Monthly Archives: May 2012

Decoration Day

May 27, 2012 By in Living Life, Professional Relationships, Respect, Honor, Duty Tags: , , , , , , 1 Comment

“You went where?”

All right, we do need to back up here and give my wife a break.  It’s Sunday morning.  Because of the chaos of Indianapolis 500 traffic, our church basically shuts down on Memorial Day weekend, so I should have been snoozing in bed, that’s true.  Now, of course, she knew that I was going to have to go down to the hospital at some point today to pick up some papers (no PHI, fellow employees and supervisors, don’t panic!), so it really shouldn’t have been that much of an issue, and after all, she and the kids had been fast asleep when I left, so I figured, heck, everybody will probably still be in bed when I return, so I’ll just run down right now and then make my little side trip before the sun gets too hot and everybody’s done with church and finished lunch and therefore heading on out, so given that nobody at my house will probably even notice anyway, no harm, no foul, right?

Well, now, yes, there’s a bit of an unusual piece, that’s true:  I did take Sasha, the wonder terrier-mutt, with me, but only because I didn’t want her barking reveille once I walked past her and woke her up and got her all stirred, and believe me, my kids wouldn’t have done a darn thing to stop her if that’d happened (“It’s not my turn!”), so I thought I’d be a nice guy (right?) and take her with me, as she’ll only be in the car a few minutes while I get the papers, plus it’s not hot yet, and the windows will be rolled down that appropriate amount, enough for air, but not enough for freedom, and then I’ll take her with me as I go walking, because it’ll be quiet and relatively cool still and probably not that many people around, if any, and then when I’m done I can go to Einstein Bagels and pick up a few of the asiago cheese and everything variety, and all the world’ll be happy, and God’ll be in His heaven, and that’ll be it.  Right?

No good deed goes unpunished.  My wife woke up around 0830h, military time.  She texted me.

“Where have you been?  Where’s the dog?” she asked, more puzzled than miffed, when I called to confirm bagel orders.

“Oh, I just went down to the VA and took Sasha with me.  She was just in the car a few minutes.  Then I went over to Crown Hill for a little bit, and now I’m on the way home, and I thought I’d stop by and . . .”

Insert at this point the opening line of the post.

Crown Hill Cemetery, located in the far Northwest corner of the center of Indianapolis, near both Butler University (of Bulldogs basketball fame) and the Indianapolis Museum of Art, was, according to its website, incorporated as a cemetery in 1863, and the federal government purchased land in it for a National Cemetery in 1866.  It remains one of the largest non-government cemeteries in the nation, and many residents of Indianapolis, from the well-to-do and (in)famous, such as President Benjamin Harrison, the writers Booth Tarkington and James Whitcomb Riley, and the gangster John Dillinger, down to the most lowly (and sometimes unnamed) have found there their final rest  As a National Cemetery, it originally served as the burial ground for the remains of Civil War soldiers, but through the years veterans of all wars have been interred on grounds, including a special area for Confederate soldiers who died while imprisoned in a POW camp that had been outside the city.  In the late 1980′s an additional section was set aside for the burial of veterans from the modern area, now called the Field of Valor, at which there is an eternal flame, along with a large mausoleum.

All right, now, further background: I can’t remember the last time I went to a cemetery on Memorial Day weekend.  As I was growing up in Des Moines, Iowa, my rural family had had a certain fascination with burial grounds, so I was no stranger to such plots of land.  To the end of her life, for example, my grandmother always referred to the holiday as Decoration Day, the original name dating back to the Civil War era, only changed officially to Memorial Day in 1967 (according to Wikipedia, the be-all/end-all of all knowledge).  And decorate on Decoration Day she did, although never the graves of any fallen in battle, as my mother’s family had been quite fortunate not to have lost anyone in World War II, Korea, or Viet Nam, and the body of my father’s elder brother was never returned from France.  Still, many a plastic hyacinth remains a memorial in some landfill somewhere to the dearly departed of my ancestors.

But you must remember: from junior high on, I grew up in Indianapolis, on the west side of the city, well within earshot of the Motor Speedway and the “Greatest Spectacle in Racing.”  Quite frankly, Memorial Day to me has often been little else than a day to avoid getting anywhere near a major artery of traffic until well after the sun starts fading into the western sky.  Trust me, don’t head out, it’s not worth it, and the stale beer smell, good Lord, I can’t even begin to tell you, Schlitz, picked-over chicken bones, and urine, all in the high heat, what memories, what memories, be still my beating heart . . .

This is my third Memorial Day as an employee of the Veterans Health Administration.  It is my first, however, as a blogger–and the follower of many blogs of combat veterans, their families, and their supporting organizations.

I knew that today I needed to head out to Crown Hill.

You must also understand: I am not “patriotic” in the usual, colloquial sense of the term.  I am glad to live in this nation, and I do believe that as a people we are committed to justice and freedom.  I am proud of that.

I have always, however, been somewhat wary of the Nation-State and especially of its leaders who have often, although perhaps with the best of initial intentions, led us–and even more, led our young men and now young women–into engagements that have not, shall we say, always been in the clear pursuit of the “freedoms” that they kept telling us needed to be fought for and preserved.  I grew up in the Viet Nam era, after all.  I remember Robert McNamara and Henry Kissinger.  I even have a vague, distant memory of the Gulf of Tonkin.  It was all, again shall we say, complicated–and carried out on the backs of American youth who merely desired to be honorable and grateful for the privileges that they had enjoyed.

As a result, I’ve never been what you would call a flag-waver.  I respect the flag.  I honor the people, all of us, whom the flag represents.  I do not, however, necessarily find myself enthralled with the leaders who make the decisions that they request us to label as “patriotic” and, thus, frequently symbolized by that waving flag

So here I was, driving through the gothic front gates of Crown Hill Cemetery, met by a young women ready to give me a map of the area and a “would you like a flag?”

It took only a moment’s reflection.  I was not there for Presidents Johnson, Nixon, Bush, or Obama, for the Joint Chiefs of Staff or the military-industrial complex.  I was there for the men and women I sit with day in and day out, for the ones whose writings I read.  For the ones they loved who did not return home with them.

“Yes, thank you.”  I donated five dollars, and I drove on.

Eventually I ended up at the Field of Valor.  There was only a red Honda Civic parked there along its edges, and an older woman, probably no younger than her late seventies, was slowly walking back toward it, away from the main area.  As I headed up the walkway, we passed, briefly greeted each other.  Why she was there, for whom, I do not know.

