Reporting for Duty, Sir

May 20, 2013 By Paving the Road Back in Living Life, Professional Relationships Tags: Grief Loss and Bereavement, longform, military, Posttraumatic stress disorder, PTSD, Red Skelton, Suboxone, TBI, Traumatic brain injury, veteran, WPLongform 22 Comments

With the permission of his family, I report, with much sadness, that another young veteran whom I have had the honor to serve died this past week. The cause of his death remains unclear, but all agree that it was not self-inflicted, and it does appear that he died suddenly and without suffering.

Ethan (not his real name) first came to my office a couple years ago. He was not in good shape. He had suffered a significant traumatic brain injury (TBI) from an IED (improvised explosive device) explosion while having served in the Middle East, and he had subsequently become hooked on opiates (painkillers). When I first met him, he was gaunt of body and of gaze. He had the distractibility that I have often seen in veterans who are struggling with the consequences of TBI, but his had a desperate edge to it, an irritation that appeared to be heading nowhere, targeting no one in particular.

How good it was, then, that he found Suboxone (an opiate-substitution medication) to be so hope-restoring for him. He filled out in body and in soul, and a smile took up permanent residence on the lower half of his much-less-lined face, a puckish one, I guess I’d say. Great word, puckish. Great smile.

He grew up in a semi-rural area south of Indianapolis. He once told me how to get there, and I realized that I had often passed the requisite landmark on Indiana State Road 37 during my many trips through the years down to Indiana University in Bloomington, where I had taught an undergraduate class. In fact, he was still in high school when I first began making that trek. It was a well familiar one to me, in other words, by the time his mother, who lived not far from that landmark, had already begun praying every morning, every night for his safe return home.

He did return home. But he was not whole. He knew it. His family knew it. Everyone knew it.

Ethan was working with two of our finest therapists at the Indianapolis VA when he came to see me, so he never had a need to share with me any of the worst aspects of his combat experiences. He did hint at them, though. I needed no more than that. His experiences of the War—both of what he saw and of what he had to do—haunted him daily.

Yet as time progressed—and even more, as he worked with his therapists—those haunting experiences receded in prominence, leaving in their wake the far-less-easy-to-treat symptoms of his TBI. Day-to-day detail often confused him far more readily than it had before deployment. Often he forgot where he was to be and when he was to be there—appointments, for example. Family did their best to help him keep track of everything, a challenge for them all. How many times did Ethan come into my office, once more apologizing for having forgotten something, sometimes an important something, sometimes not.

Then he met Robin.

Robin had had her shares of struggles also, but together they went on to make a life that, while not without its challenges, was nonetheless even more with its hopes, saturated with a love that kept a certain puppy-dog air about it, even as they faced together, head-on, all the Shakespearean “slings and arrows” that Life can bring any of us. They got married. They made plans to buy a home. Those plans fell through. They kept looking, envisioning for themselves a family that would be as safe as they could make it, as secure as they could love it.

Still, Ethan suffered, suffered from War like so many other thoughtful, good-hearted men and women with whom he had flown on that plane to Kuwait, with whom he had ridden into extremely-hot, extremely-volatile territories in vehicles that were, in spite of their advanced technology and their construction, still all-too vulnerable.

He knew that he suffered. Robin knew that. His family knew that. His therapists knew that. I knew that. Everyone knew that.

He continued to find Walmarts nerve-wracking. He still had to have a seat in full view of the door, wherever, whenever. He still had nightmares. He still had became leery of unseen powers in government, in society that could, at a moment’s notice—perhaps, just perhaps—take away from him all whom he loved, all that he had worked for.

Yet in spite of all that, recently he had been coming into my office with all the fervor of a country boy ready to start yapping away on a Saturday morning with a bunch of men, old and young, spread out in the back corner of the local McDonalds, solving the world’s problems over large cups of rapidly-cooling java.

It was his smile, though, puckish. Got me every time. It reminded me of the smile, the “I’m so tickled” demeanor of a fellow Hoosier from long before his time, one who had reigned over Tuesday nights on CBS at my house all my growing-up years: Red Skelton. Like Skelton, Ethan always looked as if he was just so taken with the punch line of the joke he was about to tell, he could barely contain his guffaws long enough to spit out the first words without being stopped by a string of giggles that would bring the audience—and even more, him—long past the verge of tear-stained laughter.

He was a good man, a young man. He had the heart of a Boy Scout rushing to walk the old lady across the street. He had the sense of honor, of duty of a soldier who, while still trying to be good, would learn how to harm, how to kill, if necessary, to protect those whom he loved, whether miles away or right next to him.

We had our regular appointment this past Wednesday. Without any notice, he, quite willingly, came and spoke to a group of my colleagues about his experiences as a patient at our VA. He was articulate. He was honest about his past struggles, his current memory problems, his hopes for a better future. My colleagues applauded him at the end of the discussion. After we had shaken hands after the meeting, he walked away with a smile about twice the size of the some of the country fields he must have run through when he was a boy.

He died the next day.

I had a chance to speak with his mother on Saturday. In her grief and complete disbelief that he was, indeed, gone, she still spoke of how excited Ethan had been becoming about Life, even as he had continued to struggle with the combat-related anxieties of the day-to-day. They had been planning for a family gathering on the day that he had died. In the preceding weeks and months, she had begun hearing in his voice a certain quality, a certain youthfulness that she had feared would never, ever return.

“So you were getting your boy back?” I said.

Her tears answered me.

Then she told me something quite extraordinary.

“You know,” she said. “Ethan had been telling Robin a lot recently that his dreams had been changing. He kept on having these dreams, these feelings that he was to become a guardian angel.”

You can’t make these things up.

Ethan was not an imposing man, yet neither was he a reticent one. Even as he displayed that puckish smile over and again, he also displayed a certain resolve, a certain protector-warrior sense, even if only in glimpses, that reminded us all—that reminded him—that he was still ready for duty, ready to assume a role that he loved, ready to face again, if necessary, a violence that would perhaps destroy him, but that would not—would not—destroy those whom he loved.

War, with its horrors and realities, did try to destroy his tender heart. It did leave its wound in that heart, its permanent reminder of what had been lost, of who had been lost. Yet along with a tender heart, War found a determined heart. That, War could not take away, in spite of the nightmares it had implanted in him, in spite of the memory and the focus it had robbed him of.

I leave it to everyone else to decide as to whether there is indeed some Heaven somewhere that serves as a place of further, dutiful service for one who had so faithfully tried to fulfill such service in this life. All I can say is this: if anyone—anyone—had the heart of an angel and the resolve of a guardian, it was Ethan. If he has indeed reported for duty, God has indeed already sent him out on his first of many, many missions.

May he rest in peace.

The Tattoo Graft

May 5, 2013 By Paving the Road Back in Living Life, Professional Relationships Tags: combat, Grief Loss and Bereavement, longform, military suicide, Posttraumatic stress disorder, PTSD, survivor guilt, tattoo, veteran, war, WPLongform 8 Comments

Even though I had promised to break my blog “fast” with reflections on the Boston Marathon bombing and its aftermath, Life led me elsewhere. Thankfully.

I have known him for a while now, this former Special Operations soldier. He had seen—and more, had experienced—more than his share of horrors in the Middle East, often accompanied only by a few men who eventually came to mean Life itself to him. “Brothers” finally took on a meaning that previously he’d only dreamed of.

There were those who didn’t make it back.

He struggled in the years afterwards, making some attempts at treatment, but finding none that he found that useful. Drugs, especially painkillers, became his constant companion. He knew he was wasting his life. Finally he faced a severe medical crisis. He came home to Indianapolis to seek the medical treatment he needed—and even more, to find a reason to keep on living.

The medical treatment, he received. The painkiller problem remained, however. And thus we met.

At first he was probably more eager for Suboxone (the opiate substitution medication) than I was. His medical treatment had taken a lot out of him, after all, and he had very real reasons to have very real pain. While Suboxone is sometimes useful as an analgesic, it has not been, in my experience, the best painkiller that has found its way onto the planet. I urged him to hold off, to have us work together first to keep his pain medications steady, on a schedule, controlled, until he could recover further.

During those initial weeks he laid out his story of War. Even when hurting, even when on pain medications, he was quick-minded, analytical to the max, a strategist par excellence, just as he had been in the military. Yet at the same time, in a way unusual for men as gung-ho as he, he was unafraid to acknowledge his more disturbing emotions, his fears of never getting better, his grief over buddies never to be seen again.

“I’ve played around with this too long, Doc,” he eventually told me. “I’ve just got to get my head together, my life. I can’t keep going like this.”

