Will the Real Me Please Stand Up?

He came in without an appointment, first to our Access Center, then directly to me.  It was time:  he had to get off the dope.  He couldn’t live like this any more.

When persons first come to me in my role as the doctor who provides Suboxone, the remarkable medication that helps many opiate addicts find a second chance at life, they are never in good shape.  To start on Suboxone, one needs to be in the early stages of opiate withdrawal, which is anything but a fun state:  gastrointestinal disturbances (nausea, diarrhea), temperature dysregulation (hot and cold flashes), severe muscle cramping–in short, a generalized state of ick.  None of my patients first encounter me with a bounce in their step–with the ill-temper of a bouncer, maybe, but never with a bounce.

He presented as quiet, even a bit timid.  I could still feel the Marine in him, though:  the occasional flash of the “can we get the point, please?”  The disgust of a drill sergeant with a new recruit (i.e., himself) who just can’t seem to get it.  But all things considered, he was respectful and cooperative.  He merely wanted all this crap over with.

Good news:  since then, a lot of the crap is over with.  He is feeling better.  Physically.

Also since then, I’ve heard from others that he has not always presented himself thus.  He has in the past had a far more confident air about him.  He has made an impact on people that has been quite lasting.

Eventually I asked him about this.

“You know,” he told me, “I’ve thought a lot about what you said in the beginning, about how a lot of guys feel as if a part of them died over there.  That’s what happened to me too.  Ever since I’ve been back, it’s as if I’ve been trying to create this new person for the world, somebody who people would like, somebody who doesn’t get all angry, who’s put together, confident, ready to take on the future. Lots of people think that’s who I am.  So I keep trying to make that guy–but it isn’t working.  The foundation just isn’t there.  I keep asking myself what I’m doing wrong, and I can’t come up with any answers.  I don’t know what to do.  I’m lost.”

“How has love been for you?”  I eventually ask.

He drops his head. “You wouldn’t believe the number of women I’ve dated since I’ve been back.  And I’ve just been awful.  I reach a point, and I  get bored, and I disappear–well, all except my current girlfriend, though.  She’s stuck with me through all this drug stuff, encouraged me.  She really loves me.  I say I love her, but I’m afraid I don’t.  I’m afraid I’m going to hurt her, really badly.  I don’t know if I’ll ever be normal.  All I want is a family, a house, a career–to help people.  That’s it.  But I’m so self-destructive.”

Fortunately he has not recently had any thoughts of suicide.  But he has indeed more than once contemplated swallowing a gun.  It’s serious.

His story is an all-too-familiar one.  His best friend in the world was blown up right next to him.  He shouldn’t be alive–literally.  In any previous war, he’d have become another name etched on a memorial.  His picture is right next to the dictionary entry for “survivor guilt.”

Yet that’s not all he is.  He is a guy, for example.  We guys are not that hot at closeness.  We know we want it, but we’d all prefer that we wouldn’t have to get all caught up in that mess, you know what I mean?  Come on, women in our lives:  you know the drill, don’t you?  I mean, we’re still here, right?  If we didn’t want to be, we wouldn’t be.  Right?

He’s also a guy on the verge of life.  A talented guy on the verge of life.  You know, I’ve been able to feed and clothe my family off the notion that somehow–don’t ask me how–intense, thoughtful men should be able to figure out where they can put their ambition, do so while also being confident but not obnoxious, while being a regular “guy” your buddies would want to hang out with, while also being a decent partner and dad who can be comfortable and supportive at home, at all times, all the while rising to become the top of their game–and doing all that easily and happily.

True confession:  I bought into that once myself.  I think my therapist was able to remodel a whole wing of his house as a result.

My therapist enjoys that wing, I’m sure.  Lucklily, in the process, he also–finally–got me to see that maybe I too could start getting real and yet enjoy life as well.

The point of today’s post is the same as the one over the past several posts:  never, never, never fall into the trap of believing a combat veteran when he or she tells you–no, believes with all his or her heart and mind and repeatedly, repeatedly tells you, if you’d only listen, numbskull–that he or she is all-PTSD, all-the-time.  Never.

For the guys, certainly:  never, never, never let them think that if only they’d not gone to war, they’d have breezed into love and work like all the other “normal” men around them.  (If ever LOL was to find its utter fulfillment, it would that last statement, believe you me.)  Never.

