Thank You for Your Service

I recently watched the movie Thank You for Your Service, where many themes related directly or indirectly to the care of sleep disorders in military personnel (active duty or veterans) as well as relating to overall treatment issues in PTSD cases and traumatic brain injury (TBI). I use the term “direct” because the three main characters were shown in the course of the film to suffer from sleep disorders, notably insomnia and nightmares; but these issues were not a main theme regarding treatment for these soldiers. I use the term “indirect” because as you will read below the major emphasis in the movie was on the problem of avoidance behavior—the signature behavioral pattern that manifests in virtually anyone attempting to confront mental health problems. Avoidance behavior also is commonly observed in patients attempting new therapies, be it exposure therapy for PTSD or PAP therapy for OSA.

To be clear, I am not attempting to write a review of the motion picture; I have no such expertise, but I will state briefly the movie follows three characters recently returned from combat in the Middle East who are going through various transitions, primarily exiting active duty to attain veteran status. The early and recurring themes in the movie are the inadequate treatment these soldiers received through VA medical centers (VAMC). Keep in mind the story is based on or inspired by true events. Several scenes highlight the long waits, disorganized healthcare systems, over reliance on medications, and the failure to recognize urgent suicidal risks. Of course from our perspective, lack of any attention to sleep disorders was blatantly obvious. More importantly, though not directly stated, one could easily have gotten the impression VAMCs don’t really know how to treat PTSD patients in general, or to be kinder, they simply don’t possess the proper resources to effectively treat PTSD or treat it in a timely manner.

Back to sleep disorders for a moment. Since I suffer from the “to a hammer everything is a nail” syndrome in seeing sleep apnea in every aspect of my work—even life outside of work, I noted two of three actors portraying soldiers showed OSA/UARS facial features. If you check out the cast at this link, you will see how characters Adam Schumann and Billy Waller both have vertical-shaped faces, and the third character Tausolo Aieti possesses a recessed chin (although it’s easier to see this feature in the movie, not the picture at this link). These findings may be purely coincidental, but I would note in contrast that other characters in the movie (who are presumably not suffering from PTSD) do not exhibit these characteristics, that is, they show square facial structures as well as stronger jaws, both of which suggest lower risks for OSA/UARS. For me, it was ironic they selected three characters suffering from PTSD or TBI who did not resemble the classic stereotype of a “soldier-as-he-man” with a strong facial appearance (large head, prominent jaw). Rather, the characters looked very much like individuals treated in my own sleep center, who suffer from PTSD or TBI or both. By the way, that the characters suffered from both insomnia and nightmares also would have increased their risks for suffering from OSA/UARS, but sleep breathing symptoms or disorders were never discussed in the movie. We will return to this point later with a brief concluding comment.

The main takeaway from the movie, however, was not about sleep, but rather about the classic and perfectly portrayed construct of avoidance behavior and how it often fuels posttraumatic stress symptoms into a downward spiral, spinning out of control, and in some cases ending in the worst of all possible outcomes—suicide. 

In the movie, each of the three characters is introduced very early on as someone already hiding his symptoms from other people or hiding his problems from himself, and of course sometimes both behaviors occur. These forms reflect the most classic avoidance—the inability to identify a problem and discuss its ramifications with yourself or others. Watching all three of the characters deteriorate through most of the movie is quite painful to watch, but also perplexing and frustrating, because you keep wondering will they take the step to seek help. Sadly, such timelines don’t just make for good movie suspense; they actually are overwhelmingly common in real-life. Again, as in real-life, things turn worse when they do try to seek help, because there is not much if any immediate aid due to the above noted healthcare system snafus.

The reason the movie is so powerful, moving, and above all so relevant is the climactic moment in the movie, which I will attempt to describe in generalities without spoiling the actual plot. This moment is the breakthrough where the main character, Adam Schumann, receives advice in an unexpected way and circumstance, especially for movies, where he finds himself on the phone with an individual (a thousand miles away) who is a mental health worker. We never see the person attached to the voice on the other end of the line and we only hear him briefly. But in this short dialogue, he has the good sense to cut to the chase and somehow realizes Adam is obviously not confronting some missing piece of the puzzle from his past. 

