From War to Residency: One Soldier’s Journey
Journal of Psychiatry Reform Vol 11 #9, July 2022
James Jung, MD, psychiatrist, Mindful Health Solutions, Elk Grove, California, USA
As I come to the end of my psychiatry residency, I find myself looking back to process a myriad of experiences from the past four years and noticing myself particularly drawn to my experience of transition from Combat Veteran to Psychiatrist. When I applied to psychiatric residencies, I was both interested in the field and had a belief about how my experiences during war and in the Army could help me understand patients more deeply. Only now, looking back, can I appreciate that this belief was much more of an intellectual understanding or desire; I did not appreciate the process I would have to undergo for this to be emotionally understood by me and how my own integration was needed to bring my experience into the room with patients in a healthy way. The reality and subsequent transition from the Army and combat to the world of academics and health care caught me by surprise and felt very discordant, like trying to mix oil and water. The truth was I didn’t know how to do this. I did not know people who had also gone through such a transition. My friends from the Army were also trying to make a transition in their own way, and while we could support each other, none of us had a guide to help us move forward in any clear, healthy way. I could not have predicted that guidance, support, and essential understanding of the meaning of this journey and my experiences came from a very unexpected place and from the people I met there, surfing in the cold Pacific Ocean at Pacifica State Beach.
When I returned from Iraq, I remember hearing the term “re-integration” frequently in PowerPoint presentations and from various veteran organizations, but this word didn’t translate into any specific actions to “re-integrate.” I thought that most of us would have to put what happened to us away somewhere outside of our conscious day-to-day life to be back with our families in any normal way and maybe, if we were lucky, deal with it later. My experiences in combat included deaths and serious incapacitating injuries of soldiers I was close to and felt responsible for, my own near-death experiences and guilt about surviving these, and the deaths and suffering of those who did not ask for war to come to them. I learned about my capacity to kill, and the ongoing toll war took when my best friend committed suicide after struggling with overwhelming survivor’s guilt. I was trying to move forward in a new academic world where “anti-war” sentiment was overt and appropriate but also made me feel even more isolated. These experiences were what I was tasked with holding and trying to “re-integrate” without an idea or meaningful guidance on how to go about this process. I have since come to believe that true successful “re-integration” requires some component of a society that can hold the complexities of war collectively to help relieve the individual of some of this burden. When I returned from overseas and went back to school, the intense polarization of the United States that we see even more clearly today had started. Our society was struggling and barely capable of understanding the complexities of our neighbors across the street, so containing something as complicated as the experience of war existed only in fantasy. Without the resource of community support in this specific sense, the process of “re-integration” became primarily individual and left me with the job of either finding a way through the confusion or being stuck between two worlds, in neither of which I felt I entirely belonged . Suffering can lead to destruction but can also lead to new growth and creativity. The late Zen Master Thich Nhat Hanh beautifully teaches and describes how one can embrace suffering in his book appropriately titled, “No Mud, No Lotus: The Art of Transforming Suffering,” which was especially important for me during this period. It was with this mindset that I first stepped into the ocean, not knowing how important surfing would be and where it would lead me during residency.
Surfing and ocean/water-based metaphors naturally found their way into many therapeutic modalities and mindfulness-based activities. Jon Kabat-Zinn said, “You can’t stop the waves, but you can learn to surf,” to describe the process of teaching mindfulness. DBT often describes the impermanent nature and flow of emotions as “riding a wave.” The intensity of emotions is often visualized as calm, smooth waves or water and other times with crashing, angry, powerful waves. Humans seem to have a natural pull to the water, and even if you have not surfed yourself, the metaphors do not necessarily lose their meaning (although if you have surfed, they may become even more meaningful). In the paper “A Paradigm for Landscape Aesthetics,” exploring the effect of aesthetics on behavior, Steven Bourassa, Ph.D. presents evidence from studies that showed that while most optic nerve fibers connect to our visual cortex, there are some that connect directly to our limbic system, a more primitive part of our brain guiding our behaviors based on emotional states [1, 2]. He suggests that this could explain a process of response to environmental aesthetics that is instinctual and potentially independent from the rational part of our brain . This may help to explain why, when having a difficult time or exhausted, we are willing to pay thousands of dollars to lie on the beach and do absolutely nothing or why someone might wake up at 4:30 AM to squeeze into a wetsuit before the sun comes up and jump into 60-degree water just to catch a wave. My mentor, Dr. Straznickas, an attending psychiatrist based out of the VA in San Francisco, simplifies this by describing surfing as “limbic grooming.” As humans, it seems to matter that we expose ourselves to specific areas of nature for our health, which has been identified in many studies looking at the important effects of this on aspects of our mental health [4, 5].