“Listen,” I eventually said.  “Did losing your best friend in the world and not even knowing it until long after he’d been in the ground, all because it took you that long to recover enough to open your eyes–did that change you forever?  Yes, it did.  Will love be hard because you never want to hurt like that again, never want to feel the pain of someone for whom you’d die in a heartbeat having the gall to die before you had a chance to prove that?  Yes, it will.  Are you lost because a big part of you believes down to your core that a loser like you, daring to breathe while others far better than you are mere memory, should never be allowed to find a way anywhere, ever?  Yes, you are.”

“But you’re more than that.  You don’t feel it, but your not feeling it doesn’t make it false.  Even if you’d never boarded that plane heading over the Atlantic, you’d still be terrified of closeness with a partner, uncertain whether you could ever make something of yourself, fret over which way to turn now, whom to trust, what to do next.  You think you’ve been creating this “actor” as if he were some figment of your imagination, smoke-and-mirrors out of whole cloth, the phony of phonies, hoping against hope that no one will catch you in the act?

“Wrong.

“You’re a guy.  You’re a guy who’s seen some really bad things.  You’re a guy who’s lived some really bad things.  You’re all that–and you’re not.  Our task ahead of us is not going to be an easy one, but we can’t shirk the mission:  you’ve got to become more able to tease apart what’s PTSD and what’s normal-guy-ridiculousness.  Every young buck has to be tamed, at least to a certain extent.  And you, my friend?  Let’s face it:  you’re quite the young buck.”

He did look away–very briefly–on that one.  Yet I caught that hint of a smile.  Good for him.  We’ve got something to work with.

The combat veterans we work with desperately need a narrative to add to the “I’m just War” story they tell themselves day in, day out.  Good news, folks:  there is one.  It’s called “human trying to make it in this world.”  Their PTSD will complicate that narrative–but it will not obliterate it.  Never, never, never let them go on thinking that.  Never.

Your reward?  The combat veteran’s “real me.”

It’s worth the effort.  For both of you.

I can hardly wait to see it in him.

It’s the smile.  Gets me every time.

Somewhere, Minus the Rainbow

A thought-provoking confluence this week.

“If I read ‘I know this Marine . . .’ in your blog, then I’ll be sure you’re talking about me–and that should be good for a few laughs, at the very least!”

Well, as it so happens,  I know this Marine . . .

This week I saw again the speaker of that quote, a Desert Storm veteran, Semper Fi to the max, whom I’ve known for almost three years now–and who is apparently a reader of this blog.  He’s indeed good for more than a few laughs, believe you me.  If I were to tell you that his favorite TV show is Family Guy, you should then be able to figure out exactly what I mean.  As he’s wont to say, “They’ll say the things on that show, right there on television, that you soooo want to say, but wouldn’t dare.”   (And true confessions:  I’ll laugh at Stewie’s pre-school play,  “Terry Schiavo:  The Musical,” until doomsday.  I’m a wicked person, destined for the Flames, I know, I know.)

Yet we have not always been able to laugh together.

Around the same time, on Tuesday I read a blog entry that has haunted me all week.  In her entry entitled “Monumental Victories and Then Some,” the blogger Uncle Sam’s Mistress of Living with PTSD & TBI writes about the day she and her husband, a combat veteran, learned that he had received a Permanent and Total disablity rating from the VA, meaning that he will never again have to go through follow-up re-evaluations.   She was elated.  He could only say to her “Sweet” and walk out into the backyard.  She fumed mightily at his lack of enthusiasm and appreciation–until she went out and saw him.

“I got up to go chew his ass out,” she wrote, “but then I saw him staring out across the yard with his hands in his pockets . . .It didn’t dawn on me until I saw him looking out over the lawn how lost and sad he looked. Although just feet away from me, he looked so far away.  I realized then that it’s not about money, it’s not about the win, it’s not about the disability with our Veterans; it’s about losing. I watched him through the window and I realized that award letter really meant nothing but  knowing the rest of his life, he will live the war.”

I’ve not been able to rid myself of that image of that man staring out somewhere, definitely sans rainbow, ever since.  It easily could have been the Marine.  He’d once loved his job:  he had often had the opportunity to work with fellow veterans to make their lives better, and he had been proud of his accomplishments.  Yet as the years had worn on, the emotional roller coaster, the nightmares, the flashbacks, the constant vigilance:  they took their toll.  I apparently was the first who ever dared ask him to consider whether all the struggles were  worth it, whether he should, instead, take a medical retirement.  He fought that tooth and nail for a while, but soon he was too worn.  He retired.  He sought the P&T rating, as the Mistress’ husband had, and he finally got it.

