Discussion: Co-Occurring Physical and Psychological Injury-6212-9

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Working with Trauma and Prescription Drugs: The Case of Darby

Darby, a 24-year-old single white male and an enlisted military medic, self-

referred to individual psychotherapy for “anger management.” The picture of good

health and self-discipline, he denied any history of legal, mental, or physical problems

but reported that recently he’d been “snapping” at people at work and that nothing

seemed satisfying. Even little things that he would ordinarily shrug off as “no big deal”

seemed to push him toward rage. He had not become violent, but he had made

abrasive comments to peers and mildly insubordinate remarks to superiors. He tried to

blow off steam at the gym and take extra time to relax, but nothing seemed to help. He

reported back pain but dismissed its significance, because he said it would resolve

when he scaled back his lifting routine at the gym.

Darby was at the time also a part-time college student who had been dating his

girlfriend since high school. Darby said he grew up in a “good” family with parents who

divorced when he was young. He lived primarily with his mom, a nurse, and fondly

recalled spending time with her extended family, especially his grandfather. In the

summer and during long weekends, he visited his dad to do “guy” stuff; fishing and

hunting were favorite memories. Shortly after completing high school, Darby became a

paramedic and worked full time while simultaneously attending college, but the long

work hours and expenses of college quickly became too much, so he joined the military

hoping to get more work experience and a source of funding to continue his education.

Having been born and raised in a small patriotic town, the military was an easy choice.

Darby deployed to Afghanistan during an especially combative time with many

casualties. He served at an understaffed outpost of a Forward Operating Base, where

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he had a great deal of responsibility caring for the wounded and dying on all sides of the

dispute. When he spoke of his time in Afghanistan, his face was transformed, as if he

were describing events that were currently unfolding. At his initial presentation for

psychotherapy, he had been back from the war nearly six months. The problem, as he

described it, was that upon return to his usual work routine (after a long vacation in his

hometown post deployment), everything was meaningless. To him, taking temperatures,

giving immunizations, and weighing patients before their appointments in the family

practice clinic seemed like a waste of time. Apparently people noticed and commented

on his increased irritability. “Of course, I’m irritable!” he said. “You’d be irritable too if

you went from making life-and-death decisions to working with people who have no idea

what goes on in the real world.” Darby denied all symptoms associated with post-

traumatic stress disorder (PTSD), saying that the blood and gore and personal

vulnerability in Afghanistan were not any worse than what he’d seen while responding to

traffic accidents as a civilian paramedic.

I conceptualized that Darby’s experiences in Afghanistan had made him question

his perspective of the world; I understood that his irritability and decreased satisfaction

were secondary to a dramatic crack or shift in his worldview. So, we set out to realign

Darby’s thoughts and behaviors in order to achieve the two treatment goals he

identified: decrease outbursts at work and identify and increase engagement in

personally meaningful pursuits. Compliant and enthusiastic, Darby always did his

homework. After about three months of weekly therapy, Darby telephoned to say, “I

haven’t been honest with you.”

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Darby confided that he had been minimizing his symptoms of emotional and

physical pain. He reported that he’d been writing himself prescriptions for pain

medication, pretending that one of the physicians in his office wrote it for him. He

reported being ashamed, and his physical presentation reflected that a significant

change had taken place. He no longer appeared confident and strong. Eyes downcast,

he slowly and quietly reported that his back had been bothering him since Afghanistan.

Unsure whether it was the weight of wearing the body armor, or the unnatural position

of constantly squatting and reaching over patient litters, or both, a doctor in Afghanistan

appropriately and legally prescribed pain medication for the pain.

When he returned home, Darby tried to obtain a refill, but he was told that he’d

have to come in for a full assessment first. The first available appointment was during

Darby’s long-anticipated father-son fishing trip. He tried to get by without the

medication, but he could not sleep, or sit, or function. He didn’t want to tell his father the

severity of the symptoms, so he did what was expedient and pride-protecting: He called

in the prescription himself using the DEA number of one of the physicians for whom

he’d called in patient prescriptions in the past. He expected it was a one-time

occurrence, and he saw no harm. The “doc” would give him the meds at that dose

anyway, and he knew the routine. But it wasn’t just once. In time, the lie became more

difficult to correct. He knew that if he admitted to what he’d done, he would not only lose

his job in the military, but likely also his ability to become a nurse practitioner—his long-

term goal. He did not know how to say that he needed medication when he went to his

health care provider, because according to his medical records he hadn’t used

medication since Afghanistan.

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Darby also minimized PTSD symptoms. He carried a great deal of guilt for not

having done more for his patients. I referred him to inpatient treatment specializing in

combat-related PTSD, and they weaned him off the illegally procured medication. He

returned far more depressed. Situational stressors mounted. He was a pariah at work.

His lawyer explained to him that he would likely be dishonorably discharged from the

military, meaning that he would not be allowed any VA (Veterans Administration)

benefits, including health care and education. He didn’t want to face family and friends

in his hometown. I was worried about suicide potential. Darby made some choices

throughout this process that eventually led to his dishonorable discharge from the

military. Although military treatment options were not available to Darby, he was given a

list of civilian treatment options to help with his addiction and his PTSD.