May 29, 2013

Did Not Finish: Accepting Failures is Key to Growth (Volume 1)

"Time Jumpmaster! You are a sequence violator. You placed your fingers inside the rim of the ballistic helmet during the rear head tilt on the first and second jumper...." Those were the words that brought my failure of the fifth parachute inspection during my first iteration of Jumpmaster school. I had recycled both Darby and Rudder phases of Ranger school, but this was the first course I ever failed. I lost it for a second, I let down my platoon, my unit, myself and I thought I would never get another opportunity. My senior parachutist wings and hard earned Jumpmaster armband tell a different story, but for a few hours I thought I lost the opportunity of a lifetime.
Jumpmaster Armband

A few hours later I walked into my company commander's office with my head held low. "Sir, I failed on a sequence violation. It was a petty gig, but I should have done it right and there is no excuse." My commander Captain (now Major), Joe Blanton was outstanding. "Well Lieutenant Miller, you're in good company." He began listing company commanders in my battalion who failed Jumpmaster school on their first and sometimes second attempt. The First Sergeant gave me a lecture on how my platoon was going to be without a Lieutenant for another three weeks and that I better not waste six weeks at Jumpmaster school because officers needed to pull their weight on airborne operations. I have often forgot about this major failure between my first and second deployment, in regards to how I judge mistakes that I make at home.

I came back to Jumpmaster school the next Monday, and the instructor who failed me walked up to me and asked me "are going to try an cheat this time?" Another Lieutenant told me couple of tricks to make parachute deficiencies stand out. I owned up to my mistake. He responded "well hopefully you learned your lesson and you have already paid the price. Trust the training we are giving you, don't cut corners and you will get through. Your instructor should have warned you, but don't do it again or I will make sure you fail." Two and a half weeks later I passed with the same instructor. He saw me take the lesson to heart and use my extra training to help the other people in my squad pass. He was excited because he helped me become a strong Jumpmaster, but, more importantly, I gained a life lesson about failure. Don't forget failures own them, learn from them, and don't waste your mistakes.

When we try to moralize success we also unwittingly demonize failures. We forget that we all fail and accepting our failures regardless of the causes is the first step towards growth. PTSD and mTBI can be a valid reason for any of us to fail to meet our own goals. We tend to also equate all of our failures as life or death when they are not. Even if we have made mistakes that cost lives, that was not always because of moral failings, but because we are human beings who make mistakes. I know that if I lost a soldier for every mistake I made in combat, then I would have lost legions of soldiers. This process of moralizing or systematically preventing mistakes helped us cope in combat not by actually eliminating failure, rather it was a way to assure ourselves that we did everything we could have after a traumatic event. We all drop balls, but you know when you have given your all and when you have not. It would be burdensome task to catalog every minor error in your life, rather than ones that taught you the most. When we demonize our failures, we reject their potential utility to make us better people. Worse, when we moralize success and failure we become defensive about our most obvious flaws.

Instead of tossing the shirt I wrote DNF and traded the 5 for a 4
This last year I experienced a few failures, and I am trying really hard to learn the right lesson. PTSD is often difficult because of the vast comorbidity of other mental illnesses and physiological responses, associated with it. One of the most frustrating aspects is figuring out what setbacks are just natural and which ones stem from PTSD. I run marathons and ultras in order to manage anger, stay my kind of fit, and to manage the high amounts of weight gain that comes with the anti-depressants I take. On two races I DID NOT FINISH (DNF) and in another race I finished at thirty miles rather than my goal of one hundred. It is important to note that on two DNFs that I inevitably did the right thing. I made the right long term decision at the cost of short term disappointment. I tend to try and Ranger through things. You can't pass Ranger school without driving on with an injury: you often cause more harm to yourself than good. It has been a real struggle to figure out when I am going too hard, and my tendency to be a stubbornly stoic Army Ranger goes too far. I am still failing at this, but I have been moving forward.

"Mr. Miller I am pretty sure you're going to be on a ventilator before night is over. You have the highest toxicity that we have ever seen and we have another patient in renal failure with much lower stats.” To be continued....

This will be the first post in a series on my relearning to embrace failures in relationship to the guilt of survival that comes with PTSD, obviously I have survived last year's ordeal.