Then he was home.  Permanently and totally.  At home.

How many times he has told me of his struggles, trying not to excoriate himself for taking this route, remembering over and again how hard it had been sometimes at the job simply to walk out for a cigarette without going postal.  He has struggled with much physical pain; that has not abated any in recent months.  He wonders whether he made the right decision–but he acquiesces in the wisdom behind that decision.   He has no clue what to do next with his life–yet his internal energy keeps pressing him to do something, anything, only then to betray him as it pushes him into a harsh word with a pedestrian or a tirade at his wife.  He told me this week that he has thought of getting further training in his religious tradition–but that he was afraid that he couldn’t be trusted with such responsibility, given his symptoms.

My response to the latter was quick and no-nonsense:  this man is anything but all-PTSD, all-the-time.  He’s smart.  He’s witty.  He’s sincere.  He can handle ritual tasks quite fine, thank you very much, and I told him so in just those words.   I remember him looking at me kind of funnily, but he said little, preferring instead to imagine some certificate on a wall somewhere that would let all who enter his domain know that he’s not the hick some think him to be.

Then later that night, I got the following message from him:

“I know when my family and co workers look at me with “those eyes” wondering if I am going to “snap” or “explode” around them today or when will it happen.  They put on this false front and I swear to you I can tell when they do it.  It’s like they start treating me like I am special or I am very vunerable.  That is what usually pisses me off.  You told me today that I dont suffer from PTSD all the time.  And, that made a impact.  I have moments and situations that makes my life difficult . . .

“I have tried writing this damn email for the past hour and I cant get my freaking thoughts in order or to make sense of them.  I mentioned to you that I wanted to show something in my life that I accomplished.  After today appt, I went home and opened up my old war chest of mine and looked at my awards.  I don’t need a college degree, or a certificate to show myself, my family, or the world that I accomplished something in my life.  I already did that 21 years ago.  I survived a f***ing war.  I went through not one, but, two f***ing minefields, secured the International airport of Kuwait, and helped liberate Kuwait City.

“My next accomplishment I will work on till the day I die.  That is to accept the fact I am sick both mentally and physically.  I dont suffer all time like you said. There are moments that aggravate my PTSD.  I will con’t to seek your treatment, to provide and care for my wife.  I guess, that about sums it up Doctor D.”

The only phrase I’ll quibble with is in that previous paragraph, i.e., “that fact I am sick both mentaly and physically.”   Yes, he struggles with physical and neuropsychiatric-physical disorders.  But in no way, in the colloquial way, is he “sick.”  He’s just brave.  And tired.

Even among some of the professionals I work with, I can hear an occasional “All he seems interested in is getting disability.”   I recommend to all of you professionals out there that you make a pledge right now–never, ever to say that, at least when you’re talking about combat veterans.  Let us have a brief review:

1.   We’re at war.

2.   We have an all-volunteer military.

3.   Therefore, all the young men and women have volunteered their service during a time of war, and therefore

4.   They’re not shrinking violets waiting for a handout (They’d have lived off their parents’ or the civilian government’s dime had they been so.)

The combat veterans of today are intense men and women who once found a place to put their intensity to a use that made them proud to be alive.  Combat does not wipe that energy away.  Quite the opposite:  it intensifies it.  Therefore every man and woman who returns stateside is deeply wanting to re-engage with that energy and make life work.

Yet emotional roller coasters, nightmares, flashbacks, fears, memories and concentration difficulties:  these all can make re-engagement with life seem like nothing more than a cruel farce.  Sometimes, I’m afraid, war takes away the option of an easy return to fulfillment.  Sometimes you just have to get through the day and hope you don’t run into any persnickety people or have to solve any multi-step problems.

My Marine, Uncle Sam’s Mistress’ husband, though?  They, along with almost every modern combat veteran,  hate that challenge–and hate the payments that remind them monthly that they can no longer handle easily what they once handled with aplomb.  They appreciate having some financial pressures relieved with their disability checks, but they resent and regret the very existence of those deposits.  Like the blogger’s husband, they stare into the future fearing that there will never be sun after the rain and therefore never be the residue of a prism arching through their sky–and certainly not one with a pot of gold at its end.

