave in a hurry.

  One morning, more than four years after my stroke, I could not bring myself to write. Like a soldier, I gave myself an order: “Cut the crap and start writing!”

  I wrote one line, then one more, and that forced beginning opened a torrent of free writing that continued almost four hours. It included descriptions, emotions, and rants. It was messy, horrific, and shitty. It was raw. It was primal. Most of all, it was real. I wrote about the postmortem exam in all its horrifying detail. I described the mutilated pieces, the ravaged bones, and the smoked smell of charred muscle. I noted every torn and missing organ. I revealed my weakness, my sorrow, my fear—all the things that I could never write in a standard Army report or tell another soldier or my wife. I showed how I was confused and at the same time embarrassed, because as a physician I could not identify what I had seen in a body bag. I wrote how I struggled to say the word “decapitation.” I let myself describe how worn and tired I had become, and how as a soldier-doctor I hated war yet loved war. Then I outlined how those incongruities tore at my spirit. At the end of my writing session, I wrote about the sound of the body bag zipper, how it distorted reality within the context of war. “In its simplest form,” I wrote, “a zipper is but a pull-tab, a slider, and two rows of teeth. Yet in the context of war, it symbolizes the constant and horrible reality of death.” In that context, the image and sound of a zipper helped me understand the struggle of having to bear the necessary imperative of combat—to kill and destroy. That was my greatest struggle as a soldier and doctor, blending the ethics of one into the ethics of the other. And that was a strained and binary ethic, one that touched the borders of love and hate, evil and good; it pitted the military dogma of killing the enemy against the religious dogma of loving the enemy. It juxtaposed death and dismemberment with rescue and healing and asked how they fit together. It questioned what it meant to be a soldier and a citizen, a father and a husband, a doctor and a patient. Mostly, it pressed against the compressed and easy answers that soldiers often give: “It was my duty or my job.” Being a doctor and a soldier was always more than a job or a duty; it was life and death played out within the wa
lls of a hospital tent and within the depths of human hearts.

  After my writing about the crash and the sound of a zipper, I showed it to Heather in a therapy session. I mostly read it to her and we paused to reflect on certain key points. She was quiet and respectful, as if perhaps she were attending a funeral or a wake. Sitting forward on her chair, she gently asked me to slow down in a few places where it was painful for me to read and where I could see her tears mounting, and in those places we both wept for all the things we had lost in war. And I didn’t care anymore that she wasn’t a soldier or hadn’t gone to war. We had both felt the force of its aftermath. I went back for a few more sessions with her, and then over a month or so I let them fade until I went no more. I wasn’t displeased with her or with therapy, but she had taken me far enough in healing. The work I still had left to do I felt I could do by continuing to think and write and ask for help if I needed it.

  —

  I worked with Gina in cognitive therapy weekly and we made gains that finally showed on my chart. Measured gains. Real gains. I was faster in some forms of puzzles and exercises. I understood more words and more complexities. She custom-designed exercises using clinical vignettes and medical vocabulary. I advanced to “master list maker” and focused on sequencing and prioritizing multiple daily activities. I remembered to take my medication on schedule at least 70 percent of the time and learned to plan ahead for things that could interfere with my schedule and activities. We talked about my future. What did I want to do? What skills were transferable? Could I teach anatomy at the medical school? Teach something—anything? I was a model patient and Gina was a model speech and language therapist. Anything was possible.

  At times, when needed, she brought me back to reality. She reminded me to maintain focus and intentionality when controlling my activities and my environment. I still needed therapy, but overall I had made so much progress that I felt like a list-making, stroke-recovering, cane-toting genius who had finally broken the therapy mold and uniquely declared, “I get it. I finally get it.”

  What I felt I was beginning to “get” was an understanding of all the changes, physical, mental, and vocational, that stroke brought into my life. But more, I was gaining an understanding that recovery involved more than a series of rehab sessions, it involved, no demanded, a change of mind and will.

  —

  With that understanding in mind, Gina and I worked toward a new therapeutic paradigm. We targeted cognitive strategies that challenged the notion of relatively fixed clinical plateaus that patients reached over time but rarely went beyond. The idea was nebulous at first, a flight of imagination, a look beyond the horizon, but it was there. We were talking about it, thinking about it, planning it. I still needed the routines of brain exercises and all the sequencing and calculations and readings that I had been doing. But if I chose, therapy would diverge from basic functional exercises toward higher-order brain functioning and problem solving that required more than brain exercises. The essence of this metacognitive approach meant that I would have to think about thinking and structure my own questions when trying to solve a real-life problem. I couldn’t simply ask for another round of therapy. The approach held the promise of increased independence and functionality, especially with complex and multidimensional tasks. Writing was a prime example. At the time, I had difficulty structuring a sentence. How would I solve the puzzle of writing a short essay or managing the structure of a book? I didn’t know, but if we were successful in our new therapy, I could figure it out or find resources to help me.