Indeed he couldn’t. I suspect he’d always been on the wiry side, but both his medical treatment and his drug usage had left him a bit less imposing that he certainly once had been. His curly hair was of a length far afield from the judicious cuts of his military days, no doubt: neat, clean, true, yet in a certain way more an afterthought, as if the rest of his body was having to work long past quitting time to keep the legions of locks on his head from tipping him over sideways.

Eventually he started the Suboxone. It was indeed helpful.

But nowhere near as helpful as the woman he met one fine day.

I walked out of my office one afternoon to find a man sitting in the waiting area whom I’d never met, his long, jeans-covered legs comfortably stretched out a good mile and a half into the center of the room as he sat askew in his chair, perusing some cheap magazine from off the table next to him, his hair cropped stylishly short, his entire musculature at parade-rest, I guess one could say, both at ease and yet, what, ready, just in case. The man looked up at me, smiled, and shot a quick wave.

It was he.

“Sorry,” I said once we’d made our way to my office. “I didn’t recognize . . . well, the hair!”

He grinned. “Oh, yeah: got tired of it hanging all over the place, I guess.”

“You better believe ‘I guess,’” I replied, impressed by how the cut made him look both older and younger simultaneously, more seasoned, yet more daring.

“I think my girlfriend likes it better like this,” he said as he folded his hands onto his lap, sliding himself down into a just-hanging-out-here slump that was anything but sloppy.

“So all’s going well with you guys?” I asked.

“Oh, yeah, real well,” he answered, as if that were so old-hat news he’d not even considered I might ask such a dumb question. “Her kids are great. I . . .”

Then he stopped, for moment staring right at me, but at the same time right through me, not in that way that gives one chills, but rather in a way that seemed to advise me that even if he were to speak further, our conversation would not be resuming any time soon.

“You know,” he finally whispered, “I . . . I was really afraid that I’d never find love, that I was too screwed up. I couldn’t ever get women to listen to me. But that’s what she does: listens. She doesn’t freak out. She just . . . listens. I feel so safe with her, steady, like I haven’t felt in I-don’t-know-how-long.”

After a few seconds, he returned his gaze back from wherever to me. If a smile can be calm, his was.

“What a good thing, eh?” I could only respond.

“Yes, sir,” he said. “Yes, it is.”

Sadly, in the world of modern combat veterans, calm smiles often last only so long.

It was a few weeks later that I received word that he was wanting to speak to me right away. Fortunately I was able to see him later that day.

The news was not good. His battle buddy, the man “closer than a brother “ to him, had just committed suicide.

“I . . . I had no idea,” he whispered to me, doing everything a good military man can do to maintain the composure that was anything but his. The two of them had been in continuous contact. They had spoken only a few hours earlier. There had been problems in the man’s life, true, but . . .

“We . . . we survived so much, he watching my back, I, his,” he continued. “ How . . . how?”

He went to the funeral, of course, faithfully watching over his buddy’s widow in the very way he knew the man would have done had the roles been reversed, had it been the ever-patient, ever-listening woman at his side who would have received the folded flag.

“I did OK, Doc,” he later told me. “Except when they played ‘Taps.’ I lost it. I just . . . lost it.”

The months passed by. He found a job. He had to in-out a few appointments, assuring me that he was doing OK, not great, but OK. Then recently he came in, collapsed in the chair by my desk, and gave me that look that I’ve seen from so many veterans with whom I’ve had the honor to work: the “yeah, Doc, the jig’s up” look.

Time to be gentle. Time to be real.

“Not good?” I asked.

He shook his head, his at-me/through-me look back. “I can’t sleep,” he replied. “Nightmares, constant thoughts about what we had to do, what we saw. I miss him like anything, yet I could just kill him if he weren’t dead! Is that a terrible thing to say?”

I had to smile. “It’s true, though, isn’t it? You’d like to smack him up the side of the wall, and yet you’d like to hold on to him as if there were no tomorrow, all at the same time, right?”

His smile in return was pained, no longer calm. Yet it was still a smile.

“You better believe it.” After a few moments, “Will this ever end?”

Again, the question I hear day after day after day.

“Will a certain sadness, a certain pain never end?” I reply. “Probably not. Probably shouldn’t. But it’s like I tell all the guys: the pain doesn’t have to hurt like this. Even though you know this all happened in the past, your brain is still experiencing everything as if it were happening right here, right now. You’re reliving it all, not remembering it. Once you can get from relive to remember, it does feel different, easier in a way—not easy, but easier, in a meaningful way.”

We talked about his various treatment options at the Clinic, both individual and group. He was certainly interested, yet his work schedule did make regular attendance at therapeutic sessions complicated. Still, he told me, “It helps to know I can get better. Thanks.”

Then came last week.

He’s gained some of his bulk back. In no way is he small. He’s more agile: not wound tight, ready to spring, but more ready to dart, stealthily, sort of like the Road Runner with good upper-body strength.

The calm smile was back.

“You look good,” I told him.

“Thanks,” he replied, almost shyly. “You know, I . . . I got a couple new tattoos a few weeks ago, and it’s like . . . well, I don’t know quite how to put it. It’s like . . . I’m better.”

“What happened?”

“Well, I had added two more, on my back. One has some initials, dates: for the guys we lost. But it was the one for my battle buddy, it . . . it changed everything. You know, it was like you said: I need to remember, not relive. I’ve joined this group of vets who get together and just talk. The leader of the group’s been great, got me to thinking, ‘what more could I have done?’ And like it hit me: nothing. I could have done nothing more. I would have done anything for him. He was more my brother than my real brother is. But I did all I could. I loved him like no one else. That’s . . . that’s it. That’s it.”

He said it all right to me. Gone was the right-through-me. Even after all the one-to-one we’d experienced together so far, this was five levels deeper. At least.

“You know,” I finally said, “if I could ask: what was it about the tattoo? How did it make the difference?”

The calm smile turned quizzical, not in a threatening way, more in a “now, isn’t that a question” way. He looked off for a bit, a few seconds only, then looked right back at me.

“You know, when he died, the moment he killed himself, he ripped a part of me right away, yanked it out. There was this big, gaping wound in my heart, my soul. You can’t know, Doc, you just can’t know how much he meant to me. He was hurting so badly, so badly, and I couldn’t save him. I don’t know what made me do it, but I just one day decided I needed to carry him on my back, the rest of my life. You know, it’s funny: it’s almost as if I needed to hurt to get him back, to feel the pain of the tattoo, to do it for him. And it’s weird: all of a sudden, when the guy was done making it, it was as if my buddy was sewn right back into me, filling that hole, like he’s going to be at my back, day in, day out. I walked out of that parlor and, I don’t know, it was as if a huge burden just rolled off me. I . . .”

He smiled again, not so much calm this time as, what, thankful. Tearfully thankful. His water-rimmed eyes ever slowly reached out and took mine in their grasp, not forcefully, but confidently. Sadly, but confidently.

“It’s like you said, Doc,” he whispered. “I don’t have to relive. I can just remember.”

The old psychoanalysts always talked about the psychic, emotional power of the skin, that millimeter-thick barrier that keeps us both whole and vulnerable, that both contains us and exposes us.

Yet for one wiry, analytical man who has finally found love, finally found the family who can accompany him into the future, his skin has also freed him, has put a past in its place, has grafted onto him a different, yet equally-powerful love that will link a well-loved past into a well-loved future and finally, as much as can be done after War, make him whole.

Briefly . . .

April 26, 2013 By Paving the Road Back in Uncategorized 3 Comments

Yes, I’m alive.

One of the veterans with whom I work said to me last week, “Boy, those last few posts of yours were pretty dark. Are you OK?”

He’s a good man who always asks me about my welfare–and I always appreciate his asking. I assured him, “Yes. Saddened, but OK.”

Honestly, the reason I’ve not posted in a while has little to do with Porthos’ death or with recent events in Boston, both of which have been off and on my mind throughout the past weeks. I’m afraid my hiatus is due to matters much more mundane–and therefore much more fatiguing.

For after twenty-four years of marriage and fifteen years in our house, my wife and I are finally downsizing. As any of you who has put a house on the market–or, even worse, prepared for a Moving Sale–knows, Basic Training is a much more preferable way to spend a few weeks of one’s life.

At least you get to march in a graduation ceremony after it’s all said and done (well, most recruits do, anyway).

So there you have it. Actually, the mundaneness of life juxtaposed with the horror of the Boston bombings has been anything but on the back burner of my daily thoughts. After all, for six years, I lived within easy walking distance of both MIT and Watertown, a quick subway ride on the T from Boylston Street.

Soon, I promise. Soon.

“Taps” and the Last Musketeer

April 5, 2013 By Paving the Road Back in Living Life, Professional Relationships, Respect, Honor, Duty Tags: Athos, combat, Grief Loss and Bereavement, longform, Porthos, Posttraumatic stress disorder, PTSD, survivor guilt, Three Musketeers, veteran, war, WPLongform 2 Comments

It’s time to get this written.