Never assume this is what they want, a lifetime on the government payroll without a corresponding time card at a federal facility.  Never.

I wish there were easy answers I could give the Mistress’ husband.  I wish there were easy assurance I could give my Marine.  There aren’t any.  For either of them.   So it’s up to all of us professionals to help them find places in this world–even if that means struggling with them to coerce this world finally to adapt to them, and not the other way around.  Happy little blue birds may not fly over the spectres of their rainbows, but there don’t have to be vultures either.

Eagles, maybe.  There, that’s a thought.  Eagles.

Resilient Tears

I met him for the first time last week.  Previously he’d seen one of my colleagues for treatment of a problem that was not  PTSD.  He had spoken some of his combat experiences, but as best as I could tell from the medical record, he’d reported that he was doing fairly well vis-a-vis that.   He’d found the treatment regimen offered by my colleague to be helpful, and he was meeting me to go over the course of the treatment and to continue it.  Simple enough.

He was a sturdy young man, like a wrestler, always somewhat on the heavyweight side, who’d put ten years on himself, but who was managing that not too badly, thank you very much.  He had a big smile with an “aw, shucks” quality that was not at all distracting.  He was pleased with the progress he had made.  He and his wife had just welcomed a new baby to join their much older child.  He’d found a job that he liked.  He was, in short, much more hopeful than he’d been even just a few short months ago.

As he told me about his MOS (Military Occupational Specialty, basically one’s job/assignment if one’s in the Army or the Marines), I knew right away that he’d seen quite a bit of combat engagement.  So I asked what I always ask in such cases:

“How are the nightmares?”

OK, side bar:  this is what we call, in my mental health life, a “mistake,”  because, in my legal life, this “assumes facts not in evidence.”  In other words, I just asked the question assuming that he was having nightmares.  Any therapist worth his or her salt knows that you never do this.  Always ask something along the lines of “Have you had/Are you having any problems with nightmares?”

Well, I don’t do that.  Not with these folks.

Why?  Well, my experience has been that if you ask that latter question–especially if it’s part of a “clinical interview”–it’s far too easy for the combat veteran to reply, short and sweet, “No.”  Yet if you ask the former question not “accusingly” or “knowingly,” but rather as a sincere effort to understand what is going on with the combat veteran, you might get an answer such as “Oh, not too bad” (which always leads to the follow-up question, “so what is too bad?”) or . . .

You might hear the veteran catch his breath.

This is not at all the spot to kamikaze into the veteran’s soul.  Instead you try to get a sense of how bad the nightmares are, how often they occur, how painful they are with daytime remembering.  If it becomes clear that the veteran is indeed struggling mightily with the memories of the night, I’ll often then ask–even more gently–

“How many did you lose?”

I warn my professional colleagues:  that’s a dangerous question.  Never say it with even a hint of curiosity or, worse, clinical routine.  Only say it with an attitude that no matter how brawny or steeled the man or woman in front of you appears, you never assume that the heart is equally protected.

That’s when the first tear appeared.

He had indeed lost several of his dearest brothers.  He looked down and began to rub his eyes.  Moments later he looked up at me with an attempt at a half-smile that seemed to be imploring me to understand.

“I’m sorry,” he whispered.  “It’s still so hard.  I don’t know, it just . . . it’s still so hard.”

“Of course it is,” was all I could reply.  He deserved some silence to attempt some composure.

“Why is it so hard?” he finally asked me.  “I mean, I’m doing better, but it’s still so, so hard.”

I offered him a Kleenex, and I told him about my thoughts about his soul becoming entangled with The War, about how our job was together to get those two disentangled, about how The War would never leave–but about how The War did not always have to have the central role in his life that it was still having.

Yes, he was doing well–but, no, The War was not going to let him off that easily.

“You know,” I finally said, “in a way, I suspect that at least a part of you actually wants it to be hard, truth be told.  For you loved those men.  You never want their deaths to be easy.  You want their deaths to stop torturing you, but you want them always to have a place of honor–and love–in your heart.”

Yes, I always do take a bit of a chance whenever I so boldly use the world “love.”  But honestly?  I’ve not met a combat vet so far who’s given me too much grief about it.