I walked up to the enclosed area that contains the flame.  The mausoleum behind it is covered in markers of many who have apparently not yet passed, but whose remains will one day fill those vaults, proudly announcing to future generations their years of military service.  On the way up, I had walked past multiple flat grave makers, essentially all of individuals who had served in World War II, Korea, Viet Nam, or at least in those eras, given the dates on the plaques.

Along the sides of the mausoleum, however, radiating out from the four corners in an X-pattern, were rows of tall, noble limestone headstones, surrounded by well-tended mulch, guarded by small, but full-leaved trees.

I walked down all four rows.  Many of the markers were engraved only with the names of a man and a woman, usually only with a birth date of each.  At the top of the markers was the seal of the military branch that had been the pride of the (almost always) man to serve.  A few were of World War II era, a few more of Viet Nam.  A few had dates of death.

Periodically, however, I passed the only graves that I saw today of men who had died long before their thirtieth birthdays.  Most had died before their twenty-fifth.

All these graves were well-decorated, as my grandmother would have whispered reverently, admiringly: small floral sprays, wreaths, stained-glass plaques, stones with phrases inked in the most beautiful of calligraphy, even a few crosses with an Irish Blessing engraved on them.  Yellow ribbons with brief notations recalling outings still remembered.  A well-sanded piece of driftwood with a platoon’s ID written carefully with black felt-tipped pen.  A stone that merely recorded that he “always had our backs.”

As I stood before each head stone, my own names came back to me.  Danny.  Mike.  TJ.  I thought of the young men who had sat in my office, none still yet age thirty, each whispering one of those names, his voice catching, his eyes slamming shut, the silence, the tear streaming down his cheek.

In front of one the grave stones was what looked perhaps to be a tract of some kind, maybe from Crown Hill?  I picked it up.

It wasn’t a tract.

It was a card.  “The Three Most Beautiful Words in the World,” it said on the front.  On the inside?  “Happy Birthday, Son.”  Signed, with love, in honor of his twenty-seventh birthday.

Looking at the stone, I could see: he had died right around the age of twenty.

Just down a few stones was another young man’s.  And next to it?  A stone of a man and women, both apparently still alive.  Same last name.  The stone proudly announced that the man had been Navy.  It quietly announced that he and his wife would one day lie forever next to their son.

According the date on the stone, the father had been born almost exactly four months before I was.  In another life, we could have been high school classmates.

On the other side of the cemetery is the Civil War burial ground, row after row of white markers, with simply a name (or “unknown”) and a regiment.  Across from it is another, relatively large monument of shiny black marble, dedicated to veterans of all branches, the emblems of all services etched along its side.  As Sasha and I meandered past the markers in front of it, I stopped at one almost directly in front of the monument.

To my utter surprise, it was the marker of the mother and father of one of my private patients.

I have known my patient for a long time.  He is a good man, smart, funny, quite talented, married for many years, a father and a grandfather.  His has been a complicated life.  He has struggled.  He has grown.  He still struggles.  I went to the callings of each of his parents.  They too were complicated people.  I can’t say that they ever were able to see their son for who he really was.  He has a paid a price for that.  Yet they did love him, and deeply.  They were good people, the product of their times, the outgrowths of their own parents’ fundamentalism.  The father served in World War II.  I would have remembered them as one of the “older folks” had they attended the church I did growing up.  I would have remembered them well, I’m sure.

As Sasha sniffed around, she finally gave in to my preoccupation, my standing there, holding tight her lead.  So she just plopped herself right down,  about two markers to the west of me, to bask in the sun, to enjoy quite blithely the fruits of the here and now.  I knelt down, balanced on my haunches.

Here was the confluence of so many aspects of my life: memories of my own departed, memorials to veterans of all ages, thoughts of men and women who have paid me much to work so hard together to find a deeper purpose in their lives, visceral experiences of men and women who have paid me so much–as a citizen, as one who lives under that flag–not with money, however, but with their youth, with their lives, with the lives of those whom they have loved, their Danny’s, their Mike’s, their TJ’s.   The sons and daughters of my peers.  The sons and daughters who still draw us to the local Hallmark store one more year, what number is it now?  The ones who had our backs, all our backs, whether we think they should have had to be there for us or not, no matter whether the Nation-State stirs us or enrages us.

I pushed the end of the small flag I had paid so little for into the ground, just in front of the name of my patient’s father.

So many have paid so much:  for the men fighting next to them who went on to be buried years later in much quieter times; for the men who, like the soldier at the end of Saving Private Ryan, have wondered whether, in return, they have truly lived as good men;  for all of us, whether or not we asked those men and women, long buried or only recently, to pay the ultimate price for us, but for all of us who, indeed, are able to sit back today where we are, as we are, simply because each of them was.

I remember each of you, Uncle Raymond, my patient’s father, Danny, Mike, TJ, each of you.

Thank you.

To Life

May 20, 2012 By in Living Life, Professional Relationships Tags: , , , , , , 2 Comments

The AC is on the fritz at the house, so last night was a bit on the steamy side, thanks to our summer-is-here-get-over-it May Indiana weather.  My wife and I are on the opposite ends of the temperature spectrum, so while I want the fan blowing directly on me, that’ll put her under the covers with a blanket, even.  So sleep was not top on my agenda last night, and I ended up on the porch, at least cool–and in the dark, lest Sasha the wonder-mutt awaken and engender what ought ne’er be engendered past midnight.

As is my wont, I glided around different websites based on my fancy of the moment, and I had this notion to google Clint Van Winkle, the author of the book Soft Spots, which I mentioned in my Friday post, Is It Something I Said? Van Winkle has his own website, and on it he advertises a documentary that he has produced, The Guilt, the story of one of his best friends from the early invasion of Iraq, a fellow Marine who was struggling with the guilt of living (thanks to a medical retirement) while his best friend died during a second deployment.

The documentary was on a site entitled In Their Boots, a place for film makers–and especially combat veteran film makers–to produce films depicting all aspects of life post-deployment, for veterans, for the families, for their survivors, no sweet-coating, just real, very, very real.

I cannot recommend this site highly enough.  It was 1:00 AM, and I was hooked.

Before sleep finally pigeonholed me, I was able to watch not only Van Winkle’s story, but also the story of a widow who found a way to reach out to other widows/widowers (We Regret to Inform You), a fascinating study in wire and clay, believe it or not, on addiction and combat trauma (Enduring Erebus), and a heart-rending story of an intense (to put it mildly) Marine whose perfect body has protected him from so much, just as he protected his two younger brothers growing up, but could not protect his heart from the pain that resonated from the streets of Iraq to the streets of his infancy (The Way of the Warrior).  The way that latter Marine held a couple of superhero action figures, speaking of them, to them as the boy in the man and the man in the boy: I tell you, at around 2AM, that just about did me in.