May 21, 2013

Preparing for Therapy


So you are ready for therapy but don't know what to expect. What's the difference between all the mental health professionals? A psychologist has a PhD, they use a variety of therapies but do not prescribe medications. They usually run programs, in rank they compare to captains. A psychiatrist is a medical doctor who specializes in mental health, they use a variety of therapies and prescribe medication. They often run departments, they would be considered a colonel or appropriate rank. Therapists would be the high-ranking Non-commissioned officers the military could not run without. They are usually clinical social workers with a master's degree and often have specialties. My therapist is a nurse-practitioner. You may need a Marriage and Family Therapists for help with your partner and relationship. But, more than likely if you are reading this you will need a therapist who practices evidence-based therapies to treat posttraumatic stress disorder, military sexual trauma and traumatic brain injury. In therapy you will need an empathetic hand to guide you through the wreckage of your mind.

Empathy is the ability to identify, internalize and experience another's emotional state. It's imperative to find a therapist you can connect with. The nature and structure of trauma leaves internal conflicts; the kernel of trauma-based disorders rest in the most recessed parts of our minds. The most important aspect of therapy will be an empathetic connection with your therapist, a therapeutic window between the therapist and the patient to reach the deepest compartments. To access this information safely, we must bond with our treatment provider. To begin the journey of recovery we must find a therapeutic window into our minds substrate. Without developing a rapport with your therapist, therapy will not work. Read that again.

Become an advocate for yourself and learn some basic information on how the Veteran's Administration works. You can fire any doctor or therapist in the VA by going to the counter and asking for a Change of Provider form. Write the reason you don't want this provider and you don't trust them. Generally it will take up to 3 months to get a new appointment so make sure you want to change. Go to at least 3 or 4 visits before you decide to fire your mental health practitioner. I fired a therapists because she talked about her issues and was more depressed me. I fired a psychiatrist due to her inability to discuss my medications with me or her unwillingness to listen to what I had to say. I've changed therapists because they were not certified in Cognitive Processing Therapy (CPT).

There are many kinds of therapy and the one you will probably engage in the most is psychotherapy or talk therapy. Talk therapy consists of sharing about psychological distresses, social, life in general and family issues. The therapist listens, gives feedback and psychoeducation on your condition along with teaching coping skills to manage symptoms. Talk therapy focuses on maintaining equilibrium and balance in life. The most effective treatments for the mentally wounded with the diagnosis of PTSD, MST and TBI is evidence-based therapies. The front-line treatments are Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT) and Exposure Therapy (ET). Ask your mental health provider if they use these therapies and if they have certification.

We'll cover two, since they are the most used. CBT examines the relationships between thoughts, feelings and behavior. By identifying beliefs that lead to self-destructive behaviors the therapist can offer coping strategies to help change thinking patterns over time. The therapies will be problem-focused and goal-directed for symptom reduction. Expect to have homework and if you want to heal actively participate.

Cognitive Processing Therapy, an exposure therapy, focuses on accessing trauma memories, identifying and challenging faulty beliefs about the event and resulting over-generalized beliefs in self. According to Cognitive Theory, trauma impacts our belief structures and how we categorize the world. That two types of emotions follow trauma, natural and manufactured. Natural emotions are universal such as fear, anger, joy, happiness, sadness and loss. They have a natural course to run unless we feed into them, then they can become stuck points. Manufactured feelings result from the way we interpret events and not fact based. I know a combat medic with four tours and many medals, the purple heart included. She was unable to return to active duty because of extensive damage received from an Improvised Explosive Device. She's fighting the belief that she let soldiers down because she couldn't return to her Mobile Army Surgical Hospital and deploy outside the wire under fire where she belonged.

Cognitive Processing Therapy starts with psychoeducation about your condition and symptoms, then therapy goals and identification of stuck points, and then 12 sessions centered around challenging beliefs and meaning of the event. The structured sessions center around identifying thoughts, feelings and stuck points associated with the event. They challenge problematic thinking and address safety, trust, power and control, esteem, intimacy and meaning. This is an exposure therapy, a writing component starts with an impact statement and then writing about the trauma again from each perspective safety, trust, power and control, esteem, intimacy and meaning. The therapist and patient will examine the writing together with worksheets and writing exercises. I've used this therapy and it's the best one so far.

Keep a therapy journal. Write a list of questions and reminders to keep track of what to talk about. Write about your insights and revelations. Write about your feelings, thoughts and trauma. In doing so you begin to take back your mental health one session at a time. A journal will keep you from forgetting the issues you want to discuss and a place to share your inner self. Trauma telling is an important aspect of healing, it enables us to re-contextualize our experiences and find meaning where we once thought was none.