Besides, my patient and I both knew:  he did love those men.

He looked at me for a few seconds, tears still streaming down.  “Thanks,” he finally said.  “That helps.  Thanks.”

We shook hands, and he headed toward the door.  Once there, he looked back at me with the hint (now) of a full smile.

“See you next month.”

“See you next month,” I replied.

There’s a lot of talk these days about what may or may not make certain combat veterans more susceptible to PTSD.  I leave it to persons much smarter than I to settle that matter.

There is also a lot of talk about “resilience” and about what makes some combat veterans able to “bounce back” more easily than others.  Repeat above response.

I do know this, though:  most of the combat veterans I meet, even those who have become able to master better their inner storms, still have a place–a big place–in their hearts where the emotions will have their due.  They need to know that if they loved big, they’re going to have to hurt big.  “Hurting big” does not have to mean a life of torture.  But pain does remind the combat veteran that what he or she shared with his or her fallen comrade was real, oh so real–and oh so worthy of a lifelong spot of respectful tears.

My patient is indeed resilient.  Like any good military man, he’s not letting life keep him from his drive forward.  But like any man–just plain, old all-too-human man–he will occasionally need to pause for tears.  Those tears are the markers of his intensity and drive, not the scoffers of them.  If you feel big, you love big.  If you love big, you lose big.  And if you lose big?  Well, you just pick up the pieces in whatever way you can, and you honor the fallen–and yourself–with a trickle or two.

Or more.

Blogging War

Life takes unusual turns.

WordPress (the vehicle for this blog) periodically puts out “ideas” for its bloggers, and I took last week’s to heart:  a recommendation to check out other blogs and comment on them, just to get a sense of what’s happening out there in the real world, of where people’s minds and hearts are, and of how my thoughts can be enriched by the thoughts of others.  So, being the complete neophyte at this that I am, I just Google’d (I mean, what else do you do?), and lo and behold I began to find some very interesting people out there.

Most of the blogs I found last night were those of the family members (usually the partners) of combat veterans.  I, of course, know in theory about how hard the life of caregivers can be, how nerve-wracking, terrifying–and, truth be told, irritating–deployments can be for those left in this country.  Yet reading the words of these women (for all whom I found last night were wives, girlfriends, or mothers), their direct expression of their angers, hopes, worries:  I realized I have so much more to take in, ponder, assimilate.  We civilians have no clue.  We absolutely have no clue.

I did, though, find two blogs by combat veterans, both men.  Both have been blogging for only a relatively short time, one for a few months, one for a year or so.  On the surface they appear quite different.  MAPS1175 is a haunting, eloquent spiral of words circling around the core of a man who is seeking somehow to make the days, the nights have some meaning, some coherence, something.   Every Day Is a New Day is a gritty, just-a-guy-trying-to-make-a-living punch at life, sometimes short and sweet, sometimes wrestling like nobody’s business with a thought, a fear–God, maybe even a hope.

Yet how similar they are, really, these men’s attempts to speak what feels as if can never be spoken–what can indeed never truly be spoken, even though it never leaves, the houseguest from Hell, smirking at your soul, daring you to try one more time, à la Charlie Brown and Lucy, to get rid of me, big guy, go ahead, you just try it.  So many of the men and women I see struggle to put anything at all into even a semblance of words.  How powerful it is to read these men’s attempts to speak not only for themselves, but for the men and women whom they’ve loved and whom they would love if they were to ever meet them.

Then, this morning, I picked up the Sunday New York Times.

There it was, above the fold, big as you please:  “Sergeant’s Wife Kept a Blog on the Travails of Army Life.”  I cannot tell you how painful it was to read that piece.  Karilyn Bales, wife of Staff Sgt. Robert Bales, maintained a blog about her fears, her frustrations, her hopes for herself, her husband, and their two small children.  She worried about him.  She felt the fluttering of their younger child in her womb as a sign of their continued linkage with each other, even with him miles–no, worlds–away.  She lamented his denial of promotion.  Finally she simply expressed a hope that her children could one day look back at her words and understand.

Robert Bales, that night outside Kandahar, changed the world in a significant way, for all of us.  Yet Robert and Karilyn Bales are also just two people, a man and a woman, trying to make four lives work in this world that doesn’t work out one iota, hoping against hope that one day their children will understand.

Or at least they were.