That’s when I remembered Helen.

Helen Gurin was a social worker at the Judge Baker Children’s Center in Boston, where I did my training in child and adolescent psychiatry in the mid 1980′s.  The wife of a distinguished Brandeis professor, Arnold Gurin, she was one of my principal supervisors for both my years of residency there.  She was the Jewish mother of Jewish mothers, a little, shall we say, on the plump side–and she had no apologies whatsoever for that, believe me.  She had trained under some of the finest in the mid-twentieth century field of child psychoanalysts/psychotherapists, including Anna Freud and, for an extended time, Donald Winnicott, one of the key theorists and practitioners of play therapy–and apparently a wonderful man.

Soon after I moved back to Indianapolis from Boston, Arnold died after a short illness.  Helen sat shiva for him, and then she somehow let her body know that it was time for her, too.  I still remember receiving the letter from her secretary, now twenty-one years ago.

Helen was anything but brash or self-promoting.  Quite the contrary: in our team meetings on the inpatient service (and usually throughout the rest of the services, I might add), she would always bring her knitting and sit there and hook, hook, hook while the rest of us (including one very brash and self-promoting young resident from Indiana) tried to outdo each other in our brilliance and clinical acumen.

But then suddenly, a point would be reached, and Helen would put her knitting down in her lap.

Absolute silence.

And then she would simply say something, a phrase or two, an observation.

And she was always a). dead-on right, always, always, and b). just slightly miffed that she’d had to interrupt her stitches in order to get us all to realize what we should have realized a good ten minutes earlier.

So why did I remember Helen as I saw that man hold that toy, that woman take her toddler daughter to visit Daddy in the cemetery, that husky guy look out that window of a diner, somewhere toward Fallujah, Anbar Province, maybe?  As I thought about evidence-based, metrics, recovery, therapy, recovering, hope, terror, what-nexts, what-nexts–and, a brash, self-promoting, now-not-so-young, now-attending physician from Indiana?

This is why.

Dear Helen,

Can it really be twenty-seven years this July that you and I first met?  Lord, I’m treating combat veterans who weren’t even born yet.  What time has brought.

Sometimes I look back at those two years I spent at the Judge Baker Children’s Center and the Boston Children’s Hospital, not even yet thirty myself, and wonder: who was that guy?  I never see kids any more, never work with families.  You wouldn’t even recognize the world of child and adolescent psychiatry these days, Helen–and you wouldn’t be pleased, but you saw that coming, didn’t you?  I still remember your turning your nose up at Ritalin all those years ago.  Good Lord, if Ritalin did that then, one can only begin to imagine what you’d be doing now.  It’s a new world, Helen, a new world, maybe a brave one–in a Huxley way, I sometimes wonder.

Yet at other times, like yesterday, today, I feel those hallways–and all the support and, yes, admonitions that I received in them–as if I had just tread them earlier this week.

I sometimes wonder where those children are now about whom you and I talked.  They’re all in their thirties now, none more than in their early forties.  I hope.  I mean, I hope they’re all living somewhere, in their thirties or forties.  We both know there are no guarantees of that.  Did anything I did with them make a difference?

Of course you remember my asking that question so many times even back then, don’t you.

I’m still asking it, Helen.

And I’m still hearing your answer: “Dr. Deaton, haven’t you known certain people only briefly, yet they changed your life forever?”

Sometimes it’s hard to meaningfully remember the “yes” answer to that question at the end of certain days.  Yet thank you, Helen, that the “yes” is still as true today as when you asked me.

All these years later, I sit in a coffee shop, hooked up for free to a knowledge base that you would have mined like nobody’s business (of that I’m sure), and I ask myself: what do I want to say to you, wish I could ask you?  It’s a beautiful day here in Indianapolis, a little on the warm side, but not bad, really, so much like those days I’d lollygag up to the hospital from the Longwood station on the Green Line, nervously, confidently, cluelessly walking into a world that was so much beyond the dreams of a neurotic lad from western Marion County, Indiana, pah-king my cah in Hah-vahd yahd, and all that–yet also into the world of the hurting, the sad, the helpless of Boston, Jamaica Plain, Roxbury, New Hampshire, the Cape.

That’s it, of course, Helen.  It was there with those hurting, sad, helpless children that you taught me in a such a visceral, human way how at least some of us psychiatrists, psychologists, social workers must be willing to stick around for the long haul, to put ourselves willingly at the whims of the lives, fates that our patients must endure without choice, never guaranteeing them that we will be there forever, yet guaranteeing that while we are with them, we will never hold them back, will always let them leave us even when both they and we know they would rather not, should not, would give anything not to–always guaranteeing to keep the door open for them as long as it’s ours to open, just in case.

I draw on that visceral, human knowing every day.  I will need it tomorrow.  I will need it until the day I pass my work on to another, just as you did to me.  I remember wanting to give up on that work so many times back then, sitting in your office, staring at your Mona-Lisesque smile, knowing that you’d never stop me from some half-baked scheme to go to Harvard Law School, knowing that you knew that, yes, I’d come back.

I did.

There are always hard times, Helen.  You had yours.  I have mine.  You could have made your times much easier, could have settled into a quiet little consulting practice in Brookline, Newton, been the slightly overbearing, yet always right, always patient Jewish mother that you were, at a price the wealthy of Concord, Hamilton, the Back Bay would have shelled out without a thought.  Yet you stayed at the Judge Baker because that was what you did, a social worker from the old school who simply believed that one stays where one is needed, that Hillel had it right:  if not us, who, if not now, when.  No drama, just faithfulness.

As I sat there last night and watched those documentaries, saw that women gently rummage through the drawers that hold the only remnants of her husband’s scent, watched the eyes of that man who had to decide who got his buddy’s dog tags, the man’s wife or his mother, saw the look of that man’s eyes as he desperately prayed that he could get better enough to face his younger brothers, the men who once had been frightened boys who had so needed their big brother, who had been his life, his reason for being, his charges to protect from the monsters in their lives, under a table, quiet, shhh–when I saw them all, Helen, I thought of you.

How did this chubby kid from Ben Davis High School end up pouring out his worries, his passionate confidence, his testy wisecracks to you, a student of Winnicott’s?  How did he get so lucky as to experience a transitional space with you, just as I suspect you did with Winnicott, just as I am going to try to provide tomorrow, Tuesday, next week, to these men and women who have seen so much, knowing that they saw what they saw, did what they did out of the same honor, the same Hillelian words you taught me: if not us, who, if not now, when.  No drama.  Just faithfulness.