Spring has slowly been intimating its way into Indiana these past several days, although, admittedly, I’m being kind in giving it this much due. Still, the snow is gone, and temperatures are edging toward their becoming worthy of some notice beyond “scorn.” Yet while the thermometer has only been cooperating begrudgingly, the barometer has been anything but: beautiful, nearly cloudless skies have been ours to enjoy.

Funny, isn’t it, how the living prefer sunshine for funerals.

As I have noted in previous posts (Goodbye, My Friend and In Memoriam: Porthos, 1985-2013), my patient, Porthos, a combat veteran of two deployments to Iraq, age twenty-seven, died in an auto accident a little over a week ago. He had grown up in a town that had once had the decency to be out in the boondocks, but which has, over the years, become another bedroom community for Indianapolis. It’s quite a hike, nevertheless, from my house, so I headed out in plenty of time, ostensibly so that I could secure an adequate parking spot.

In reality, I was just needing the time to myself.

All the way down there, I couldn’t stop thinking about a topic so near and dear to so many therapists’ hearts, minds, and critiques: boundaries. Truly, I’m not sure what some therapists would do if they weren’t policing not only their own, but everyone else’s, twenty-four seven, usually with, if I may so say, a certain self-satisfied, ethical purity.

Yet in spite of my snarkiness, the topic is indeed a critically important one, signifying as it does the question of how much should the personal and the professional be allowed to co-mingle in a therapeutic relationship. Certain answers to that question are easy, of course: no sexual favors, no financial manipulation, for example. Others plague all young therapists and many older ones: when, if ever, does one accept a nominal gift from a client/patient? How much does one reveal about one’s personal life, one’s experiences, one’s disappointments?

Or . . .

Does one embrace a patient’s grieving father, his grieving mother, his grieving brother—his grieving best friend who also has medicine bottles in his bathroom cabinet that have printed upon them my name?

As the traffic thinned out, as the several lanes merged into two, I had to wonder: for whom was I going down there? For Porthos? His family? My other patient, his battle buddy through both deployments, Athos?

For me?

After thirty years in this business, I have come to the conclusion that the answer to all such questions is E, i.e., “all of the above.” I can live with that. I have learned that these things have a way of working themselves out.

I pulled into the lot of the funeral home with more than enough time to spare before the service, dutifully then backing into my parking spot as I was instructed, my purple “Funeral” flaglet well-perched on the roof above me.

Men and women were already there, though, even more dutifully standing guard along the sidewalk leading to the entry door, all clearly my senior, most dressed in leather, many with the familiar POW-MIA emblem from the Vietnam era emblazoned on their backs, holding the United States flags that so readily were flapping in the cool breeze, their Harleys parked only feet away, ready to be mounted, to be driven at the head of a procession to the cemetery, in a silence that not even the loudest of mufflers could pierce.

About ten minutes later, Athos and his fiancée arrived in their SUV. After backing the car in almost directly across from me, he turned off the engine and, in moments, was looking directly at me. The smile of recognition was there on his face, yet he knew it as well as I did: neither of us wanted to be seeing each other at that moment. He zipped an open palm past his face, once, in that muted “Hi” so often seen in old home movies when a person has that ridiculous light glaring into his or her face, hoping against hope that Uncle Maury will just move on to the next relative and leave me the heck alone.

I got out of my car first, only then to watch him somewhat pour himself out of his, almost as if he were maple sap reluctantly exiting through that spigot in the trunk of the tree during a sub-zero winter. Yet door shut, he turned to me in his suit, dark shirt, dark tie, a little too slender, true (as countless maternal types had reminded him at the viewing the night before), yet still ready for his Jos. A Bank’s photo shoot. He smiled again at me, adjusted his tie as he did his obligatory “look both ways,” so well learned in first grade, and then began to walk across the driveway toward me.

He marched right up to me, eyes refusing to let anything even approaching a tear to leak out, trying to maintain some semblance of a smile. His beard was well-trimmed. His hair was neatly cut, longer than military, definitely, yet still a certain “short chic.” Tobey Maguire’s Nick Carraway was back, in other words, at your service. Preparing to bury Leonardo DiCaprio’s Gatsby.

For a second or so, we just looked at each other.

“Thanks for coming, Doc,” he finally said, a certain hesitancy more than apparent.

This was it. I knew it. The boundary decision.

So I made it.

I opened my arms wide.

His eyes saw their chance, and for just a few seconds they forced his entire facial musculature to contract in response, both giving in to tears and refusing to do so, as he nearly fell into me, wrapping his arms around my upper body, his head in an instant buried at my neck, his body seeking my ballast to help steady those eyes and get those partners back in line, buddy-boy, and I mean, right now.

“I don’t know if I can get through this, Doc” he whispered, quickly, desperately, right into my ear.

“I know you don’t,” I whispered back into his. “You don’t have to think you will. You just will. You’ll do it, and you’ll have no clue how. For his family. For him.”

For a few seconds, nothing, then another whisper entered my ear. “Thank you, Doc.”

Just as quickly we separated and looked at each other. His smile was trying to weasel its way back into place.

“I’ve got to go in and see his folks. You’re coming to the cemetery, aren’t you?”

“Of course,” I replied.

He cleared his throat, adjusted his tie one more time, and then his sunglasses. “OK, great, I’ll . . . I guess I’ll see you inside?”

“Of course.”

The smile having reasserted itself, he was gone with the nod of a head.

Several minutes later I entered the funeral home myself, making my way to the large room where just the night before I’d walked in to see at the end a large wooden casket, carved and stained in such a way as to remind any onlooker of a life that had been honorably, even beautifully lived. A United States flag, well-folded into its triangular form, lay on top of one end of the casket, various pictures and a sports jersey on the other.

As I took my seat in the far back corner, by all the pictures that had been assembled and displayed along the back of the room, I looked down to see on the table next to me a five by seven of two very young-appearing men, stocky, I think, more because of all the outfit and combat gear each was sporting than because of any good, home-cooked meals out in the desert. Each had a “go ahead, cross me, I dare you” look chiseled on his face. I had both to smile and to bite my lip.

Porthos and Athos, bodies so proud, yet eyes already having begun to be transformed by War.

In Central Indiana, it usually seems as if all funeral homes are constantly jockeying for the title of “Most Gaudily Edwardian.” Fortunately, this one had bowed out of competition at a more respectable moment. I was quite glad, in fact, that as the music began to be piped in, it was not the usual, top-ten hits of nineteenth-century, Methodist hymns being played far too slowly and far too cheesily on a Hammond, draw-bar spinet.

Quite the contrary. It made me smile without any lip-biting.

It was Josh Groban.

All I could think: Porthos, a veteran of many a barroom scuffle brought on by some unsuspecting, churlish drunk who’d made the poor decision to “dis” or threaten one of Porthos’ buddies; Porthos, the guy who’d argue a point with you well into near-absurdity just to prove to you that you couldn’t run over him . . .

Porthos, the man who, after being awakened one more time by the terrors of nightmares that had left him drenched in sweat, would calm himself by watching Harry Potter movies, over and over again, so often that he could quote entire scenes by heart . . .

Of course, Josh Groban. Of course.

Soon the room was packed not just with the usual cadre of retired individuals who apparently plan their golf schedules around funeral services, but also—even mostly—with dozens of young men, still well-built as their hairlines were receding, and dozens of young women, still with sensuous smiles after having put on that extra pound or so after their last pregnancy. Some were dressed to the nines. Some were wearing T-shirts and jeans. All would embrace over and over, smiles radiating “It’s been too long,” yet voices soft enough not to remind any of them that one of their gang, though still in the room in body, was now quiet, quiet as he’d never been in high school, never in the Army, never in life.

At some point, Porthos’ mother saw me, came over, hugged me, and said “Thanks for coming.” My reply was as it had been to Athos: “Of course.” We looked briefly at each other, two parents of different children, yet both parents nonetheless. We both knew there was nothing more to say. We left it at that.

Eventually his older brother and his girlfriend made it toward the front of the room, then his younger brother and his husband. His younger brother, D’Artagnan, caught my eye. He smiled, waved sheepishly, as did I in return. Once more, we left it at that.

Finally, as Porthos’ mother took her place next to her youngest son, his heartbroken father walked in and took his place on her other side, the college professor dressed for a no-nonsense lecture, ready to see his son off with the honor the younger man deserved.

Athos and his fiancée were barely a few seats away from them.