Beyond catching waves, systems theory helped me understand why surfing and doing it with others was so important in learning to integrate difficult parts of myself and may benefit individuals who have experienced trauma, moral injury, and the isolation that often follows. Systems theory at its core, is a process of finding similarities in what we think is different and finding differences in what we think might be similar. This process helped me to grow, to find more complex and open ways of thinking, and inevitably to find more ways to see myself and all the amazing complexities that exist in me and others. Despite the research on the positive effects of being in and around nature and water , surfing is not always a purely positive experience. Sometimes you think there are going to be good waves, and you spend the entire time getting “rolled” by large angry feeling waves wondering if you might drown. Sometimes you go out and must deal with rude and aggressive surfers who seem to feel they own the waves and resent the presence of others. Other times you might be hoping that the ocean will take away your problems only to realize that this is not the case or find that the same polarization and political differences exist in Veterans just as they do in everyone else. To add to this process, the ocean offers both beautiful, awe-inspiring moments as well as terrifying moments demonstrating its capacity to kill you, capacities not so different from ourselves. The Veteran’s Surf Alliance (the group I am connected to) and other programs like it offer an important opportunity for Veterans struggling to reconnect to a world they have felt isolated and different from, to see complexities more clearly in ourselves and others. This space allowed me to look at and work to accept the parts that come with being human, the positive parts and the shameful, angry, and scared parts that all make me who I am. All these separate parts also inform who I am as a psychiatrist and how important it is to be able to sit with patients and welcome all that makes them, into the room.
The human impulse to look away from the disturbing parts of ourselves is natural, strong, and can be very painful to overcome. Taking this on can cause confusion, steps backward, and beliefs that we are failing or not strong enough to persist. But if we can learn to look at these aspects and bring something that has been relegated to the darkness and shadows into the light, it can be where hope, healing, and acceptance of ourselves can be found. I believe that we can find a way back to embrace the complexity of others and ourselves. For some that might start with learning to catch a wave and finding good people to surf with. Of course, it certainly helps that I find surfing unbelievably fun and awe-inspiring even when it is difficult. It also is important to give specific credit to finding a community that is willing to take on the complexities that our current society has a hard time accepting, and it does not hurt to be lucky to have someone like “Doc” or “Straz” (which is what Dr. Straznickas prefers to be called), sending you text messages like, “Looks a bit raw out there @Windy Lindy…but who’s up for looking @7 AM and seeing if its surfable- Hot drinks are wind resistant (Shaka emoji)”, or his recent text of a sticker he has on his truck from the sitcom “Seinfeld” after a particularly brutal morning that says, “The sea was angry that day my friends.” Surfing is not for everyone, and I want to explicitly state that there are numerous effective activities that can help support the process of integration I have described. It is just as important to find activities that others may find easier to connect with based on their individual interests and access. Surfing has been this activity for me and helped me see and accept myself as a Combat Veteran, Psychiatrist, and Surfer all wrapped into one. As a result of my own integration, I have come to believe that maybe we should be using the word “integrate” rather than “re-integrate” when describing what returning from war or recovering from other forms of trauma really entails. There is a lot to learn outside of the DSM, and I hope that I and the field of psychiatry continue to explore what can reduce people’s suffering and bring more meaning to help others find a more fulfilling life, whatever this may look like to them.
1. Maclean, P. D. (1973b). Man’s limbic brain and the psychoses. In T. J. Boag & D. Campbell (Eds.), A triune concept of brain and behaviour (pp. 23-41). Toronto: University of Toronto Press.
2. Weiskrantz, L. (1986). Blindsight: A case study and implications. Oxford: Oxford University Press.
3. Bourassa SC. A Paradigm for Landscape Aesthetics. Environment and Behavior. 1990;22(6):787-812. doi:10.1177/0013916590226004
4. Jo H, Song C, Miyazaki Y. Physiological benefits of viewing nature: a systematic review of indoor experiments. International Journal of Environmental Research and Public Health. 2019;16(23):4739.
5. Ulrich, R. S. et al. Stress recovery during exposure to natural and urban environments. J. Environ. Psychol. 11, 201–230. https://doi.org/10.1016/s0272-4944(05)80184-7 (1991).
6. Bratman, G.N., Hamilton, J.P. and Daily, G.C. (2012), The impacts of nature experience on human cognitive function and mental health. Annals of the New York Academy of Sciences, 1249: 118-136. https://doi.org/10.1111/j.1749-6632.2011.06400.x