Like many good movies and in real life, avoidance behavior often involves “keeping secrets.” Sometimes the secret is known by others, and sometimes it is known only by the individual. Secrets are the linchpin that keeps avoidance behavior intact. In psychological terms, we might say someone is well-defended or overly defensive in ways that prevent or otherwise block painful emotions and disturbing insights from surfacing. And, this approach to one’s mental health problems almost invariably leads to the worsening of the symptoms, because keeping the secret means letting the poison, so to speak, fester inside instead of releasing it from the mind and body. 

In the movie, it is obvious the main character, Adam, finally gets it and shortly thereafter elects to discuss the secret with the one person he has been avoiding throughout the story. And, again, like all great stories and just like in real life, we often discover that revealing the secret to the person most affected often triggers a response very different than the secret-teller (Adam) was expecting. And, this is one of the keys to overcoming avoidance behavior, because the holder of secrets is often afraid to reveal the information for innumerable reasons. What then makes it safe to in fact go forward and disclose the details?

The answer I would give at age 68 is that the older we get, the more aware we become of the frailties within each of us. Not only do we see flaws more clearly in all those around us, but we finally develop the ability to see our own flaws and recognize how this aspect of our humanity afflicts us all. In time, this leads to a greater understanding about the mistakes others make as well as the mistakes we make, all of which culminates in learning the ability to forgive others as well as to forgive ourselves.

As you can imagine from the movie plot and what you know about your own life experiences, you can’t get to forgiveness until you overcome the avoidance that has prevented you from facing the demons inside. And, these demons often arise from your perception of yourself as having done something horribly wrong, which sometimes is an accurate appraisal. When we do something wrong, we should feel shame, embarrassment or guilt, but not because we need to debase ourselves, but rather because we need to try to learn something from our mistakes. These three very negative feelings teach us or remind us of our errors. And, to permit yourself to experience these emotions, you must overcome the avoidance by letting your mistakes come to light either for your own awareness or in certain cases for others such as friends and family.

This process is not an end in itself. Rather, it is often the beginning of recovery. Overcome the avoidance, face the daunting truth no matter how painful, learn from your mistake and find a way to forgive yourself or to ask for forgiveness from others you have hurt.

We all know these steps are not an easy process. And, for many trauma survivors of many different types, these experiences may unfold over the course of years and decades, because the avoidance tendency is so strong and insurmountable depending upon our age and experiences in life, not to mention our personality styles or the way we learned as a child or adolescent to cope with adverse emotional experiences.

The movie demonstrated beautifully how the process of treating a trauma survivor is not simply or only about psychotherapy. Instead, if circumstances lead a person to confront the past and cease avoiding the painful aspects of the traumatic events, it is not just a therapeutic experience, but rather it is a spiritual awakening that shifts the person’s consciousness toward a recovery to become whole again.

The timing of the movie is also interesting because a major paper was just published in JAMA comparing the leading standard technique for PTSD know as exposure therapy to more minimally invasive psychotherapy that teaches patients to become more mindful about their day to day experiences. The surprising finding was that treatment results were not dramatically different. Yet, exposure could be described as a head-on attack at the avoidance problem compared to a mindfulness approach, which is more of a natural and unforced method of tapping into your emotional state. Regardless of which treatment method works best or is embraced most easily by trauma survivors, the ultimate therapeutic component in the vast proportion of patients is recognizing and overcoming avoidance behavior. And, this movie Thank You for Your Service showed that until you take this step, pain and misery are sure to follow. Whereas, through whatever healthy means you can overcome avoidance is very likely to make you whole again.

As intense as this discussion has been about trauma survivors, never underestimate the potential for avoidance behavior to manifest intensively in someone struggling to use PAP therapy. To be sure, using PAP is not equivalent to the life-threatening traumatic exposure experienced by combat veterans, but on the other hand, pressurized air and fixed pressure (CPAP) in particular is a traumatizing stimuli, because it can trigger the sensation of “drowning in air.” And, this particular feeling is what causes so many people to then choose to avoid using PAP altogether.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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