Alex Joyel as Elliot in New City Players’ production of *Water by the Spoonful*

For most of us, the Iraq war is and has always been distant enough from our day to day lives that it now feels, mostly, like a faint memory. But for Water By The Spoonful character Elliot, as well as for many of the real life soldiers who valiantly fought in that fraught, misguided war, the scars inflicted during their time in service remain a powerful influence on their lives.

In Elliot’s case, his travails are physically evident as he suffers from the after-effects of a leg wound severe enough that it required four surgeries. But while external wounds at least have the benefit of being visible, the less apparent but often equally crippling emotional impact that combat trauma can have on veterans can be far more misunderstood.

In a way, though, the psychological condition known as post traumatic stress disorder is also just as physical as more obvious injuries. This is because traumatic experiences don’t only make their mark by altering our conception of who we are and what we are capable of, though that is also a huge component of their impact. They can also literally rewire our brains, with the life-or-death stakes activating more primitive “fight-or-flight” areas that take over at the expense of the areas associated with our higher order thinking that typically reign during our day to day lives.

In a prequel to Water By The Spoonful that dives even more deeply into Elliot’s experiences during wartime, as well as those of his father and grandfather in the Vietnam and Korean wars, he tries to articulate the intensity of this kind of adrenaline override.

People say, oh shit, that must be scary. But when you’re there, you’re like, oh shit, and you react. When it’s happening you’re not thinking about it. You’re like, damn, this is really happening. That’s all you can think. You’re in shock basically. It’s a mentality. Kill or be killed. You put everything away and your mentality is war. - Elliot, A Soldier’s Fugue

Especially if a person is exposed to these traumatic experiences repeatedly, as many warriors are, the brain can then become hyper-alert to signs of danger, constantly scanning the environment for future threats. This can translate into symptoms like intense anxiety, increased sensory sensitivity, and flashbacks, moments in which the person is thrown back into “survival mode” when something reminds them of their traumatic experience, and these symptoms in turn put veterans at risk for poorer career and relationship outcomes, like divorce and unemployment, which can proceed to worsen mental health further.

As far as what this can actually look like, during my research, I came across stories of veterans whose PTSD was so severe that it interfered with their ability to drive, or to be comfortable around even people they’d known for years. Others found themselves having to avoid places they once enjoyed like clubs or theme parks because they could no longer stand to be around crowds, and one described having to calm himself down after mistaking a repairman on a roof for a sniper.

Though someone suffering from PTSD will often consciously avoid any reminders of their trauma for fear of re-experiencing the painful sensations associated with it, the brain also cannot help but dwell on what happened is it struggles to make sense of it, leading to an inability to “move on” from the event and, often, to obsession, insomnia, and nightmares. Nightmares that, in Elliot’s case, tend to revolve around the first civilian he killed in Iraq, who is also represented in Water By The Spoonful as a physical ghost who appears to him periodically.

Fawad Siddiqui as *Professor Aman/Ghost* in New City Players’ production of *Water by the Spoonful*

This metaphorical rendering movingly encapsulates the profoundly “haunting” effect that military trauma can have on soldiers struggling to adapt to civilian life. As many as half of veterans report “significant difficulty acclimating” and as many as a third go on to develop full-blown PTSD or related mental health issues like depression and anxiety, with as many as 20 percent of veterans experiencing PTSD at some time in their lives.

Further driving home the poignancy of Elliot’s experiences are their real life roots in those of his namesake: playwright Quiara Alegria Hudes’ cousin Elliot Ruiz.

“There were just more and more young people in the city showing up in uniform and especially in the Latino neighborhood, which is where Elliot was raised in North Philly. And I thought, it's not just Elliot's story. This is going to be the story of a generation,” she described in an interview.

In another, Ruiz himself described the ghost as “an issue that a lot of the guys deal with. We have to live every day with the things that we’ve done.”

The way that Elliot’s identity as a veteran intersects with Water By The Spoonful’s exploration of addiction is also incredibly true to life. As many as one in ten veterans are known to struggle with substance use disorders, and one in three of those who do also have PTSD.

In fact, as many as 50 percent of people with PTSD have a co-occuring substance use disorder, for reasons that are almost self-explanatory—the need to calm down a keyed-up nervous system and for escape from painful memories. As is the case with most mental health problems that frequently co-occur with addiction, substance abuse can temporarily relieve symptoms but tends to worsen them in the long run, hurting an individual’s chances of long-term recovery.

This vulnerability took a tragic turn when it intersected with the wider-spread opioid crisis and the exploitative marketing practices of the pharmaceutical companies that spurred it on, and with the fact that an alarmingly high proportion of veterans also suffer from chronic pain due to wartime injuries.

Along with paying off doctors to misrepresent the risks associated with opioids and funding the creation of advocacy groups that spread misinformation about their usage, evidence suggests that ringleader Purdue Pharma specifically targeted veterans by funding the Veteran Affairs (VA) pain management team itself, which, as one article put it, “essentially turned the VA into its propaganda arm.”

In another of their more egregious misdeeds, Purdue also hired veteran Derek McGinnis, who lost a limb overseas, to be a spokesperson for their ersatz campaign. They then paired him up with a medical writer to produce a book called Exit Wounds: a Survival Guide To Pain Management for Returning Veterans & Their Families, which contained gross misstatements about the risks of opiate drugs and baseless exaggerations about their benefits.

Unfortunately, these deceptions were successful ones; so, between 2002 and 2013, the number of opiate pills prescribed by VA physicians increased 259 percent. As one Water By The Spoonful character puts it, anytime “a soldier said they hurt, the docs practically threw pills at them”—rather than referring those whose wounds were more mental than physical to the appropriate form of psychological treatment.