All times are hard, Helen, yet my colleagues and I who learned from you and your colleagues? We’re behind.  Really behind.  So much has changed in the years since you died: new medications, new technologies, new ways of understanding age-old problems, new approaches clearly outlined, clearly focused.  So much good is happening to relieve so much of the emotional pain that we once merely had to watch.

Yet what was it the French say, plus ça change . . .?  The more things change, the more they stay the same?  Still so much of the “holding environment” that Winnicott taught you, so much of the patience you and your colleagues taught us is so necessary as we sit with these combat veterans, even when we are teaching deep breathing techniques–or desperately in the moment trying to practice them ourselves, living them with those who are needing them most.

Yet I’m not quite sure, Helen, how many are ready for the other truth you taught me:

“We stay faithful.  We’re here for as long as we can be.  Remember, Dr. Deaton:  life is always going to be harder for them than it is for you and me.  They have seem more than we have, hurt more than we have.  We must be thankful that we have not seen, not hurt similarly–and therefore we must give in return.  That’s why we do what we do.  They need our steadiness.  They need to know that we’ll somehow find a way to be fine even when they feel that they never will be.  Nothing ends at the end of the hour except the hour, doctor, remember that.  They have to live, have to hold on long after they’ve left our offices.  We have to do the same:  live with them, hold on with them, at the next hour and the next, for as long as we and they can, just so that we can live, hold on inside them, inside their minds, their hearts, hour to hour, in all those hours before we sit together again with them.”

And I’ll never forget what you told me, so straight-in-my-eye honestly, so caringly:

“It’s hard for all of us to hold their pain, Dr. Deaton.  But I know, it’s so hard for you.  You want to use your mind, your words, that smile of yours to say just the thing that will make everything better, just like that.  You’ll be a father one day.  You’ll never be a mother.  Fathers want to do.  We mothers want to do, too, but it’s easier for us to hold.  Not easier on us, mind you, but easier for us.  But you’ll learn, Dr. Deaton.  You’ll find your way.  You’ll learn.”

Helen, I’ve only got fifteen years or so before I too have to turn over the reins, just as you and your colleagues had to turn them over to me and mine.  I actually am a Dad now, Helen (I’d say believe it or not, but I know: you knew).  It’s still hard for Dad to hold.  I want to, Helen.  But I still try every day to remember: I can’t change the past.  I can’t guarantee the future.  I can merely be faithful and–well, how about hold on, even if holding still ain’t my forte?  Good enough?

Thank you, Helen, that if you were still here to hear that question, you would just look back up at me from your knitting, never dropping a stitch, smile that babushka smile of yours, with your hair always in that bun, and merely say, “It’s time, Dr. Deaton.”

And then with a wink, “Back to work.”

They’re great men and women, Helen.  They’ve seen so much.  They’ve had to do so much that they never in their wildest dreams ever knew they’d had to, ever wished they’d had to.  They’ve had to make decisions about life and death, about perfumes and dog tags, about when they’re ready, finally, to come out from under hiding under the table.  Some weren’t even born when we met.

There’s so much left to do.

That’s why you did it for so long, though, isn’t it, Helen.  For the future.  For life.

L’chaim, eh?  Yes, I can still hear you say it.

To life.

Thank you so much, Helen.  Thank you.

Rod

Well, What Do You Know . . .

May 19, 2012 By in Culture at War, Medical Issues, Professional Relationships Tags: , , , , , , Leave a comment

So here I am in my new private office on a Saturday morning, waiting for my next patient, and I think:  OK, go ahead, let’s check out Facebook and see what’s happening in my corner of the world.  There I discover that a friend and colleague has posted a link to a New York Times article, “Ed Ray, Bus Driver During Kidnapping, Dies at 91.”

This is a nice, brief story eulogizing the bus driver who was so instrumental in saving the lives of the twenty-six children who were kidnapped from a school bus in Chowchilla, California in 1976.  Anyone alive and above the age of, say, ten in the United States at the time remembers this event quite well.  It even became somewhat of a cause célèbre in psychiatric circles years later.  The article ends with a very touching report that many of the then-children, now all in their forties, came by to visit him in his final weeks.

Nice.  So, as I usually do, I check out the “Most E-Mailed Articles” list on the side.  Have got to keep up with what’s au courant in progressive circles, after all.

And, lo and behold, there it was, at Number Eight, pretty as you please:  How Reliable Are the Social Sciences?

Well, my, my, my . . .

The article is by Gary Gutting, who, according to the bio blurb, is “professor of philosophy at the University of Notre Dame, and an editor of Notre Dame Philosophical Reviews.” 

I merely quote his final two paragraphs:

“My conclusion is not that our policy discussions should simply ignore social scientific research.  We should, as Manzi himself proposes, find ways of injecting more experimental data into government decisions.  But above all, we need to develop a much better sense of the severely limited reliability of social scientific results.   Media reports of research should pay far more attention to these limitations, and scientists reporting the results need to emphasize what they don’t show as much as what they do.

“Given the limited predictive success and the lack of consensus in social sciences, their conclusions can seldom be primary guides to setting policy.  At best, they can supplement the general knowledge, practical experience, good sense and critical intelligence that we can only hope our political leaders will have.”

My, my, my . . .

Next time I drop my eldest off at Goshen College, I just might have to take me a little side excursion to South Bend and pay a little visit to the good professor.

My, my, my . . .

Boy, Do I Have a Problem, Or What?

May 18, 2012 By in Professional Relationships Tags: , , , , 9 Comments

It’s been an interesting day:  my blogpost from earlier today, Is It Something I Said? has been shared on some listserves within the VA, and I’ve had some thoughtful comments in response.  Perhaps I will have more as time goes along.

This evening, though, I found myself checking my e-mail on my iPhone as I awaited my son’s departure from his Eighth Grade Dance, tapping my foot to the beat of that Number One Nostalgia Hit of my children’s generation, Graduation, by the group Vitamin C, wafting its way through the gym door in a kind of subtle salute to the late Donna Summers and The Last Dance.  I get e-mail notices from the Defense Centers of Excellence on various media publications on “psychological health and traumatic brain injury,” and, well, what do you know, here’s the lead story, from My Health News Daily:  Troops Today Have Better Prospects for PTSD Recovery, Expert Says.

I’ve read this story several times.  Several.  Because I am on the faculty of the Indiana University School of Medicine, I have access to the journal Science, from which much of the information in this story is drawn, from an article published in today’s edition of the journal.  Unfortunately, because of copyright issues, I cannot quote any from that article in a public blog such as this one.  I will say this, though:  I read the article several times.  Several.

