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It's natural for warriors not to want to talk about things that happened
in combat, because they don't want to think about it themselves and they
know that most people are not capable of comprehending what they went
through. Warriors sometimes feel like they re-experience combat events
when they talk about their experiences, including physical sensations like
heart pounding, nausea, or emotions that are overwhelming. As a result,
they avoid sharing their stories.

On the other hand, there's also a strong urge to tell one's story. Since
the beginning of history, narration (or storytelling) has been one of the
most important rituals after returning from war, and ancient war storiessuch as the story of Achilles-are still relevant today. The importance of
narrating one's story explains why there are thousands of books and articles written by U.S. warriors about their experiences in World War I, World
War II, Korea, Vietnam, Gulf War 1, Somalia, Panama, Bosnia, Kosovo, and
now OIF and OEF, as well as books by warriors from other nations recounting events from hundreds of other military campaigns. I believe that narration is essential for making a successful transition home. Telling your story
doesn't mean spilling your guts to just anyone, but finding a way that best
suits your style and level of comfort.

Why Narration Helps

Why does narration help? There are no clear answers to this question, but
there are a lot of things that are associated with narration that seem to be important; for instance, connecting emotions and feelings with events.
When warriors wall off their emotions, it can negatively affect other things
in their lives. An important component of narration is recognizing that
you're not alone in your experiences. Even if the person you're sharing
with has no experience with the military, they may have had other life
experiences that can help them to relate to yours. Wartime experiences
are some of the most profound that humans can endure. War evokes both
what is most terrible and most divine about being human. War brings out
the best and the worst in us. Sharing stories and feelings that are painful
is a very personal experience and can bring you close to the person you
share them with. Narration helps you to live with your experiences and
move forward with them as part of you.

Probably the most important thing that narration does is allow you to
express your emotions and feelings in words. One of the skills from the last
chapter is learning to monitor your emotions internally, acknowledge how
you feel, and when necessary, put space between your immediate feelings
and actions. The limitation of this skill is that it's very difficult to know
exactly how you feel unless you have someone to talk with. We need feedback from others. We need to struggle to come up with the right words to
express our feelings, and it's very difficult or impossible to do this alone.
In order to even acknowledge our deepest feelings, we need to know that
there is someone who cares and who's willing to listen without judgment
as we struggle to express ourselves. This is the power of narration, and the
reason why ministers, rabbis, and therapists will always be able to make a
living. There is something very healing in being able to put our experiences, thoughts, emotions, and feelings into words.

There are considerable data from the mental health community on
the importance of narrating your story. Various studies have shown that
the single most important component of therapy for PTSD and many
other mental health problems is having the opportunity to speak with
someone who is concerned, caring, and empathetic. Of all the different
treatments for PTSD that have been tested, the most consistently effective
involve narrating the story of the traumatic event(s) in some way so that
the story becomes part of who you are.

Narration in Therapy

In one of the most popular forms of treatment, called exposure therapy, the
therapist asks the client to recount the worst traumatic event(s) repeatedly until the level of reactivity, anxiety, or hurt surrounding the events
becomes bearable. By revisiting the memories of the trauma in the therapy
sessions, they become less intrusive, and nightmares, flashbacks, and other
symptoms subside. By telling the therapist the details of the traumatic
events, the memories become organized in a more coherent narrative way,
and this coincides with a decrease in distressing symptoms. An important
technique used in exposure therapy is called "imaginal" exposure, which
is a terrible name because talking about painful traumatic memories does
not in any way feel like it's "imagined." Nevertheless, mental health professionals have adopted the term imaginal exposure to describe a common
technique used to help the client talk about traumatic memories.

Classic imaginal exposure involves the client recounting the painful
traumatic event(s) in the present tense with eyes closed, as if the event(s)
is going on right now. For example, a warrior in therapy might say, "I'm
the gunner in the third vehicle of a convoy and we're headed back to our
outpost. The vehicle in front of mine is hit with an IED on its left side.
We stop and dismount and start pulling security. Just after getting out, a
second IED goes off under my vehicle. I'm thrown against a wall and can't
see anything for a few seconds. I hear screams. Smoke is all around me ..."
Although this warrior is talking about an actual event that he experienced
months (or years) earlier, the therapist has asked him to recount it as if
it's going on now. The therapist provides support and positive feedback,
asks for clarification, and helps the warrior learn to cope with distressing
emotional and physiological reactions. The therapist then asks the warrior
to start over again and repeat the story. The warrior is asked to add in as
much detail as possible, including the sights, sounds, and smells of the
experience. This process is repeated over several sessions. Sometimes an
audio recording is made of these sessions, and the warrior is asked to listen
to the recording between sessions.

One may rightfully think that it's completely nuts to repeat combat
stories over and over, much less go home and listen to a recording of yourself doing this. Indeed, those who undergo exposure therapy often feel
very upset when they start treatment because the stories can be extremely
painful. They often feel a strong urge to leave treatment immediately and
never return, trying to avoid anything that reminds them of the trauma.
There may be tears, anger, and anxiety that occur while remembering the
experiences. However, studies show that the treatment reduces their symptoms and anxiety if they stay with the therapy long enough for it to be
effective. One issue is that most of the research on this has been done in
civilian populations, primarily with victims of assault and rape, and modifications to this treatment are probably needed for warriors.