It is quite stunning when you think of it, you know:  with the click of a mouse, you can find yourself transported into the depths of another human, into their trivialities, their profundities.  Words, popping up on a screen:  that’s all they really are.  Words.

And lives.

Sometimes I envision myself on a beach somewhere, looking out to sea.  And there it is.  I see it.  The tsunami.  The tsunami of men and women, combat veterans, who are coming, coming.  And I know one day it will hit.  The lucky ones will be able to reach out to me, to others, with eyes pleading, “Please.  Please.  Help me.  Please.”  Others will simply roll past me, pulled deep down into those horrible waves, curled up under a bridge, imprisoned, dead by their own hands.

You know, I’m so old now, I’m not even sure I’m overwhelmed by the imagined scene.  In a way, yes, of course I am.  Yet in a way, there’s really no time to be overwhelmed.  It’s so beside the point.  I’m just going to have to reach out and grab this man, that woman.  Pull with all my strength.  Remember that I must not let myself be taken under with them.  Realize that there will be some who will let go of me, no matter how I try, whom I’ll watch sink or float away.  But then there’ll be another coming.  Keep grabbing.  Hold on.  Keep grabbing.

There’ll be nothing else to do.  There is nothing else to do.  So why waste precious time being overwhelmed.

All of us are seeking words, aren’t we?  Grabbing the ones we can.  Over.  And over.

Buddy, Got the Time?

When my eldest was in the sixth grade, I think it was, she introduced me to Tuck Everlasting, a short novel by Natalie Babbitt.  It is the story of a family, the Tucks, who drink from a spring of water that grants them immortality.  The book makes it clear that being outside the realm of time may not be as enviable a position as one might think.  In fact, I remember William Hurt, the father in the 2002 movie version of the book, saying something to the effect of “We Tucks just are.”

An eternal present tense, with a defined past, yet now with an undefined future, condemned to watch “real people” come and go, never able again to connect fully with them, lest year after year, decade after decade the pain of separation be repeated over and over and over.

I thought about that book, that quote as I was speaking this past week with one of the veterans I work with.  He’s brilliant, articulate, finally learning to trust himself again, maybe even to trust the world around him again, yet still suffering greatly from the war that he experienced firsthand.  He asked me point blank (and out of the blue, as I recall), “Will time ever be normal for me again?”

“As in how?” was the only response I could come up with.

“Well, when most folks reach my age, they talk about time ‘flying,’ with there never being enough time to get things done or to enjoy their kids or whatever.  For me, though, time is just, well, not.   I don’t know how else to put it.  It’s not as if things seem to move slowly or anything like that.  It’s just that I don’t experience the day to day as meaning much of anything.  Sure, I see my kids growing up.  I know it’s happening.  I know I’m getting older.  Yet somehow nothing seems to register like it once did.  I’m just here.  They’re just there.  Hopefully they’re going somewhere.  But I’m not.”

I was so taken by his self-assessment, its cogency–and its pathos–I could say nothing.

“But, you know,” he went on, “when I do make up mind to do a task, it’s just the opposite.  It’s as if everything is whirling around me, as if I’m moving faster than anyone or anything.  It’s push, push, push, and nothing seems to stop that need to press forward, more and more.  Is that what PTSD does to you, keeps you bouncing between no time and not enough time?”

I had to pause on that one.  In a way it felt right; in a way it didn’t.  He could have been Wiliam Hurt in that movie, after all, although he had drunk from a far more bitter cup than Mr. Tuck had.  Time is for him, or maybe better put, time can just be.

But that wasn’t all he was saying, and I knew it.  I finally came up with this.

“Many of you guys tell me that it feels as if you’re detached from everyone and everything, as if life’s going on in front of you, but you can’t be a part of it, no matter how hard you might try.  That I do believe is PTSD.”

“But I’m not so sure about the other.  In fact, the way you described it, that sounds like what a good military man or woman should do, in any situation, really:  keep the momentum going, never give up, don’t pause until the job is done.  Wasn’t it the case in the military that you were surrounded by others who felt that urgency as much as you do?”

Clearly he’d never considered that.  “You’re right” was all he could say.