Did you know that wars are now shorter and less lethal than they’ve been in the past?  Really.  The article said so.  As best as I can tell from the references, Steven Pinker would probably agree with that statement.  And he’s smarter than you.  Don’t you forget that.

It got better, though:  in the story, a reference is made to the group Strong Star, out of the University of Texas.  The following is a news snippet featured on their home page, entitled Military Matters:  The Search for PTSD Cure.

I just watched this once.  Just . . . once.

I have come to one of three conclusions:

A.  I have fallen down the rabbit hole.

B.  I really do have a problem.

C.  A and B

Oh, yes, one final thing:

This afternoon, I shared with my special ops guy the post.  He was deeply touched by it, and we had a good conversation afterwards.  He told me an interesting story.  He once participated in one of the VA’s 90-day residential programs for the treatment of PTSD.  He remembered the stay as intense, so intense, in fact, that on day 87 he went off grounds and got drunk.

He was forthwith discharged administratively from the program.

A few days afterwards he tried to contact his psychiatrist in the program to talk with him about his medications and about what he should do about further treatment.  According to my patient, the psychiatrist told him, “You’re not in our program any more.  I can’t help you.”

It was several years before my patient darkened the door of a VA.

Rabbit hole.  That’s it.  Selection A.  Rabbit hole.

Is It Something I Said?

May 18, 2012 By in Living Life, Professional Relationships Tags: , , , , , , 11 Comments

Often I fight the sneaking suspicion that I am just not quite getting something about which everyone else around me feels perfectly confident and natural.

It can be disconcerting.

For example,  I live in a world of measurements.  One of the hot terms in my mental health corner of the sky is metrics.  Metrics are needed for hard evidence, and you need hard evidence to know that what you’re doing is evidence-based, which is, bar none, the hot word in my sky corner.  If you’re evidence-based, you’re golden.

If you’re not, you’re toast or, even worse–merely anecdotal.

Please understand that I am not against research, nor am I against assuring that treatments have some degree of predictable uniformity, especially across a vast group of programs such as we have at the VA.  Currently, officially-sanctioned treatment for PTSD is very much of the following form:  an expert, such as a therapist, teaches techniques to a veteran so that he or she may better manage his or her emotional swings.   Therapy is roughly one-third lecture and two-thirds lab–and always evidence-based.

From what I can gather, I am supposed to be very, very excited about evidence-based treatment.

I believe I’m supposed to be more than simply glad, in other words, that there are now techniques available to be used to be help manage veterans’ emotional dysregulation.  Indeed I should now be sensing the highest levels of pride that I am part of such excellent, research-oriented competence.

One of my favorite people, Max Harris, the blogger of Every Day Is a New Day in “Combat Veterans With PTSD” recently wrote that General Barry McCaffrey announced that PTSD can be successfully treated within a year.  Max found himself surprised at that statement (or perhaps better put, completely and mind-bogglingly dumbfounded.)

I can’t say that I was, though, precisely because I spend my days in Metricland.  I have zero doubt, in fact, that a well-regarded colleague somewhere in my VA/DoD sky corner assured the General of that very fact, almost certainly using empirical data from the most carefully-designed of research.

Furthermore, another of my favorite bloggers, Bobbie O’Brien of Off the Base, wrote of an interview with a psychologist from her local VA who is the local Recovery Coordinator, the liaison for the national program designed to empower all veterans (but especially those suffering from mental illnesses) to claim greater access to and control over their healthcare. Apparently the coordinator wanted Bobbie to make sure all knew that it is possible to recover from severe mental illness, including from severe PTSD, i.e., that people “can and do” get better.

I wholeheartedly agree with the doctor that veterans with combat PTSD can and do get better.  I will say, though, that I could never imagine myself conjoining the words recovery and combat PTSD.  I associate the word recovery with the flu or a broken wrist.  It has a certain, I don’t know, “well at least that’s finally over” connotation to it.  I do understand that the VA and its Recovery Coordinators are in fact working to “change the definition,” and again I’m all for that.  Yet I still have not wrapped my head around why they chose the word recovery to redefine.  Progress, maybe, initiative, possibly, but recovery . . . ?

Again, I am often left with the sense that I should be using terms such as recovery and metrics and evidence-based with a certain fervor, a deep-seated joy that finally we are moving beyond the negative and the merely anecdotal into the purposeful and the confidence-building, finally into the new, hope-filled world of positive psychology and scientific rigor.

That is why I–seriously–wonder whether I have a problem.  I mean it: while of course I speak with some irony, I do wonder what it is that a lot of people see and express with ease that I, well, can’t.

Take, for example, a recent veteran.

We did not start out on the best foot, and it was all my fault, pure and simple.  Through miscommunications, he ended “jones-ing” from opiates longer than he needed, and he was not pleased.  Nor should he have been.  Opiate withdrawal gives new realms of meaning to the mere word miserable.

Fortunately, though, we found our footing, and we have enjoyed a pleasant, initial relationship.  He is a bit older than some of the veterans I’ve been treating, a veteran of earlier engagements.

He was special ops.

It’s a funny thing: I have run across more than a few people who seem to feel it is quite important to doubt a veteran’s claim that he or she was in special ops, as if it is their patriotic duty to make sure that all malingerers are ferreted out and properly disposed of, with more than a few pounds of indignation and outrage at the audacity of the claim.  It’s even more funny, given that veterans have, from my experience, zero problem whatsoever figuring out who’s a blowhard and who’s not.  I’m not quite sure why we civilians must be so fervent in pursuing a task that the veterans are handling quite well on their own, thank you.

This I will say: I have zero doubts this guy was special ops.  I can see it in his eyes, in how he holds himself, how he moves his body–in how he does not say what he does not say.

Special ops is War up close and personal.  Special ops is sometimes having to watch War wreak its havoc on innocent civilians–and being absolutely unable to do a thing about that as the screams invade your inner ear.  Special ops is about the strong and prepared of body–but there is only so much you can do to strengthen and prepare the soul.

He has been through evidence-based treatment programs.  He found them helpful.  His emotional regulation is better.  His medications help.

He asked me if I knew any good books to recommend to his fiancée.  I mentioned to him the memoir Soft Spots, which I reference on another page of the blog.  I offered him the book.  I was honest as to its content, as to Van Winkle’s extraordinary ability to make a flashback come alive, its suddenness, its removal of the reader (and the veteran) from the present into the past before a sentence is even completed.

He held the book briefly, looked up at me, and then handed it back.

“I’d better not,” he said, with a slight smile that had a knowing edge to it.  “I’m not wanting to end up rolled up in the fetal position on the floor any time soon.”