  Iowa City, Iowa; Summer 2009

  Toothpaste, toilet paper, hamburger, ketchup, buns. Five items made a Saturday morning grocery list. Collin rehearsed the items with me, face-to-face, asking me to repeat the list. It was the only way she knew if I understood her. When she asked if I understood, I always nodded my head. On the way out the door, I double-checked my wallet for money, stuffed the list in my left pocket, and headed to the grocery store. Got it. Simple. Drive directly to the store, buy the items on the list, return home. Thirty minutes max. En route, I stopped at a coffee shop to relax a bit. I bumped into a friend and we bantered about the everyday stuff that coffee shops elicit: our families, current events, politics, and the recent trend in the price of gas. Two hours passed. As I finished my coffee time, I remembered that I needed to make a grocery store run.

  At the store, I wandered the aisles and gazed at the shelves. I traveled every aisle, up and down, sometimes twice. I was looking for something, but I didn’t know exactly what. The meat and seafood section was especially appealing. I watched live Maine lobsters and silver-scaled tilapia swim in Plexiglas cold-water tanks. Their movements fascinated me. I finally decided on one pound of king crab legs and two half-pound T-bone steaks. The demo lady at the end of the aisle near the seafood displayed a special cranberry horseradish sauce that she promised went well with steaks. I gobbled a sample on a cracker. “Wow, that’s really good,” I said. She smiled. I couldn’t imagine we didn’t have this at home. I added two jars to the cart.

  In the bakery, the yeasty smell of fresh bread overwhelmed me. I gently laid two French loaves in the child seat of the cart, up high and out of danger from being crushed. I added four éclairs just for effect. As I thought about dessert, I sensed the need to get some other items, but I couldn’t remember what they were. Whatever information was conveyed in the “nonexistent” grocery discussion with Collin had vanished, so of course I wasn’t concerned that I didn’t remember it. I only knew I was in a grocery store. I knew how I got there and that I needed to buy food. The list in my pocket did not even register in my mind. I had no agenda, no plan, no list—just this compulsion: buy food.

  Following that general notion, I roamed the store. Pickles. I needed pickles. Barbecue sauce would be good. And cake mix. I added three milk chocolate, three French vanilla, and three lemon—all on sale. I savored the thought of Collin being so happy with me because I looked for discounts. Bright orange placards announced a temporary price reduction on cake frosting. I added six cans of various flavors, then rushed over to the dairy department and threw in three blocks of cream cheese because I always used cream cheese in my frosting recipe. Near the cream cheese aisle was the yogurt aisle. I couldn’t recall seeing so many interesting combinations of fruit and yogurt. Ten cups for eight dollars. A steal. I arranged them artfully next to the French bread. The bread reminded me that a nice cabernet would go well with the T-bones. Off to the wine section I rolled my cart.

  I spent a full half hour gawking at the artistry of the wine labels. I finally decided on an Argentinean blend with a nice colorful label. The wine reminded me that aged cheese would be good. I headed to the cheese display. Same treatment as with the wine. I spent thirty-some minutes eyeing the cheeses. In the cart went Camembert, a wedge of Canadian Black Diamond cheddar, and a new cranberry goat cheese spread. Cheese needed crackers. I added two boxes of gourmet crackers.

  I continued my shopping spree until my cart was about half-full. I sensed that I didn’t need all that I had decided to get, but I really didn’t know what, if anything, I was supposed to get. So I added just a few more small items: jelly beans, tangerines (my wife liked them because they peel so easily), a few candy bars, and a quart of Ben & Jerry’s ice cream.

  At the checkout counter, the cashier asked if I had found everything okay. “Yep,” I said. “Gonna have surf and turf tonight.”

  “How fun,” she said. “It looks like you’re planning a party.”

  “Just the two of us,” I responded. She smiled. The tally went well over $100. I swiped my credit card and the bagger loaded the cart. Off to the parking lot I went with seven plastic bags for dinner.

  I got home about noon. Collin was making lunch. I was so excited as I brought the groceries in and plunked them on the kitchen counter.

  “I got you some jelly beans,” I announced with a smile.

  “Oh, no…” she began. “What’s all this? What happened to the list?”


  “What list?” I asked.

  She moaned and shook her head, then reminded me of our grocery conversation earlier that day, of the list she made, of the folded slip of paper in my pocket. I told her that I didn’t remember any list. She asked if I checked my pockets.

  “Five things, that’s all you had to get.”

  She was a bit upset with me. I pulled the list from my pocket.

  “Oops,” I said. I felt badly, but had no remorse. I was not sorry for things I could not yet control.

  —

  Following my instructions from cognitive therapy, I made lists for everything: medication, medical appointments, errands, writing, reading, free time, and family time. I made lists for cooking and cleaning, for yard work and housework. Banking and taxes were on a list. Handling money was tricky without a list. Sometimes I lost checks for deposit because they were not on a list. I decorated the house with Post-it notes. Take meds. Feed cat. Gas car. Stay home. VA appointment. Read book. I left the cat out on the screened porch one day in the middle of winter. I didn’t write a note to let him back in or set a timer to remind me. I left for a coffee shop and stayed for three hours. Collin returned home for lunch and found the cat—still alive. I caught hell from my wife…and the cat. If something needed to be done and was not on a list, it usually didn’t get done at all.