Often, addiction was the predictable result, leading to chilling scenes like the one Elliot describes: “I seen barracks that looked like dope houses.”

For other veterans on the receiving end of those prescriptions, the home front turned out to be more dangerous than the battlefield as overdose rates skyrocketed in turn, rising 33 percent by 2011. Doctors also frequently ignored typical guidelines and prescribed opiate drugs at dangerously high doses or along with other medications that have sedating properties, as well as to patients who had documented histories of addiction or who had health conditions putting them at greater risk of overdose.

In one striking case, a veteran described being prescribed a cocktail consisting of 23 different medications and over 100 pills a day, which left him practically a zombie. In another, a veteran who had been referred to detox was instead prescribed more opiates by the doctor he ended up at and proceeded to overdose in his car.

It was only in 2013 that the VA began to recognize its errors as public outcry grew, and to push back on the problem with an Opioid Safety Initiative (OSI) that increased restrictions on the dangerous drugs. But though the initiative succeeded in that it indeed led to a significant reduction in the prescribing of opioids by VA doctors, it was implemented in a way that reflected a profound lack of understanding of addiction, with catastrophic results.

As in the aftermath of the crackdown on Florida pill mills, many veterans turned to illicit drugs like heroin to relieve excruciating withdrawal symptoms. And, even more disturbing, some turned instead to suicide, including many who had injuries so severe that opioids were their only real option if they wanted to enjoy any quality of life. Shockingly, one study found that the OSI’s implementation was associated with a thirty three percent rise in suicides among urban veterans and a seventy five percent rise in suicides among rural veterans, and that the rates of suicide attempts and other mental health crises increased at a similar rate.

Unfortunately, this spike is only a microcosm of the staggeringly high suicide rate among veterans more generally, with veterans being twice as likely as civilians to take their own lives and over 30,000 veterans having lost their lives to suicide since 9/11. In fact, the problem is so prominent that, in the first half of 2009, the year Water By The Spoonful takes place, more American soldiers committed suicide than died in combat.

As with the addiction epidemic as a whole, the epidemic of undertreated mental health disorders among veterans is a complex problem that will require complex solutions. But it is also another epidemic in which stigma appears to play a significant role in inhibiting veterans’ willingness to seek help. Due to military culture’s emphasis on strength, admitting weakness is often a particular anathema, to the extent that one article described the military attitude towards mental illness as “equivalent to the stigma of mental illness that pervades our society-but on steroids.”

Those who are struggling and still in the service may also be worried about the impact that admitting to mental health struggles may have on their military career. And, given that the majority of veterans are male, many are also affected by the forces of toxic masculinity that discourage open expression of emotion at the expense of projecting invulnerability at all costs.

We can also see these forces at play in Elliot’s story as he hides the extent of his struggles from Yaz and resorts to unhealthy outlets like lashing out at his family members or boxing despite his leg injury rather than seeking appropriate help for his PTSD symptoms.

And as for what that appropriate help would look like? Well, though ghosts are not easily satisfied, they can, in fact, be mollified, a process that I learned a great deal about by reading The Body Keeps The Score, Bessel van der Kolk’s fascinating and comprehensive tome on the wide-ranging effects of trauma on the human psyche and the often unconventional ways that those effects can be managed.

For some patients, their path towards wellness involved using techniques like yoga and massage therapy to physically calm down the body and to get back in tune with it. Others were helped by measures like neurofeedback, which can help patients to observe and to alter their dysfunctional brain activity, or eye movement desensitization and reprocessing therapy, which works to reduce the intensity of painful memories by allowing the brain to more fully process them.

More interesting to me given my particular preoccupations were Kolk’s tales of patients helped by participation in support groups and by communion with others, or by forms of therapy that helped them to come to terms with their trauma by re-framing the “story” they told themselves about their experience and coming to a more nuanced understanding of it.

One chapter even delved into how opportunities for artistic expression and communal experiences like those that can be provided by the theatre can play a critical role in fostering healing, including how involvement in a theatrical production gave one group of homeless veterans what was “clearly a more transformative experience than any therapy could have offered them.”

Experts have also noted that many of the veterans who are most successful in their recoveries from PTSD are those who have been able to find some way to give back to their community, and that, as with addiction, social support can be critical, which is why maintaining an empathetic attitude might be of the utmost importance.

As Water By The Spoonful illustrates viscerally, veterans who are fighting for their mental health, whether against addiction, post traumatic stress disorder, or some combination of the two, are clearly fighting a war just as real and just as harrowing as the one they fought on the battlefield, and one where the stakes of failure are just as heartbreakingly high. And since there’s still one more weekend left for you to go see New City Players’ haunting production, I won’t go into the way Elliot’s confrontation with his own ghosts plays out: only that the way Hudes represents his journey is a stunning and satisfying one.

So far, it’s been a thrilling ride to see the hard work of all my comrades in the cast and crew finally come to fruition in our first two weekends of performances, and to see both critics and audience members alike getting the chance to appreciate it. As far as what’s next for The Build, you can expect some insight from the cast, some insight from a professional in the field, and I may just have a few other wild-card excursions up my sleeve before all is said and done, so be sure the check out the show if you want to make the most of it!

Blog crossposted on recointensive.com

Our Water by the Spoonful blog series is sponsored in part by Reco Intensive. To learn more about Reco Intensive, a Delray Beach addiction treatment center whose holistic and compassionate approach aligns with NCP’s vision of helping South Florida to become a more empathetic and thoughtful community, visit their website.

Understanding The Unique Mental Health Challenges Faced By America's Veterans by Ilana Jal

Water by the Spoonful

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