I guess we could say that he is recovering.  Will there ever be recovery?

From what I gather, I have colleagues who answer a resounding “yes” to that question.

That’s when I wonder: is it something that I said?

Maybe it’s the population of veterans I see.  Most have struggled with opiate addiction.  Maybe that’s it.

But whatever it is, to a man or a woman, each tells me stories of wounds that remain far from being healed, long after the last session of the manualized, evidence-based treatment.  I think all I do is ask them: “How are you?  How are the nightmares?  How are the days going?”  I think.   Don’t I?

And I listen to what they tell me in return.  Or at least I thought I did.

Don’t I?

For I have yet to meet a recovered combat veteran.  Recovering?  Oh, yes, thankfully, and I hope that I’m offering a part of that process.  But I’m still struggling with the notion that the verb will ever become perfected, as the linguists say: that recovering will ever be recovered.  I guess it’s a language problem after all, isn’t it?  For recovery can either be the process of recovering or the state of having recovered.  Tricky thing, language.

I wonder whether anyone will ever study life after evidence-based, life a year afterwards, five years afterwards, ten years.  Forty years.  Seventy years.

If someone does, I promise I’ll do my part to advance the rigorous-research project: I’ll let Max and my special op guy know to give that person a call.

Kilroy Wasn’t Here

May 8, 2012 By in Culture at War, Living Life Tags: , , , , , Leave a comment

For the past several years I have taught a weekly class at Indiana University in Bloomington, which is about an hour south of Indianapolis.  Bloomington is the prototypical college town, with great food, fun places to eat it–and even a bookstore or two left in which to hang around and peruse everything from postmodernism to true crime.  We had a warm winter and spring this year, so even in March I could leave my evening class on campus and pass through quite the high life at the restaurants, bars, and ice cream shops that are everywhere, in every flavor of every nationality.  Twenty-somethings (and even early-thirty-somethings): Btown is the place to be, hands down, no questions asked.

One of the more hot of the hotspots is a bar (actually a couple of bars) named Kilroy’s.  Lots of booze, lots of munchies, and lots of the hottest of the hot, well-gathered in large groups of very-laughing seas of cream and crimson sportwear (or depending on the weather, less): alums can feel young, undergraduates can feel old, I mean, this is America, right?

I wonder how many who gather there have a clue as to the story behind the mascot, I guess you’d call him:  Kilroy himself.  Truthfully, I’m on the young end to have much of a clue.  I suspect I heard the infamous line somewhere in a cartoon I caught back in the Sixties, who knows, maybe Rocky and Bullwinkle?

“Kilroy was here.”

Kilroy was here.  One of the low-brow cultural icons of World War II, graffiti’d around Europe, domesticated in the US on walls and bathroom stalls from Ogunquit to Santa Barbara:  Kilroy was here.  The symbol of the soldier, the simple guy passing through wherever, just trying to stay out of trouble (or not get caught at it), an ersatz painter’s version of “Hey, Ma, look at me!”

 

Kilroy and soldiers.

He moved to Indiana with his wife, who had been accepted to an excellent graduate program (not in Bloomington).  Neither of them knew a soul there, but soon she was immersed in her studies, making friends.  He would meet them on occasion, do his best to be pleasant, supportive.  But mostly he stayed home, not doing much of anything.

He had been a combat medic.

I have to admit: my heart skips a beat when I learn that the man or woman in front of me was a combat medic.  First, I know that he is sharp as the proverbial tack.  I know that she is proud of her service, of what she was able to learn, to make work on the fly, to respond to no matter when, no matter what.

I know what horror they’ve seen, not only with their fellow soldiers and Marines, but with Iraqi soldiers, Afghan villagers, pregnant women, toddlers, old men in the wrong place at the wrong time.  They did their job for all of them, for that was their job, and they did it well.  Theirs were sometimes–no, I’m sorry, often–the last eyes persons gazed into.

He was no exception.

He’s not gone into much detail with me.  He hasn’t had to.  One memory haunts him most, a memory I now share with him: the guy who should have known better than to jump where he did, the guy without the legs, the tourniquets, God, now, please make it stop, all the blood, there’s no more time, please.  The tourniquets.

Long before he hit the Hoosier state he’d been having the nightmares.  The flashbacks had gotten somewhat better.  But everything came back with a vengeance with the move, with his being away from anyone he might possibly know, from anybody even remotely military.

He is older than most of the undergraduates.  But not the graduate students.  And there are a lot of them in his neck of the woods, catching the latest NBA game at the local version of Kilroy’s, laughing over a beer and joke that’s only funny because it’s the third beer, cursing like a sailor–or should we say, a soldier.  Over nachos.

“I so rarely get out of the house during the day or evening,” he tells me.  “But whenever I do, it’s so hard to see them.  Part of me just wants to go up and introduce myself.  I could have played softball with those guys, dated some of those girls in high school.  But I can’t, I . . . I don’t know what to say.  I’ve seen too much.  I don’t want to be like this.  I don’t blame them, really I don’t.  But I just don’t know what to say.  When people find out that I went to the war and was a medic, they get all weird.  They . . . they try to be nice, but they don’t even know how.  They say dumb things, or they get embarrassed when they say dumb things, or . . . they just don’t say anything at all.”

He’s not crying.  He’s not staring off in the distance.  He’s simply relating his life to me, as if he’s not quite sure what even to say, as if he’s somehow looking for approval to say anything at all, as if he doesn’t want to be too much of a bother, really.  I’m almost expecting to hear him say “Permission to speak, sir.”  Or maybe “Mother, may I?”

He’s not a vulnerable-looking guy.  He’s stocky, still with good military posture, even if his eyes tend to wander downward.

Yet he looks so sad, sad as if he doesn’t want to bother me with how sad he is, sad as if that’s just the way it is, you know, just the way it is.  Sad.

I want to say to him that there have to be men and women in that town who will be willing just to hang out, not to talk about anything big or little, down a Killians or even a Bud Light with him (no need to be hoity-toit, after all), pontificate about the Pacers, the Lakers, the Hooterville High-Toppers, the guy across the street who shouldn’t be embarrassing himself in front of the whole world on that ridiculous skateboard of his.

But I know better.  He knows better.  The guys he played softball with, the girls he dated, the guy on the skateboard, the grad students debating Nietzsche or Warren Buffet:  they all know better.  His has been the gaze upon which people have last fixated, young people, old people, strong people, weak people.

God, I want to fix it all for him, arrange a few play dates, make sure they don’t run out of chips and salsa.