“You know,” I went on, “it’s really important not to turn everything in your life into some sort of pathology.  You feel more intense and focused about everything you’re doing than anyone else around you because you are more intense and focused about everything you’re doing than anyone else is around you.  That’s what drove you into the military.  That’s why you were so successful in it.  And you were surrounded by men and women who were just like you.  In fact, had you never gone to combat, had you just retired after twenty-five some years of service, without a drop of PTSD in you, you’d have still been facing this same problem.  Civilians just don’t approach the world the way you guys do”

He smiled at that one.  “Maybe that’s why a lot of us drop dead soon after retirement?”

I do think it is important for us as professionals to point out quite adamantly to those whom we serve that combat veterans with PTSD suffer in civilian society not solely because of the symptoms of their neuropsychological illness (which PTSD most assuredly is).  To go back to the theme of the last several posts, they also suffer because they are warriors, with a warrior’s temperament–and a warrior’s awareness of time.

Many, if not most, victims of trauma (of all types) have very vivid memories of the traumatic event(s), memories that seem to stand outside the realm of time, taunting the victims with their ever-presence.  These persons recall details, chains of events with such intricacy, it seems as if the whole traumatic event must have lasted for minutes, hours even, rather than the few moments it really did.  That experience arises directly from the way traumatic events get embedded into the neurons.  They go for the limbic system, the emotional brain, the brain that doesn’t bother itself with trivialities such as time and logic, but rather immerses itself in experiences that grab us and won’t let us go.  In that way, combat veterans differ little from victims of other traumata.

Yet in no way are most civilian victims of trauma also warriors-in-spirit.  Warriors have an added burden to deal with:  they must return to a civilian world that never would have felt quite right to them.  They are burdened by their trauma; they are burdened by their essence.  A double whammy, back and forth, as in the words of my combat veteran patient, between “no time and not enough time.”

My point today is less about these painful experiences and more about how combat veterans come to understand them.  It turned out indeed to be helpful to my patient to be able to visualize himself, even if for a moment, as just another retired military, no big deal, completely clueless as to what to do in a world that doesn’t play the National Anthem twice a day.  For a moment, he felt normal, even if his “abnormalness” was the very source of his normality.

Combat veterans are not all-PTSD, folks, even the ones who suffer the most.  Never forget that within them is an energy that, if only released from war and directed into the world, can still be–should still be–labeled “good.”  Even if that “good” can be quite a burden itself to bear.

I need never forget that as well.

So, in retrospect it turned out that our hour together was indeed time well spent.  For both of us.

The Monsters Are Here, So They Say

I am unabashed fan of the original Rod Serling series, Twilight Zone.  Deep in the recesses of my memory, I seem to recall my parents watching the show at least occasionally, although at most I could only have been five or six.  The opening music still draws me in, every time, and when I found out I could watch episodes on my iPhone via Netflix, life suddenly took on new meaning.  Seriously.

A few weeks ago I re-watched an old classic from the show’s first season, “The Monsters Are Due on Maple Street,” featuring a host of great character actors whom I remember playing roles in film and TV throughout my early and teen years.  The story is a simple one:  in the opening scene, a discus-shaped shadow passes over the street of an idyllic town of the late 1950′s.  Soon afterwards, nothing on the street works:  electricity, cars, even lawn mowers.  Then for some inexplicable reason, some people’s cars or lights begin to work, while everyone else’s do not.

The key word there is inexplicable, for the whole point of the episode is simply this:  people will not live without explanations, even if they have to come up with them based on the flimsiest of evidence.  A young boy tells the neighborhood that he has just read a story about how aliens send scouts ahead of them, in the form of humans, so that the eventual invasion will go more smoothly.  Soon the various people on the street begin to throw out recriminations left and right (“He’s the alien!  No, she’s the alien!”), until finally, in a fit of fear, one man ends up shooting another neighbor to death.  Within minutes the whole street devolves into a series of terrified accusations and attacks, with lights coming on in some houses, only to dim again, with lights then coming on in a house a few doors down, then off, then on in another house, then off, cars going on and off, lawn mowers going on and off.

The Twilight Zone kicker, of course, is at the end, when the camera fades back from the street that is now in a state of riot, upwards toward  a hill overlooking the scene, only to show an actual discus-shaped space ship with two very human-looking aliens looking over the destruction below them.  One of them marvels that it only takes a few tricks, and soon humans are more than willing to destroy themselves.  The other, apparently more experienced with our kind, assures his colleague that it always works that way with humans.  Always.