As the service progressed, as the National Guard chaplain whom Porthos had so deeply admired spoke, as Indiana’s Adjutant General looked on, as both his father and his younger brother tearfully remembered him, admired him as their hero, as the quintet of friends apparently from high school sang in Appalachian open harmony, quite in tune, a song drenched in country-western fervor, yet universal in sentiment, I could only think: my God, what if I hadn’t come?

Boundaries, schmoundaries.

I have to wonder: if more of my VA colleagues across the nation were to attend just such services, feel the lives of the men and women we have served, absorb the sadness and the futility of lives cut off far too soon, whether in battle, in the accidents of those who had always imagined themselves indestructible, in the self-destructions of those who could no longer imagine a future without excruciating pain of body and soul—what then? Who would we be? To whom, to how many in this country could we then announce, scream, pontificate, plead to not forget, not abandon, not leave these same men and women worrying one more day about where their next meal will come from, about whether they will have a roof over their heads?

The service over, I was one of the first to be escorted up front. For a couple seconds, I stood before the casket, not even sure I was wanting to have the wherewithal to understand the import of the moment. Just as quickly I turned to meet the eyes of his younger brother, to embrace him and hear him say “Thank you,” to hear myself once again saying “Of course.” Then it was his mother, same.

Then it was his father.

For a moment we looked at each other, Dad to Dad. As we embraced, his voice broke ever so softly. “Thanks for helping him talk about what he needed to talk about.”

This time, my “Of course” served more as my defense against the breaking of my own voice.

I shook the hand of his older brother, and then I turned to see Athos sitting there, head down, quickly batting at his eye. He looked up at me, and then in an instant was standing, and one more time, boundaries were . . . well, I don’t know, they just were.

Another firm embrace. Another “Thank you” whispered into my ear. Another “Of course” whispered into his.

The cemetery was not that far from the funeral home, though it wasn’t a stone’s throw either. It was quite a line of cars making its way down the divided highway, led by the police car and a pack of very loud, very silent Harley-Davidsons. Interesting, I thought: out in this more rural area, cars were stopping as the procession went by, even when they were going the opposite direction on a divided highway. You’d never see that in Indianapolis.

We wound our way to the rear of the cemetery—to the burial ground of soldiers from all the way back to the Civil War. His was a beautiful spot, right next to an ancient tree. The family sat down in the tent. The rest of us gathered along the sides. Across from us were the two rows of marksmen (and women), standing at attention, ready. To the far right, a lone man stood, also at attention, a bugle tucked underneath his arm.

Men and women in uniform gathered to the left of us, all ages, each falling into a respectful parade-rest. Six men then came to full attention and, in well-orchestrated fashion, marched their way to the back of the hearse. With a series of precise, right-angle turns, one of them made his way to the door and opened it.

There he was, Porthos, casket draped in the flag that he had more than once told me that, in spite of all his suffering, he would serve under again and again.

Ever so precisely the men maneuvered the casket out of the hearse. Ever so precisely they carried it to the grave site. Ever so precisely they rolled it into place. Ever so precisely they stood back, turned, marched off.

The chaplain spoke a few words. The crowd recited the Lord’s Prayer. A few more words from the chaplain, and then another man in uniform precisely made his way to the casket, precisely and respectfully requested that all stand.

From across the way the commands were barked.

Rifles clicked. Fired.

Clicked. Fired.

To the right, men and women stood at full attention, their white-gloved right hands slowly making their way to a salute as the bugler slowly, precisely brought the instrument to his lips.

Ever so slowly, ever so precisely, ever so, dare I say, musically, he made his way up the major chord, each note clarion-like and yet not, both forceful, yet haunting.

He hit the final high sol easily, sustaining it just long enough, then made his way down the octave, perfect interval by perfect interval, until the final do filled the air, no vibrato, just tone, a good eight counts.

Porthos would have loved it.

As the guns were firing, the salutes lifting, the bugle playing, one uniformed soldier stood at the head of the casket, a second at its foot. As the final note of the song faded, the two men clicked into action, lifted the flag draping the casket, and ever so slowly, ever so precisely began to fold it, in half, in half again, then right triangle by right triangle.

Finally only one of the two men was left standing there, holding the folded flag, as Indiana’s highest-ranking National Guard officer walked slowly up to him. The man handed the General the flag, then saluted. He walked off.

And then it happened.

From behind the family, Athos stood and walked toward the General. At full attention, he put out his hands, and slowly the General lowered the flag into his, ending with a salute, older man to younger, both living and dead.

Athos then turned and made his way to stand in front of Porthos’ parents, to be met there by Porthos’ Uncle Jack, a Vietnam veteran whom Porthos had often spoken to me lovingly about, his inspiration for taking his energy, his mind, his body to serve, even knowing that death could result, by his hand, to his dearest friend, to himself.

Athos handed Jack the flag. And he saluted.

Jack nodded, turned, knelt down, and handed the folded flag finally to Porthos’ mother, his father right beside her.

Minutes later, the service was over.

People began to walk around, speak softly, hug. I looked over to see Athos embracing his fiancée, whom I’d only met for the first time the night before, a woman who’d been Porthos’ childhood buddy, the girl he’d taken to Prom “just because,” the woman who’d have never known Athos, whom Athos would have never known, would have never found comfort with, had it not been for that wisecracking charmer from Indiana.

Eventually I made my way over to him. He was standing next to Aramis’ brother-in-law: Aramis, the first of the Musketeers to die, in battle, the kid from the big family in Maryland, the man whose body Athos had lovingly guarded to his final resting place (Taking Him On Home).

Athos looked at me and swallowed. For a few seconds we stood there. The tear was trickling down his cheek. I think one was trickling down mine as well. I can’t quite remember.

Slowly he walked toward me, and once again boundaries evaporated. This time, though, I could feel the shaking of tears in his chest as he embraced me, not sobbing, just . . . tears.

“I’m not ready to let him go,” he finally whispered into my ear.

“I know,” I replied.

Slowly he pulled back. As we looked at each other, we both knew there was nothing left to say. He nodded, as did I. Then he turned away.

I wondered whether he was going to finish what he had to finish.

He did.

He’d told me the night before. “The last salute. That’s what’s going to be the hardest.”

I watched him as he went over to another man, his age, in full uniform. Briefly they spoke. Then, together, they walked up to the casket. People continued to walk around, speak softly, hug.

The two men assumed full attention. They looked down at the casket. Then, in a fashion just as the men and women had assumed at the sounding of “Taps,” just as the General had done to the flag and to him, Athos and his friend slowly began to raise their right hands to their foreheads, the entire journey from chest to brow extending over four, slow beats, at the end of which their hands stood still, as did Time, one last time.

Although not in heart, but at least in body, the last Musketeer had done it: had let his second brother go, had saluted him one last time at a casket, had taken his place, unwillingly, yet bravely, as the last one standing.

Slowly both men lowered their hands. Slowly they turned away—and then embraced.

About five minutes later, I turned to find him standing in front of me.

“You still in the hospital this week?” he asked.

“Yes.”

“Maybe I could come by on Friday?”

“Of course.”

I think we both attempted something like a smile. That may be the best either of us can hope for. For a while.

Eventually it was time for me to go. I walked over to the casket and lowered the tips of the fingers of my right hand down onto it.

I, of course, had not earned to right to salute.

And so I thought what I needed to think, whispered what I needed to whisper.

Words that I now must write.

For I, too, don’t want to let Porthos go. And I, too, like Athos, must find a way to begin to do just that.

And so I type what I whispered to his body—perhaps, I hope, in some way even now whisper to him. Even though I could not salute him, I could say something, something that perhaps as his psychiatrist—and even more, as his somewhat boundary-bending friend—only I could say.

You see, I was by no means the only one to whom he bared the terrors and grief of his soul. He did to Athos. He did to his chaplain. He did to a few other buddies. Yet I do know that even with them, he’d only been able to graze against the guilt in his soul, the grief in his heart, the suffering in his mind.

With me, however, he had honored me enough with his trust to allow me to watch him begin to grasp those demons more firmly, to take the risk with him that everything could blow up, to have the faith that it wouldn’t, to feel together what never should have been felt by him in the first place.

Perhaps, then, there are words that only I can pronounce, not as some sort of blessing—far from it—but rather as a statement of fact, a “performative” utterance, as the literary critics are wont to say, words that by their very speaking both acknowledge what “is” and bring that “is”into being.

I have to laugh, actually. Porthos gave me no end of grief about being a “Harvard hot-shot.” He, more than anyone, would have enjoyed the ridiculousness of some Westside Indianapolis boy acting as if he could spout off some highfalutin’ Latin nonsense in the tradition of the Lux et Veritas so proudly displayed on anything Harvardian one can buy at the Coop in Cambridge.