But I’ve seen his eyes.  The eyes that have seen.  And it’s just not that easy.

Facing Reality

May 6, 2012 By in Living Life, Professional Relationships Tags: , , , , , Leave a comment

It has been a challenging week.  From the more “trivial” standpoint, I moved my private office after just under seventeen years at my former location.  A good time to purge, I must say.  My wife was more than willing to counsel and exhort me in that endeavor.  Threaten is another word that comes to mind.

Also, we had another regulatory agency visit my VA this week.  All went well.  I’m happy.  My bosses are happy.  All God’s children are happy.

From a far more important standpoint, though, it has been a challenging week.

Earlier this week I had a series of contacts with a young veteran whom I know well–and about whom I care deeply.  For purposes of anonymity, I cannot go into detail about all our recent contacts.  Suffice it to say, however, that this week this man did not fare well.  He has struggled with significant symptoms, both physical and emotional, since the first wave of deployments.  He struggled with life before his military service.  He has struggled mightily with life since.

He did not have it easy coming up, not by anybody’s reckoning.  He is, however, very sharp, very warm-hearted–and very, very funny, in the driest of ways.  With a barely-muttered aside, he can crack me up to beat the band, no lie.   I crack him up by my being so cracked up.  We fit together quite nicely, thank you.

And he probably has one of the most severe cases of combat trauma that I have encountered to date.

He is doing so much better than he had in the past.  Gone are the periods of near-dissociative episodes, in which he felt himself split apart into “good” and “bad,” warring factions that threatened to pound his very sanity into nothingness.  In their place are far more extended periods of calm, of hope, of fun with his kids, of dreams for a future in which he can help other veterans find their greater stability as well.

Yet all can change in an instant for him.  That happened this week.  More than once.

He called me first in near-desperate panic, begging me to help him pull together, to tell him what to do now.  He listened to my thoughts.  I listened to his storms.  We found a way out, for that moment.

But there was another moment later in the week.  Same drill.  He, another colleague, and I worked through it all.  Another way out.

But then there was another moment.

Physically he is all right.  His family is all right.  Life has, however, become far more complicated, for all of them.

Less dramatically–but no less challengingly–I met this week with another veteran whom I’ve known for a long time–and whom I also care about deeply.  He is older, a veteran of a previous engagement.  He has suffered both from combat trauma and from the longstanding consequences of traumatic brain injury.

In spite of the latter, however, he has managed to complete a college degree in a science-related subject, and he is pursuing graduate work with success.  He has had to work hard–and I mean, hard.  Correlations and causations that had once come so easily to his understanding are now far more challenging to discern, at least with any rapidity.  He has to read and re-read what he used to skim.  He has to keep the reminders, the sticky notes, the periodic reviews far more at hand, far more routinely.

He had a disappointment this week, a major one.  He will move forward.  He will succeed.  Yet this one hurt.

And neither of us will forget it.

After a pause in his narrating his disappointment, he looked at me.  “You’re a smart guy, things come easily for you, right?”

I wasn’t quite sure what to say, but given that he was well-acquainted with my academic provenance, I could only be so self-effacing.

“I guess you could say that.”

“You know,” he continued, “things used to come easily for me as well.  In my training classes–big time ones, mind you, not just run-of-the-mill stuff–I was always top in my class.  Until the TBI.  It’s never been the same since.”

He paused again.  His eyes bore right into mine.

“You’d hate it more than anything, wouldn’t you, if your thoughts became as scrambled as mine can be, if you could remember all that you once could do, if every day you were reminded that you’ll never be able to go back there fully, that you’ll never again be top-of-your-game, that you’re lucky if you can just remember all the steps to heating up a can of soup.”

Silence between us.  You can bet that I was feeling those eyes smack down into the center of my peritoneum.  My gut.

“You can’t even let yourself imagine it, can you?” he finally said, softly–yes, accusingly as well, but only somewhat, truly only somewhat.  He was less interested in making a point.  He was more interested in seeing whether I’d try to imagine.

It’s an odd experience when one interacts with a patient while trying to remain aware of one’s own shortcomings, challenges–come out and say it, one’s ultimate fears.  Even though only a second or two might pass between me and a patient, time can seem to go on forever in my head, hours of self-confrontation, wondering whether what I might say is for the patient’s well-being–or for my own self-soothing.

“No,” I finally said, “I can’t.  I’m sorry.  I . . . I have no clue what you’ve gone through.  And . . . it’s hard to even consider the thought.”

He didn’t look self-satisfied.  He didn’t look accusatory.  He just looked at me, barely nodding his head.  He glanced down, as if somehow to say to himself, “OK.  Check.”  Then he started talking about another subject.  Soon we were laughing–a joint activity that we have only recently come to enjoy together.  Nothing more was said about scrambled thoughts and painful recollections.

People sometimes ask me, “How do you do it, listen to all this?”  Honestly, I don’t, for the most part, find it that hard.  More often than not, a painful series of moments will lead, at least eventually, to less painful ones, to “truths” that become less fixed, to possibilities that will lead, at least somewhat, to new realities.

Not all realities, however, as as forgiving.

I can indeed find myself speechless before certain realities: realities about illnesses that can still, in spite of one’s best efforts, overwhelm a man or woman and set back even the most determined of combat veterans; realities about neurologic capacities that will indeed grow–but only so much, and never back to a place of halcyon, intellectual ease; realities that force me to face men and women whom I care about and force me to acknowledge, even silently, that I have indeed been spared their suffering, that I have in abundance what they can only remember in sighs: an emotional stability that can keep the days from exploding at a moment’s notice; a logical ease, both inductive and deductive, that can waltz from point A to point B to conclusion C as gracefully as a modern-day Astaire.

Speechless does not mean incapacitated.  But it is speechless, nonetheless.  I dare not claim what I cannot deliver, an “understanding” that can never be anything even close.  Thankfully–truly, thankfully–the men and women I serve never hold my ignorance against me.  If anything, most of them appreciate that I don’t try to get it more than I can.

But that doesn’t necessarily make my gut feel better.  And that I have to face.  For them.  For me.

Location, Location . . .

May 2, 2012 By in Living Life, Professional Relationships Tags: , , , , , Leave a comment

When I checked with him Monday to verify our appointment time, he let me know that he couldn’t “make it downtown,” but suggested we could meet later in the week. I took him up on the offer, arranging for Tuesday.

I can’t fully describe the smile on his face as he then confessed to me that day that “I’m really sorry, but I have to tell you:  I just didn’t really feel like getting out of bed. I’d been up all night, you know.” Doing what, I’m still not quite sure, but there were movies involved. I think. In the business we call that “resistance.”