When warriors start to tell their stories, it's common for them to describe
the most horrific and painful combat events in a completely matter-of-fact,
nonemotional, and neutral way. This is understandable, since shutting
down emotions is an important skill in combat, which the warrior may have
applied during the very events they describe. Once the story is explored in
more detail, the events become better connected to the emotions.

The first time the story is told, it's common for many details to be left
out; events might be presented like random photo images unconnected
in any logical sequence. For example, the warrior might say, "The IED
explodes. Smoke is all around me. All I hear is screams. I'm against a wall.
I'm pulling security ..." Feelings or reactions, and the fact that the story
may be disjointed when first told, are expected during the narrative process. The therapist's job is to establish the environment that facilitates the
warrior telling their story in a more linear way.

What happens after telling the same story in sufficient detail is that the
memories of the traumatic events gradually become more organized, and
the warrior finds that they can tell the story both with more emotion and
connection (if initially detached) and with more acceptance and less distress
in the form of guilt, self-blame, anxiety, or physical symptoms. This doesn't
mean that the events become any less painful, just that the warrior becomes
better able to tolerate and talk about them without reacting as strongly. Telling your story may feel to your body initially like being back in combat, but
over time it helps to make the events part of you, rather than keeping them
separate, buried, or avoided. When sessions are recorded and you listen to them (which, understandably, no one likes doing), this provides unique
feedback that helps take some of the sting out of very painful stories and
allows the stories to be better integrated into who you are.

It's not clear what components of talking about traumatic memories
or feelings in therapy are most helpful. Although therapists utilizing imaginal exposure therapy usually encourage warriors to tell their story in the
present tense with their eyes closed, as if it were going on right now, the
reality is that most of the time warriors share their stories in the past tense
with eyes open. How often a story needs to be told is unclear. Therapy
doesn't work if the client recounts the traumatic story only once or twice.
It's necessary to tell the story enough times to flesh out the details, express
emotions, and integrate it.

The Narrative Experience

Although narrating the story has been shown in research studies to help,
there is poor understanding of what it really means for narration to be
effective, or what elements of the interaction between a warrior and the
therapist listening to the story are most beneficial toward the goal of being
able to live with very painful experiences. Additionally, very few studies
have been conducted with warriors; most of the research on this type of
treatment has involved civilian patients who were victims of trauma, such
as assault, rape, motor vehicle accidents, or natural disasters. The premise
underlying this form of therapy might be incorrect.

The reason this therapy may work better than others is that it most
strongly emphasizes sharing your story. Therapists who do imaginal
exposure therapy believe that repeatedly telling the story leads to the
client's body and mind learning that there isn't a need to react to the
story like it's the actual traumatic event (a process termed habituation).
However, what's probably most important is the personal connection
with someone (in this case, the therapist) who's engaged, nonjudgmental, and sincerely cares about helping you work through your very painful personal experiences. The benefit might have nothing to do with
the number of times the story is repeated, but because recounting the
story to someone who is supportive leads to a willingness to explore the details. Through this process, the warrior develops a greater understanding of exactly what happened, and no longer has to hold on to the guilt,
self-blame, depression, anxiety, or rage surrounding the story. The story
also gets connected to things that happened before and after the event
and becomes part of the larger narrative of the warrior's life. The story
stops having a "life of its own" and starts being one of many important
stories over the course of the warrior's life.

Therapists need to have high situational awareness for how they come
across in this (or any) type of therapy. If they try to administer the therapy
as a "technique" in an overly neutral, impartial, or detached manner, or in
a way that seems to the warrior to minimize or trivialize their story (such
as making statements that reveal subtle assumptions or judgments), things
are not likely to go well. If a trusting and supportive relationship hasn't
been established, launching into imaginal exposure (or any other treatment for PTSD) could make things worse.

Most PTSD treatment has been tested in civilians, and there's no "off
the shelf" technique that's guaranteed to work for warriors. The therapist
needs to meet the warrior where they are, and do whatever is necessary to
ensure that the warrior feels understood and supported while telling their
story, and comfortable returning to continue their journey. Most important are empathy, compassion, and meeting the warrior where they are.
There will be more on the topic of navigating the unique insanity of the
mental health system in chapter 8.

In my experience, therapeutic benefit seems to come from a genuine
interest in exploring the details of what happened and clarifying points
of confusion in an empathetic way. For example, I remember a combat
medic I treated who described a horrific event when he lost a close friend
who was hit with a rocket-propelled grenade in Iraq. He attempted to keep
his friend alive but was unsuccessful, and carried intense guilt for years
after the incident. It wasn't until we probed deeper into the story that he
began to let go of some of his guilt. I discovered that when he initially told
the story, he left out the fact that he kept his friend alive all the way back to
the aid station and into the operating room. We probed the specific details
of why CPR would have been fruitless in this situation given how cata strophic the wound was and the amount of blood loss that had occurred.
Over several sessions numerous details emerged related to this incident.
For instance, the convoy commander made a command decision to send
the vehicles back through the "kill zone" at considerable risk, in an effort
to get the casualty back to definitive treatment as quickly as possible. The
medic had been blaming himself for failing to save his buddy when the
story clearly indicated that he had acted heroically as part of a team effort
to save this soldier. Telling the story was painful and difficult, but after
several sessions there was a sense of relief and a greater understanding
that he didn't need to blame himself anymore. Narrating the story did not
take away any of the grief related to losing his buddy, but it did bring this
soldier closer to his grief, which was helpful.