Yet at the same time, sometimes I would wake up in the morning to find that he had texted me in the middle of the night to tell me that another nightmare had awakened him, shook him to the core, but that he was “going to be OK, Doc. I’m feeling a little better.” Why?

Because he’d watched a couple Harry Potter movies.

It was J. K. Rowling, of course, who helped make Latin fashionable again, with her spells, curses, and family names that hearken back to the language of Rome. How Porthos would have so appreciated, then, at least one word in the phrases, that wizarding word for a curse that could, if left unchecked, destroy both body and soul of any man or woman who had to endure it.

He knew something of that process, after all.

Yet, thankfully, he also knew of other processes as well. He knew, like Harry, that ultimately what saves us all is simply faithfulness and love.

I only hope that well within boundaries, yet well not constrained by them, he learned something of the latter two from me, enough so that I can say what I have to say, perhaps the only good I can see arising out the sadness sounded in that bugle’s call, in that beloved brother-in-arm’s salute.

And so one last time, now with fingertips touching wood only in spirit, I let you go, Porthos. As your doctor, I give you the final diagnosis to set you free.

Cruciatus consumptus est, Porthos. Requiesce in pace.

Indeed, the torment is over, Porthos. Rest in peace. Amen.

Amen.

In Memoriam, Porthos, 1985-2013

March 30, 2013 By Paving the Road Back in Living Life, Professional Relationships Tags: Athos, combat, Grief Loss and Bereavement, longform, military, Porthos, Posttraumatic stress disorder, PTSD, survivor guilt, Three Musketeers, veteran, WPLongform 3 Comments

With the permission of his family, and with much sadness, I let you all know that this week, as I said before, I lost not only a patient, but a friend: a man whom some of you have come to know as Porthos.

In the late afternoon of Monday, March 25, 2013, he died in an auto accident, leaving his parents, his brothers, his family and friends, me—and a brave, tired, bereft battle buddy, Athos—rich in memory, yet broken in heart. He will be buried with full military honors this coming week.

I first wrote of him over a year ago now, just after the shootings in the village near Kandahar, Afghanistan, in an entry entitled No Trouble At All:

Today I was in contact again with one of the veterans I work with, one who has struggled almost incessantly since coming home. He’s a dashing rake, by anybody’s measure. He comes from a well-educated family. He’s smart. He’s intense. He was once a bit of a bad-boy, but he’s working now to pull his life together, to find love, to find a place back in his family, back in this world.

In a matter of days after landing in the Middle East, this man’s dearest friend—his brother to the core—was dead. Others in his unit soon followed. He wakes up in the night screaming, sweating, panicked. Not a day goes by that he doesn’t think of his friend, often—usually—with tears. To this day, when he promises me something important, he does so on that man’s memory and on his grave. . .

He always apologizes when he contacts me. He’s so ashamed to do so. But he gets so desperate. And he hopes against hope that I won’t hold the contact against him, one more time, another, another.

Honestly, they’re indeed no trouble at all. He knows the drill: if I can get back with him, I will. If I don’t right away, he knows that I’m with family or with other patients. He knows I’ll get back to him eventually, even if it’s just a “hang in there.” He knows he’ll have his time later that week to come see me, to try somehow to find that devilish smile of his one more time, to remember when it was all easier, to borrow as hope what is my certainty: that he will find a better day. One day. Not today. Most likely not soon. But one day.

I can say that because he’s a warrior’s warrior, through and through. Behind that Abercrombie façade (albeit a brunette one), there’s a force of nature. He was a handful as a kid. He’s a handful now. He won’t give up. Never did. Never will.

All I can say is: good for him.

We took care of today’s matters in short order. He thanked me quite genuinely. “I’m sorry,” he said again, “to mess up your weekend.” I heard the break in his voice, quick, but definitely there.

“No trouble at all,” was my reply.

What else do we have, really, except time, a future.

He doubts he has a future, of course. My job—our job, as professionals—is to disabuse him and those like him of that notion one day at a time. No guarantees of any particular outcome. Just life, with its joys, its challenges, its months off, its back-to-works.

We’ll see each other tomorrow.

“What else do we have, really, except time, a future,” I asked, so confidently, so seemingly a lifetime ago. If only, if only.

He reappeared nine months later, in Merry Christmas, Reality Notwithstanding:

I’ve already spoken of [him] in “No Trouble At All.” He and I have struggled back and forth over what to do, when to do it, how to do it. He’s always respectful, quite engaging, the whole gamut from jocular to irritable (with an apology therefor immediately afterwards, I might add).

He comes from a professional family, several members of which are not, shall we say, reticent to express views that he’s not too thrilled to hear, his younger brother in particular. They’re an intriguing pair, these brothers: both quite physically striking in appearance, kinetic-energy extroverts par excellence. When they sit in the room together, they jockey for position as to who is going to make the next comment about whom—and have no fear, the younger one is not about to be the loser any more than fifty per cent of the time. One might be tempted to call each of them a “pretty boy”—but believe you me, you’d better not do so to their faces, and you’d better not count on the usual associations to that term if you were to get on their wrong sides. . .

Whenever. . . the rakish Porthos . . . had spoken of [his deceased battle buddy, [Aramis], he’d only been able to choke out a few words before telling me that he could say no more. I never could learn from him [his] buddy’s full name, simply because he could never bring himself to speak it without beginning quietly to sob. . .

Porthos returned to a family with whom he has cried, laughed, struggled. He returned to a younger brother who can outflank his every protestation, yet who can then quietly shed his own tears as he listens to his big brother’s overwhelming grief.

Again, with tears that younger brother called me Monday evening, just as I was texting him to express my concern and condolences. We spoke only briefly. There was little to say.

Yet as I thought about it that night, the night I wrote the previous entry, Goodbye, My Friend, I did realize there was indeed one more thing to say, to text to this handsome, younger brother, to this—perhaps?—D’Artagnan:

“I wanted you to know: when he and I met on Friday, he told me that he was worried about you and asked me to check on you. . . I know the two of you could go at it at times, but please do know that he loved you dearly and was proud to be your brother. That I know, and that I wanted you to know as well.”

I finally, then, wrote of him just last month, in To Remember, Not Relive:

Porthos and I have known each other for a while. Our relationship has always been warm–though, shall we say, complicated as well. As the middle of three strong-willed sons born to a strong-willed father, he knows how to make his wants and wishes known. Fear not that, I can assure you.

And I might add: I wouldn’t get into a scuffle with him. Some of the more foolhardy in his time have. They learned. Forthwith.

Yet can that boy pour on the charm, or what. His is a perfect mixture of the quite genuine and the quite consciously manipulative. He’s had more than his fair share of practice through the years.

He actually leaves me reeling much of the time, truth be told. I’m never quite sure whether I want to give him a warm rub on the top of his head or smack the living daylights out of him. Usually both.

Porthos, in other words, is one of those individuals about whom no one–and I mean, no one–can feel nonchalant.

Porthos is quite a handsome man. How we think the attractive never have to suffer, don’t we? How wrong we are. Anguish is just anguish, whether on the good-looking or on the plain.

He looked at me, with a face both steeled and tear-stained. He has all the gear in place for “Leading Man” status, yet I’m hard-pressed to come up with a modern exemplar for him, given that most A-list stars today are simply too “pretty.” Perhaps a young Mark Harmon as the surgeon on the “St. Elsewhere” of the 1980′s, even then oozing the “NCIS” Gibbs-attitude that would one day make him America’s favorite Marine, back then painfully walking down that hospital hall for the final time, his character well-aware that he might soon die of AIDS.

“I sometimes just don’t know if I can do this, Doc,” he finally whispered. “I’m not going to kill myself or anything, but sometimes I’m afraid I won’t make it. It just hurts so, her, Aramis, the War, everything. It just so, so . . . hurts.”

The final word had plopped out of him, as if it had been teetering on his lip all the while, not wanting to risk the reality that would result from its mental equivalent having found voice, sound, transmitted out to a world, to me, to . . . what?

And then it happened: in the middle of his anguish, he started to look as if he were ready to fall asleep, to look as I imagined he must have looked at the end of that twenty-four hours he and Athos had had to stand watch over the body of Aramis, waiting for the helicopter to arrive: too exhausted to run, too charged to collapse.

And I realized: he wasn’t with me. He was in Iraq.

“No one has any idea, do they?’ I finally asked, too exhausted, too charged myself. “You’re there, right now, aren’t you.”

He was staring off to the side, grudgingly allowing one tear at a time past the checkpoint, his eyelids in a bizarre, internal arm-wrestling, the upper halves determined to shut this show down, the lower halves determined not to give in ever, do you hear me, ever!

“I’m sorry, Doc,” he whispered, his tears, few as they were, so robust, so proud to be Army-strong, his eyes fixated miles away. “I’m trying, really I am. I hope you believe me. Please believe me, Doc. Please.”