I could talk again about the Kandahar incident in this light, but instead I want to consider a much more mundane, much more insidious process, one that many combat veterans (both men and women) face every day.  It’s a simple proposition, really:  when anything goes wrong and a combat veteran is within blaming distance–blame the veteran.  For many of us civilians, it works every time.

An interesting story made the rounds of the VA recently, The “Dangerous” Veteran:  An Inaccurate Media Narrative Takes Hold, telling about efforts being made in the San Diego area to establish a treatment facility for combat veterans with both PTSD and traumatic brain injury (TBI)–and about the efforts of the locals to prevent this from occurring.  Behind their concern is their fear that the facility may be too close to a school–and, of course, who knows what might happen to innocent children, right?

If  you meet a combat veteran, in other words:  thank the veteran for his/her service–and then lock your doors.

I have had more than one very frank, very painful discussion with a combat veteran about how (usually) his energy and intensity will automatically place him as the number one “blame object” whenever anything goes wrong between him and another person.  It will matter not that the other person might have just texted him some vicious insult.  It will matter not that the clerk has an attitude as big as Montana.  If any voice is raised, if any withdrawal occurs, it will be the combat veteran who is the one at fault, the one who cannot cope, the one who cannot manage his emotions.

Remember:  we’re not talking about domestic violence here, although clearly that is a serious problem among certain combat veterans.  We’re talking about the lights and lawnmowers, if you will, of life:  the throwing of the cell phone against the wall, the cursing of the clerk.  For such veterans, provocation will never be considered by civil society as a two-way street.  The veteran, we are told, like the rest of us should be able to take whatever is dished out to him, smile, firmly assert his boundaries, and then leave well enough alone and move on.

Yup, that’s exactly what he was taught in boot camp.

These are complex situations.  One should be able to say that blame is not the point.  One could say that blame should not be the point.  But usually–it’s the point, pure and simple.  When warriors-in-spirit become combat veterans, they don’t always play nice in the sandbox.  I certainly am not arguing that we should carte blanche exonerate them.  Nevertheless, neither should we ride too high a moral high horse as we collect our reasons to fear and to judge them.

Remember:  one can be angry until the cows come home, and one will not necessarily–in fact, not even usually–explode simply out of the anger.  One explodes when one has been made to feel weak, one-down, unimportant (as compared to the speaker’s importance), whether man or woman.  That’s what leads to outbursts.  The guy who cuts off the veteran, saying essentially “my goals are more important than yours.”  The clerk who gets put out by the veteran’s impatience or sarcasm, saying essentially “my manners are better than yours.”

Serling was a master of his genre–and a master psychologist.  Seek and ye shall find, the Good Book says.  Works well when you’re seeking  monsters, the kind that invade homes in the middle of the night in far-off places or that hole up in cabins in the woods, ready to assault the innocent at a moment’s notice.  No such monsters in our neighborhood, so they say.  Thank goodness.

Woe to the man or woman with a warrior’s intensity who happens into that neighborhood.

Woe even more to him or her:  the neighborhood is probably his or her own.

No Trouble At All

Been a long month away:  good stuff, challenging stuff, life.  Good to be back.

I just learned of the incident in Kandahar.  We’ll have to see what comes of it, both as explanation and as consequence.  Tragedies never cease in war.  They never do.

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’s been trying to get back to school.  It’s been anything but a cakewalk, to say the least, though that says absolutely zero about his talents and his potential, both of which are quite abundant.  He endures the lectures that many of us remember in those 100-level courses, trying to stay focused, trying not to wonder what these kids around him are thinking about him, kids who are just about the age he was when he walked off that plane.

When he sent his buddy’s body back home.

He’s trying.  He’s trying his darndest.

It’s the courses with the papers, though.  They’re the ones that get him.  Too much time to sit in front of a computer.  And remember.

He tries not to overuse his medications.  He’s put his family in charge of them.  Yet there are the times that he wakes at night and can’t stop shaking, can barely move, barely swallow.  He knows a pill won’t save him.  But, God:  it’s so awful.  A war raging, smack dab in the middle of his bedroom.  In the middle of his soul.

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 facade (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.  I had a few minutes on the way to the Starbucks, after all.  I have a few minutes now on the porch,  absorbing this quite pastoral Sunday afternoon for mid-March in Indiana.

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.

May God be with those families in that village.  May God be with that soldier.  War is, indeed, hell.

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