Yet I was so glad to see the smile–who cares, really?

I’ve spoken of him before, in Will the Real Me Please Stand Up? He’s doing better, much better, in fact. He’s responded well to the Suboxone treatment. Furthermore, he finally decided to consider antidepressant treatment. He’d been finding it hard to get up no matter what the reason, had been tearing up more than normally, had felt so depleted. He wasn’t excited about the prospect of medication, but he gave it a try. He even experimented with a little med furlough on his own–and started himself back on it after a few days. He was feeling more energy, getting more active, getting along well with his girlfriend and his family. Nightmares had decreased quite a bit. He finally decided that he and I were on the same page after all when it comes to this medication stuff.  Good news all around, in other words.

I want to write today about decision points: metaphorical places from which, in any encounter I have with a veteran, I have to decide whether to stay put and be happy with where we are–and hopefully where we’re going–or to push both the combat veteran and me forward, maybe toward territory the veteran and I both know needs to be traversed, maybe simply into unknown territory, or better put, the dark.

I also want to talk about foundational points, metaphorical places from which we find our steadiness to move forward, into the light, the dark, metaphorical places within us, always there.

He was happy enough.  I could have left well enough alone.  Truly, I wasn’t (at least consciously) trying to stir trouble.  Still, I thought: heck, why not pitch a little something in one direction and see if he follows it?  If he doesn’t, let it lie, wherever.

“So how are you spending your days?” I asked.

In retrospect, I can’t quite recall when he made his admission: although feeling much better, he was still stirred by the lack of focus that he’d talked about with me when we first met.

“There’s something big out there that I should be accomplishing, it’s just . . . I don’t know what.”  He hesitated a bit, appeared about ready to switch the subject, but then fell silent, his head tilted slightly downward.

That’s when I decided to make the metaphor explicit, again to see what would happen.

“So what’s getting in your way or keeping you tied down?”

The location-movement metaphor is a common one in therapy, even banal.  Most of us associate progress with forward motion, failure with backward motion, a stale discontent with being moored in one place, unable to move. Maybe obstacles get in our way. Maybe we don’t have the fuel to get going. On and on, the narrative can just flow out from us.

“I . . . I don’t know. I just . . . keep screwing myself up, you know?  I can have it good for a while, a great girlfriend, a good job. But then after a few months I begin to question it all and . . . well, like I said before, sometimes I just cause trouble to get it all to end, be over with.”

He’s an insightful guy, and I have to agree with that assessment. There’s a certain diabolical–even hellish–cycle to it all. It was curious, though: as he spoke, gone was the painful self-deprecation that had so tortured him pre=medication.  Still, there was something.  What was it?

So we seem to be ready to move, I’m now thinking.  So what will it be? Forward into “new future, new life”? Or backward into “old past, old death”?

I feel this question a lot.  I wonder whether I do more harm than good sometimes, mentioning–try as I may, gently–a  past, perhaps a feeling that still can pop up whenever that past peeks through the window to see if anybody’s home.  Maybe it’s just me, my remembering how there were ghosts in my own life that eventually were best faced, places in my life where such ghosts tended to lounge around and haunt, times when those ghosts in those places refused to remain silent, even in the face of my best breathing techniques.

“Deep down, is there a part of you that still feels him, your buddy?”

I’m vague only for purposes of this post.  I remembered the man’s name.  I remembered how he, like my patient, had been blown away that day on that road–but how, unlike my patient,  there’d not been enough of him left together to med-evac to Germany.

He noticed that I remembered.

“Not every day, thankfully,” he finally murmured.  “But a level or two down?”  He looked up, right into my eyes.  “Every day.”

This was not depression.  This was not just grief.  This was The War.

Why I went down the next road, I haven’t a clue.

“Have you ever spoken with his family?”

The look he gave me was–what?–wounded, I guess, but not one from a wound that exsanguinates life, but rather one of those that bleeds slowly, steadily, lethally

“No,” he whispered.  Then after a few seconds, “I’m afraid they’ll hate me.”

I was my usual clueless for only an instant, thankfully.  Then it was obvious.  “Because you lived.”

He could only nod, barely at that.  There were no tears.  This felt even deeper than tears.

How tempting it is to blurt out at this point something like, “Oh, no, they won’t.”  But I’m no fool, and neither is he.  Probably they wouldn’t.  Maybe they would.   But that wasn’t the point, at least this juncture, was it.

I decided to go ahead and pull out a big gun.

“You do know,” I said, “that if it had been you who had died, not him, and that if you could have found a way to speak to him today, you’d have told him that you wanted him to move forward in life, right?  That the last thing in the world you’d want would be for him to stay stuck in all this because of you?”

He’s a bright guy.  He doesn’t need the concept of analogy explained to him.  His closed eyes and subsequent downward tilt of head told me so.

For a few moments, silence.

“You’re not leaving him behind,” I finally said.  “You’ll never forget him.  You’re building upon him.  He’s become–and he’s becoming–the foundation from which you set out every day.  You’re not stepping on him, as if you were groping somewhere at his expense.  You’re building upon him.  He’ll never not be there with you.  Never.”

He was still looking down, but he winced.  Then he had this epiphany look on his face, an epiphany-from-hell look.  He directed that look right at me.

“I hate me.  That’s it, isn’t it?  I hate me.”

It’s a funny thing about therapy, life: sometimes we say words that we have said many times before–but we’re not saying the same words.  The words have finally done their job, infiltrated our souls, finally.  And then they dissolve, leaving just their scratched-on messages upon our hearts.

A few more seconds of silence.

“We have to do something about this, you know,” I finally say.  “Else the cycle will keep playing itself out.”

He lowered his head again.  “I know.”

“Once you admit it, then you’ve got to sit with it.  We’ve got to sit with it.  Maybe a long time.  But have no fear: if we take it seriously, don’t fall into it and drown in it, you will do something with it, something that will move you forward.  You’ll have no choice.  That’s the way life is.  That’s the way you are.”

He looked right up at me, not accusingly, not imploringly, just looked at me.

“I’m trusting you on this one, you know,” he finally whispers.

“I know.”

And I do.  This is serious.  I take it seriously.  He’s given me permission.  He’s given me a gift.

A few housekeeping matters, and then he stands up, pauses, and offers me his hand.  The smile’s back, nowhere near as broad, but it’s back.

“See you next week,” he says.

“See you then.  And remember that if–”

“I know, I know,” he smiles at the door, now the old broad one.  “I can call you if I need to.”

My turn to smile.  “Yup.”

“See you.”

“See you.”  Then he’s gone.

We move forward.

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