“I do,” I answered, hoping perhaps that some information, meager as it was, would jar us both out of the grip of those tears. His energy, his intense drive, his inner push never to give up, never: there they were, torturing him, yet keeping him alive, simultaneously, right in front of me, with my every verbal reminder of the truth, the Truth.

It was horrible to watch.

All I could think at the moment was, “My God, this is what they all go through, isn’t it, all these men and women, the ones whose Facebook posts, whose blogs I read, who talk of being walloped back and forth through Time, through emotion, psychically miles away from the loved one before them, then within nanoseconds careening right into them, then back, then in, tethered to a yo-yo only Satan himself could have manufactured–with a smile.”

I had to stop. Had to.

“Will it ever get better, Doc?” he asked.

“Yes, it can,” I said as I leaned forward.

Still exhausted, but somewhere, unbelievably, still rakish, he closed his eyes, took in a deep breath, opened his eyes back up, looked into mine, and merely whispered, “If you say so, Doc. If you say so.”

I do say so. And I do believe so.

And I can at least say this, for the sake of his family, for the sake of Athos, for the sake of all combat veterans who have worried that, indeed, “hope” is an oxymoron: he was indeed getting better. He had a long ways to go. His road would have been a challenging one. But he was walking it. He would have continued to walk it.

The reliving was becoming remembering. In a way, he’d gone out on the road this past weekend to continue that very process. It was the process he was living when his time—like that of Aramis, also one to Live capitalized until the very end—came.

I can write no more now. Amazing what you can do with the Ctrl-C and the Ctrl-V commands. Copy and paste. Works like a charm.

I’m dreading next Wednesday. I’m dreading the guns. I’m dreading “Taps.”

And yet who am I, really? I did not raise him. I did not wrestle with him, argue with him, dream about the future with him, at five, fifteen, even twenty-five. I did not stand with him over the body of a dead comrade, sing with him at the top of our lungs Back Where I Come From, miles and miles away.

But he did permit me to feel his heart, to honor me with his pain, to trust me with his future.

I so wish there had been more of the latter, Porthos. I so, so wish.

He died at age twenty-seven, having seen so much death, having hurt so much pain, yet having also smiled so many smiles, having pulled so many pranks, having charmed his way out of so many tight squeezes, having watched so many episodes of The Vampire Diaries with his Dad, having known he could talk to his Mom about anything, having deeply enjoyed his brothers’ happiness with the loves of their lives, having texted one last time to Athos, the last Musketeer, just hours before his death, “Love you, bro.”

And he did, Athos. He did. That I know, and that I wanted you to know as well.

Goodbye, my friend. Goodbye.

Goodbye, My Friend

March 26, 2013 By Paving the Road Back in Living Life, Professional Relationships Tags: doctor-patient relationship, grief, Posttraumatic stress disorder, PTSD, veteran, war 12 Comments

Mere hours ago, one of my patients died, not by his own hand, but suddenly, unexpectedly, far too young, far too soon.

Words fail me. Yet at the same time, I cannot let this night pass without my having typed at least a few such words onto a screen, into cyberspace, for him, whose smile I will never again see.

My God, never again.

Goodbye, my friend. For indeed we were not just “doctor and patient,” were we? It matters not that in another few hours, in the very next daylight I will see, I will write my final note in your chart, does it, for you were never just another note, never just words under federal protection.

These very words that I type, at this very moment: God, I wish you could see them. I wish I could see you seeing them. I wish we could laugh about them. I wish I could hear you say, “Jesus, Doc, lighten up, why don’t you.”

I promise, my friend, that one day I will. The memory of your smile will help me do just that.

But for now, I have to ask you to give me a few hours, a few days, as long as it will take.

May somewhere, somehow, not just my memory of you, but you—you—know: it was never just a job.

At this very moment, you cannot know how glad I am that I can write that.

But then on second thought: maybe you always did know that.

Ergo, your smile.

Goodbye, my friend. Goodbye.

Combat Veterans and “Closure”

March 21, 2013 By Paving the Road Back in Living Life Tags: Dr. Casagrande, grief, longform, Max Harris, Posttraumatic stress disorder, PTSD, veteran, WPLongform 1 Comment

A few days ago, Max Harris wrote the third of his blog posts (from Every Day Is a New Day) about his losing to death his therapist, Dr. Joseph Casagrande. In my two previous posts, I shared Max’s frustrations and anger. Today I share his grief, just he shared it with all of us:

I went out to the cemetery today. I had learned late Thursday night that Doc does have a final resting place and it was less than a half hour from my house. Needless to say, after spending Friday getting everything sorted out with the VA (that’s another post for another day), I was exhausted and couldn’t make it out to the cemetery yesterday.

So I went this morning. Talk about surreal. There I was, not a soul in sight anywhere. I was standing in front of his grave marker, solemn and contemplative, head down. No cars drove by the cemetery in that moment and the snow started to come down very heavily. It felt like one of those moments you read about in books or in serious dramas. Yet this was real life. This was MY life and, for some reason, it just felt right that I should have solitude and quiet in that moment.

And then it passed and the emotional pain hit like someone ripping off a Band-Aid. Intense, searing, yet short lived. I was left with the dull throb of missing someone I would never see again, but being there – seeing Doc in his final resting place – gave me the closure I needed desperately to fully move on. I didn’t realize how badly I needed it until that moment. It made me wonder why I needed that closure, that finality, so keenly.

I thought about it on my walk back to the car, on the ride home and a good portion of the early afternoon. And then, it hit me. I needed this because I never got closure for all of the death and violence I experienced over in Iraq. It made me think about all of the other veterans with PTSD that were suffering just like me and it made me realize: If there is ONE THING that can trigger us and bring it all back into our consciousness, it’s having someone close to us die and not getting the closure we need to move on.

In retrospect, I recognize now that a lot of the anger I have felt for the past few days was not anger felt but, rather, anger remembered. Grief. Not felt, but remembered. Helplessness, intensely remembered. I recognize now that this event, the unfortunate circumstances surrounding Doc’s passing and the way in which I was informed, has been a blessing in disguise. It may take it a while for me to fully accept that, but I know I eventually will. What I have gained from this experience is how losing someone I care about will affect me in the future. It also equips me to support my fellow veterans if they find themselves in the same position.

So take heed. If it is in your power, do everything you can to provide adequate closure for veterans with PTSD. Don’t blindside them. Do what you can to be compassionate and try to leave them feeling like they are in control of the situation and how they choose to grieve.

VA Admin, ARE YOU LISTENING?

The combat veterans whom I serve often ask me “When will it end? When will I be able to move on?” They—and I—often struggle to understand what, at any particular point, that “it” is: the emotional instability, the nightmares, the flashbacks, the guilt, the grief? All the above?

If only the latter, if only.

There is a part of the brain called the hippocampus. Among its various functions, it serves as the “cataloguer,” if you will, of our life’s experiences. It is the part of the brain that allows us to remember an event and actually remember it, i.e., put it in the past, in a particular context, one that began and then ended, one which no longer abides with us today. The hippocampus is our own personal scapbooker, of the good times, of the crummy times, one of the main producers of our episodic memory, the this/then-that/then-that of our existence.

For the most part, the hippocampus turns off when we experience trauma, when Reality overwhelms us with the fire and brimstone that ignite our emotions into a wildfire worthy of any California hillside. No time to catalogue in such a situation: it’s time to move!

Unfortunately, as a result, such memories then hang around as vivid videos inside our heads, as if we’d been transformed into a smartphone that could transport us back to Hell with the mere tap of a finger. They’re not downloaded off the phone, if you will, into our brain-laptops, into file folders marked “War” or “Attack” or “Earthquake,” with each segment named and stored as a WMV file, ready to be watched at any time, true, yet just as ready to be shut off by a click on the Play button.

Ready—and able—to be “closed.”

The “closure” of grief and the “closure” of trauma are not, in quite important ways, synonymous, even though both processes are ultimately about loss: the former of someone real, the latter of a fantasy, a hope-against-hope that “it will never happen to me.” It is precisely because the experiences are indeed both about loss, though, we can see how they often find their ways to plow together into our souls like the proverbial Mack truck.

Max, like so many combat veterans, is once again having to catalogue the world: Dr. Casagrande is gone; his buddies and the Iraqi civilians are gone, whether they “left” a month ago or, as Max noted recently, ten years ago this month. There is a comfort in cataloguing, in filing a memory, an emotion into a neuronal cabinet so that it isn’t just sitting around ready to be stimulated at a moment’s notice.

Sadly, though, neither the cabinet drawers of “grief” or “trauma” have the common courtesy to stay closed. They have this tendency to fly open at the most inopportune of times: a song heard on Pandora, a film clip on the History Channel, a photo on page five of the local morning paper.

Once they have been downloaded and filed at some point, though (all metaphors wonderfully mixed), they can be filed back, even after they’ve popped out here and there. There is comfort in that. One doesn’t have to live in the mind-cinema from Hell, in other words, stuck on the front row, all that horror careening toward your senses, larger than life.

That theater at least can be closed, hallelujah.

I’m glad that you had that time in the cemetery, Max. I’m glad that Dr. Casagrande can be “filed,” while never filed away. May his “folder” pop open at all the right times, causing you to remember once again his warmth, his wisdom. May he rest in peace in Pennsylvania, and may he continue to bring you peace wherever you might find yourself.

A Veteran Speaks Out About His VA Clinic

March 15, 2013 By Paving the Road Back in Living Life, Professional Relationships Tags: combat, Doc Casagrande, Grief Loss and Bereavement, longform, Max Harris, Posttraumatic stress disorder, PTSD, VA, veteran, Veterans Health Administration, WPLongform 7 Comments

The following is the most recent post from Max Harris in his blog, Every Day Is a New Day. As I have often said, I admire Max greatly for his passion, his service, and his willingness to walk the walk that he talks. He doesn’t pull punches.

Given how important recent events have been for him (see my last post, In Memoriam: Joseph J. Casagrande, PhD, 1943-2013), I felt it important to reblog this post as well.

I, of course, cannot speak personally as to his experiences with VA personnel over the past days.

I will say this, however: Grief is real, physically real, not an emotional option, but an emotional necessity. Of the seven primary emotions postulated by many modern affective neuroscientists, CARING and LOSS/GRIEF are two. It is the former that draws us to our families, our friends, our communities. It is the latter that lets us know that all is not right, that we are in danger, alone, in need. Our brains and minds take these basic emotions and elaborate them in all the ways we have to experience closeness and distance, from ways prosaic to those poetic. But at their bases, these emotions call us as deeply, as insistently as any other.

For combat veterans as well, it is these very emotions and their offspring, CARING and LOSS/GRIEF, that often waylay them most powerfully and, I must say, most predictably. Combat veterans learned the power of CARING, of the deepest of friendships, even of love in basic training, in the dorms and chow halls, outside the wire, together. And sadly they learned, sometimes in ways deeper than they ever had previously dared imagine, the power of LOSS/GRIEF, the loss of love that takes with it a part of one’s very soul.

I’ve said it time and again, as have many far brighter than I who have worked with those who have served in combat: never underestimate the love and the grief of a soldier, a Marine, a seaman, an airman, a Coast guardsman who’s put himself or herself in places where terror can sidle right up to him or her, tap the shoulder, and whisper a “boo!” that emanates from the depths of Hell. Never.

As professionals, even as loved ones, we cannot rescue the combat veterans in our lives from the loves they have lost, the pains they have endured. We can, however, do the best that each of us can—some a little, some more—to absorb at least portions of those griefs, those pains, never fully (believe me, the veterans never ask that of us; they know far better than we do the impossibility), but always genuinely.

It’s the least we owe them, the absolute least.

My heart goes out to you, Max, for losing Dr. Casagrande, for having lost all those you lost as you served, for having seen all the losses around you over which you had no control. You have always been a strong man. You are one. You will always be one.

Remember: strength and sadness, resolve and tears can co-occur. They’ve been doing so for centuries, yes, even among warriors.

That’s just the way it is.

For all who have loved and lost, who can be angry because of that, who still struggle to make sense of a world in spite of that:

After everything that happened yesterday, I needed to find answers. I was in no condition to work but tried anyways. I made through a little over two and a half hours of my shift before I couldn’t hide my grief anymore. I was emotionally drained and physically exhausted. I left work and I headed straight to the VA and asked to speak to the Patient Advocate. I was ushered into his office and he asked me how I was doing and what he could do for me.

I told him about the past month and the way that I had been treated and that I was very upset with the manner in which I had been informed of Doctor Casagrande’s passing. He responded without remorse that he and upper level administration had decided the best way to handle this ‘situation’ was to not allow non-clinical personnel to say anything and to keep mum until the vets came in for their next scheduled appointments. At that time another doc would be waiting to (sarcasm here) ‘blindside’ an unsuspecting veteran with this horrible news. I was stunned. I told the advocate that I don’t have scheduled sessions with Doc Casagrande and that I was only in his group CPT session. The advocate responded, “So many people come and go through the groups that we didn’t bother.” Again – stunned. I told the advocate it would have been easy to see, if he would have bothered to look at the rosters that I had been at EVERY session for the last six to nine months. Remorseless, he deflected my comment with something along the lines of what’s done is done and ‘gee, we’re so sorry you found out this way.’ I followed up by telling him that no one offered me grief counseling, nothing. He very quickly offered, :”would you like to talk to someone now?”

It was at this point that I realized that the administrators had no flipping clue how to handle these situations. This advocate, along with administration higher up, put hundreds of behavioral health patients at risk with their approach to dealing with the doc’s passing. I wondered if the disconnect flowed into the care side, so I said I would like to talk to someone. I was introduced to a clinician (I don’t remember if she was a doc or a nurse or a social worker) and talked about how messed up I was from all of this and it became very evident to me that she was distressed at how distressed I was. She told me that every veteran that she had seen in connection to Doc Casagrande’s death had reacted EXACTLY the same way I have. She also mentioned (although I don’t think she really meant to) that there were still veterans that didn’t know because they hadn’t been in for their scheduled appointments yet. She told me, “I know, after everything that’s happened that you have no reason to trust us, but would you at least talk to one of the docs tomorrow who is taking over Doc Casagrande’s patients?”

I could sense her frustration with the whole situation. This was an utter mess and Doc’s co-workers were just as caught in this storm as I was. I said I would meet with someone tomorrow and I scheduled my time to meet.

After I left and was on my way home, I thought about the whole situation and it made me incredibly disgusted. That patient advocate was to advocate for what was best for the patients. Either one of two things explain his decision: He was lazy and didn’t want to put in the extra work and due diligence to make sure every one of the doc’s patients was informed as quickly as possible OR he was put in the position to make this decision without any knowledge of what WAS best for us. The VA needs to understand how much danger they put the veterans in. If I was any less stable than I am, I would have done things I would have regretted (become a danger to others) or done something I would never be able to regret (committed suicide). Every veteran should have been afforded an equal opportunity to grieve and should have been told in enough time to attend the memorial services. The way they decided to handle this situation was reprehensible and inhumane.

So, I stand by what I said yesterday in my post. The VA needs radical change. And it needs it now. No longer can we continue to put our nation’s heroes at risk due to the ineptitude or apathy of bureaucrats. I will fight from now until my last breath to make sure this change happens. Come hell or high water. I have had people tell me the system is too big to change. I respond with this. Bullshit. When the people you are designed to serve are forced to go elsewhere to ensure they receive quality care and compassion, you have failed to meet the most basic of requirements for your continued existence. I will not bear the legacy costs of a broken VA when those legacy costs are paid for with the blood of my fellow veterans who have lost hope and take their own lives. The time for change is now. Let’s be heard, folks. Don’t stand silent and condone this with your inaction. Fight for the change we all deserve.

In Memoriam, Joseph J. Casagrande, PhD, 1943-2013

March 14, 2013 By Paving the Road Back in Living Life, Professional Relationships Tags: Cognitive Processing Therapy, grief, Joseph Casagrande, Max Harris, memorial, Posttraumatic stress disorder, PTSD, veteran 1 Comment

In several past posts I have talked of Max Harris, a former Army Arabic linguist who has bravely written of his struggles with combat trauma /PTSD in his blog, Every Day Is a New Day. Below is Max’s most recent post.

I have had the honor of working with Max as a friend and fellow blogger over the past year, and I have especially been glad that he had been able to find a solid, meaningful therapeutic relationship with his psychologist at his local Community-Based Outpatient Clinic (CBOC) in Allentown, Pennsylvania. I was quite saddened, therefore, to learn of his therapist’s recent passing–and especially saddened at how deeply the doctor’s death has impacted Max.

Below is Max’s tribute to his therapist, Dr. Joseph Casagrande. It speaks for itself, both in his pain, his frustration, and his hope. I gladly reblog it to share with others the work that this dedicated clinician did with Max and with other men and women who have served in the military. May Dr. Casagrande’s work and compassion continue to be an example to us all.

I try to keep the tears from hitting the keyboard as I write this. I found out today that I lost a man who held a special significance in my life. In his honor, I want to share what I knew of the man.

Read His Obituary Here: Dr. Joseph Casagrande

I never even knew his first name. We just always called him ‘doc’. I didn’t even know him for very long, but Doc Casagrande had a huge impact on my life. About a year ago, when I was out on short-term disability and learning how to cope with my PTSD, I found out about his Cognitive Processing Therapy (CPT) Group and asked to join it. That’s when I first met him. We met one on on and he asked me pointedly whether I was committed to learning the tools I needed to learn to better my life.

That should have been the first clue that this doc was different. I went to my first group session two weeks later…and my life was changed forever.

Over the course of the past year, I have taken control of my life. I still have horrible nightmares, I still get triggered. I still have to fight the depression, the anxiety. The difference is that I have acquired, through emotional growth and a considerable amount of emotional pain, how to better cope with these symptoms of PTSD. I learned these skills in my CPT group and at the direction of Doc Casagrande.

He was an amazing man. He never wore his heart on his sleeve but his passion for helping veterans came through in his straightforward attitude and brutal honesty. He told us what we needed to hear, no matter how difficult. This was his gift to us, he taught us to look at our behaviors and beliefs unflinchingly, to never back away from a problem. Doc always knew what we needed to hear and talk about the most and directed group discussion. He didn’t drone on and monopolize group time. He asked pointed questions and, throught his direction and the support of the other veterans in the group, each of us learned more about ourselves and what we could do to make changes for the better.

Four weeks ago, Doc wasn’t at group. Neither was anyone else. When I asked where everyone was, I was told that Doc was out sick. Concerned, I let it ride. Two Wednesdays ago, someone else was leading the group, a clinical social worker (for more about this group session, click here.) By this time, Doc Casagrande had already passed away. No one said anything. When I asked about Doc, the social worker evaded the questions with ‘I don’t knows’. Growing more and more concerned, I went to group today and noticed that the room was empty again. I didn’t wait around. I left and drove around for a little, thinking. In the end, I came back just after the group was ending and I ran into another doc that I have worked with and asked him for a no-bull explanation as to what was going on. The doc stared at me, stunned. The look in his eyes told me everything I needed to know but the doc said. He passed away. I found out that Doc Casagrande had passed before the last group session that I had been to and I felt the lights grow dim. My world took on a much more threatening glow.

As I said in my previous post, ‘The VA Screwed Up, Big Time.’ I was angry and very distraught. My grief was eating me alive. As I have had many times in the past when I have worked with Doc Casagrande, I felt a moment of clarity. The grief is still there and still profound. The fact that I never got the chance to say goodbye, to have closure, will haunt me for quite some time. What that moment of clarity gave me was resolve – to continue to do the work he would have wanted me to in order to make the most of my live. And to make a difference for others. That moment of clarity showed me that, while I was robbed of my right to honor the man after he died, I could live my life – the live he had made possible – in his honor. To live my life as he lived his: with compassion, honesty, integrity, and unflinching resolve to do the right thing.

It is with this in mind that I share with you my vision. I want to take what he has taught me and make a difference for veterans with PTSD. As I move forward with creating my non-profit, I will be needing a physical location. In his honor: It will be named the ‘Joseph Casagrande Center’

I ask for your support in making this a reality. Please help me and others that knew him honor his memory and his mission.

In Love and Grief,

Max Harris

In Memoriam, Clay Warren Hunt, 1982-2011

March 7, 2013 By Paving the Road Back in Living Life, Respect, Honor, Duty Tags: 60 Minutes, Byron Pitts, Clay Hunt, combat, Jake Wood, longform, Posttraumatic stress disorder, PTSD, survivor guilt, Team Rubicon, veteran, war, WPLongform 5 Comments

I have been putting off this post for several days.

Fortunately, Life has been more than accommodating in this procrastination, given that it has certainly proceeded at a hectic pace recently, what with travel, snow, college visits, surgeries (my wife’s, and she’s fine, all things considered), and—hallelujah!—the book manuscript finally at the editors, ready to be sliced and diced.

But it’s time.

This past Sunday, as CBS’s 60 Minutes was airing, I was in the car with my eldest as she was driving us back to Goshen College after her (so-called) Spring Break. Our most pressing issues of the evening were, upon arrival, a). whether her fish was or was not pale and b). whether she and her boyfriend would have the leftover Costco chicken pot pie the next night or the night after that.

How lucky a father I am.

Only much later that evening, as I was checking my e-mails far too late in the night, did I learn from a Google news tracker that earlier that evening the CBS news show had aired a segment, presented by Byron Pitts, entitled “The Life and Death of Clay Hunt.” Given that it was well past midnight, I decided to check it out later.

On Monday, I did.

It is this picture that I cannot get off my mind, the one that greets the curious web surfer who happens upon the 60 Minutes site:

It’s his eyes. Pure and simple, the eyes.

God, how many times have I seen those eyes.

Not only am I a lucky father, I am also a lucky psychiatrist. On many a day as a Suboxone provider, I have had the privilege of helping men and women who have struggled with opiate (painkiller/heroin) dependence re-find their lives. For many—and, thankfully, I do mean many—relief from opiate addiction helps relieve them of much of whatever combat stresses they might have endured. Thank goodness, “return from combat” does not have to equal “PTSD.”

But then there are the days I see those eyes.

Uniformly, the men behind those eyes are, like Clay, quite handsome, sturdily-built, intense as all get-out. Whether in the waiting room or upon entry into my office, they sport that same smile Clay flashed so naturally, so alluringly as he struck that “hey, I’m just a cool guy” pose in the college video interview shown on the segment, straddling the table chair, forearms debonairly leaning against the chair’s back, looking, for the life of him, as if he were a screen-test finalist at the next Ryan Gosling look-alike contest.

Yet how much more than charm and magnetism do such eyes convey. Mirrors of the soul, they are, or so the proverb tells us. How sad it is to realize that, yes, the proverb knows whereof it speaks, painfully, wrenching-ly so.

I’ve said it before, I’ll say it again: how we’d like to believe that the attractive never suffer, that somehow good genetics and a few extra hours at the gym insulate someone from the truths that Life will simply not let most in this world avoid.

Even more, though, how we’d like to believe that the attractive never think deeply, never ponder, never see the images of the dead pass before them, daytime, nighttime, never feel their very souls being wadded up and flicked into some plastic-lined, psychic receptacle at the far end of the park downtown.

Clay was born a mere two weeks before I finished my last medical school rotation, Pediatric Neurology at the James Whitcomb Riley Hospital for Children in Indianapolis, over thirty years ago now. Seeing his eyes; seeing the effect he continues to exert two years later on the men and women he touched; seeing his battle buddy, Jake Wood, no slouch in the looks and intensity department himself, struggle to maintain his own cool-guy composure not just in front of a camera, but clearly, by his own admission, day after day after day, at his every thought of this man who, even as we speak, should have been preparing to get himself measured for a groomsman’s tuxedo—seeing all that, I’m glad that I have thirty years behind me, that I’m foolish enough still to believe that I can somehow hold within me another’s sadness that can never be fully held, that I’m self-forgiving enough to allow myself to keep trying to do just that long after a wiser man would have hightailed it out of town and not looked back.

“Survivor Guilt” is what they call it, of course, the progenitor of those eyes. Clay hauled it around as a rucksack heavier than any that a sadistic, higher-ranking chain-of-command could have ordered him to carry. Winston, my “correspondent” over the past several posts, has been doing the same, though still alive, thankfully, still hoping that one day it will no longer commandeer his dreams, hijack his all-too-brief moments of happiness.

How many times a day do I see it in the men and women whom I have the privilege of serving, the guilt, the sadness in those eyes? Sometimes they flash before me, those pains, much as they did in those moments in which Jake Wood was no longer the honcho from Team Rubicon, but rather was simply the grieving best friend of a good man. Sometimes, though, they camp out right there in front of me, in eyes that literally have seen too much and that now, somehow, are desperately trying figuratively to see again, uncertain whether they dare brighten again, uncertain whether they are worthy of even considering doing so.

To Clay’s parents, his family, to Jake Woods and all those who served with him, I can only say: I wish I could have known him. I wish I could have appreciated those eyes in much lighter, much more rascally days.

I am so glad that each of you had many of those very days with him.

May the memories of them sustain you always. And may he rest in peace.

Paving the Road Back

Serving Those Who Have Served in Combat

Reporting for Duty, Sir

The Tattoo Graft

Briefly . . .

“Taps” and the Last Musketeer

In Memoriam, Porthos, 1985-2013

Goodbye, My Friend

Combat Veterans and “Closure”

A Veteran Speaks Out About His VA Clinic

In Memoriam, Joseph J. Casagrande, PhD, 1943-2013

In Memoriam, Clay Warren Hunt, 1982-2011

Follow “Paving the Road Back”

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Share this:

Like this:

Follow “Paving the Road Back”