Monthly Archives: July 2012

A Mennonite at the VA?

July 29, 2012 By in Culture at War, Living Life, Professional Relationships, Respect, Honor, Duty Tags: , , , , , , , , , , , Leave a comment

As some readers know, just this past week I enjoyed my one Warholian fifteen-minutes-of-fame:  one of my posts made it to WordPress’s home page, sort of my version of being “on the cover of the Rolling Stone,” if you know what I mean.  It was in that Warholian post, Conical Combat Linkages, that I revealed that I’m a “Mennonite by choice.”  According to my stats, more than a few people now know this about me.

Interestingly, also last week Anna Groff, an editor of one of our Church’s national periodicals, The Mennonite, contacted me about an article she’s putting together on Mennonites who work at the VA.  Apparently there is not a huge crew of us, surprise, surprise.

For readers who may not know: Mennonites are a Protestant group who were originally known as “Anabaptists” during the Reformation.  Originally from Switzerland, southern Germany, and Holland, many came over to the United States in the eighteenth century, first living in the Pennsylvania area, then moving to the Midwest, especially Indiana and Ohio, with later groups settling in Kansas and points West, or in the western regions of Canada.  There also is a large group who live in Central America and in Paraguay.

Don’t ask about the latter two.  It’s complicated.

(I did feel compelled to mention the latter, however, given that a group of one of our more distant, conservative cousins, the Beachy Amish Mennonites, living in Nicaragua, were described in a not-too-flattering front page article in the New York Times today.  For those who have read the piece, just rest assured: when I say distant, I mean distant.  I’ll leave it at that.)

Traditionally Mennonites, like the Quakers, have felt strongly that the Christian faith requires its adherents to avoid violence, seek peace, and refrain from participating in wars.  In other words, we are usually referred to as pacifists.

Ergo the title of this post.

Anna sent me a list of thought-provoking questions to answer for her article, and so I decided: well, since I’ve identified myself as Mennonite on the blog, I might as well answer her questions in a post.  After all, readers–and even more, patients–should know whom they are getting when they get me so that, well, they can decide whether they even want to get me at all.

Because this is such a complex issue that speaks so directly to many areas of my life about which I feel strongly and deeply, my essay in answer to her questions is quite long, even for me!  Also, it has a certain in-group-ness about it which may not be agreeable to many readers.  Moreover, for many readers a discussion of issues of faith itself might not be the way you’re wanting to while away your next more-than-several minutes of your life.

Given that, I have posted the essay separately, under the title Letter to a Mennonite Pastor, which can be accessed either through the link just provided or through the “Thoughts” menu above.  It may end up of interest only to fellow Mennonites.  (It may end up of interest to absolutely no one at all.)  Still, as I deal in it directly with my role as someone who is both a member of a particular faith community and as someone who serves combat veterans, I hope that others might find that the discussion in it will, at least in some way, prove enlightening.

Many thanks to all those who have visited the blog these past few days, and especially many thanks to those of you who “liked” the Conical Combat Veteran post and to those of you who have subscribed.  I hope that I continue to write posts that each of you will find worthy of the respect and caring every returning combat veteran deserves.

525,600 Minutes

July 25, 2012 By in Living Life, Professional Relationships Tags: , , , , , , , , 1 Comment

This past weekend, I went with my wife, my elder daughter, and her boyfriend to see a local production of Rent, the winner of the 1996 Tony Award for Best Musical. The show is based on Puccini’s La Bohème, and it tells the story of a group of young adults who live on the Lower East Side of Manhattan, facing life with the threat of HIV/AIDS all around them.

This particular show, part of the young adult theater series of our local, quite excellent Footlite Musicals, was well-done and energetic to the max. The production happened to be directed by the drama coach from my daughter’s high school (but believe me, we ain’t talking High School Musical writ local, here: this was the real deal), and the female romantic lead graduated from that school a year ahead of my daughter. In the chorus were three of her classmates, one of whom has been one of her best friends since middle school. Old home week, in other words.

The show was loud. It was raw. It was great. It was Rent.

Both Bohème and Rent are stories of the young, of dreams and love fulfilled, of dreams and love lost. La Bohème, however, is anything but a score for the young: Puccini is at his best in his opera, with arias, duets, choruses and more that require voices that have aged at least ten or so years beyond their characters’ ages in order to realize the full depth of their emotional power. It does take a Pavarotti and a Freni to walk off stage and hit those high-C’s at the end of the first act in such a way that you will forever doubt that musical bliss belongs solely to the angelic.

Rent, in contrast, is for young people with young voices, still with that raw edge, that ache of early adulthood that bores through a musical score and slaps an audience smack dab across the face. Both romantic leads were probably only months older than my daughter, a rising college sophomore. The narrating lead is a medical student here at Indiana. I could easily one day walk up to our inpatient service and find him in the conference room ready to present the previous night’s admission. The members of this cast are the members of the generation I am charged with encouraging into the future.

They also are the members of the generation whose peers are trying to serve honorably among the poppy fields of Afghanistan, who are hoping against hope to avoid dying honorably next to those fields, who too often find solace back here in the States with the economic fruits of those fields, who end up in my office begging for relief from that long-forgotten solace, not even sure whether they dare pray for a meaningful future beyond a pill, a medication strip to keep them from jonesing one more day.

The signature song of Rent is “Seasons of Love,” the opening number of the play’s second act. The first act tells the story of a group of young women and men who come together on Christmas Eve to find some meaning–and hope for some love–in lives in which they are only peripherally participating in the “meaning” and “hope” that modern American society appears to demand of its young.

The second act tells the story of their following year together. The act opens up with the entire company on stage (and in this production, in the aisles), singing “Seasons of Love.” Anyone even vaguely familiar with pop culture over the past fifteen years will recognize the tune upon hearing.

Five hundred twenty-five thousand six hundred minutes,
Five hundred twenty-five thousand moments so dear.
Five hundred twenty-five thousand six hundred minutes.
How do you measure, measure a year?

In these few days since I saw the show, I can’t get this tune out of my head, not because of its haunting beauty, though that, true, plays its part. Instead, that song reminds this much older man of a meaning, a hope that he too once held, that fortunately he found in the life he made, that he desperately hopes that the young men and women in his life, whether at home or at the hospital, will find in the lives that they are trying to make themselves.

In daylights, in sunsets, in midnights
In cups of coffee
In inches, in miles, in laughter, in strife.
In five hundred twenty-five thousand six hundred minutes
How do you measure a year in the life?

Certainly I could measure it in my daughter’s boyfriend, a great young man who is bringing her so much happiness, with his quick, quiet wit that can make me guffaw–and, look, the guy acted as if he wasn’t dumbfounded by the fact that, yes, I was playing Bach’s Toccata in D Minor on the accordion, right there in front of him, whether or not he did think it was the looniest cornpone he’d ever seen. Big-time points in my book for the fella, let me tell you.

Or I could measure it in her childhood buddy who danced his heart out on that Rent stage, with whom I spoke only briefly after the performance, yet who I could see was loving every minute of the life he was creating, exactly in the right spot as a musical theater major at Indiana University, himself in love, smiling like all get-out, dreading the dissolution of the company of singers who had come to mean so much to him in such a short time.

Or I could measure it in her own life, in her continuing excitement over her trip to Greece and Rome earlier this summer, in her anticipation (such a puny word) of the rock group Coldplay coming to Chicago in a mere few weeks, mind you, weeks!

Or how about the life of her sister, who is sooooo excited that the air conditioner is finally fixed, who will hound me endlessly until we finally learn Italian together, who will one day be such a wonderful companion as we explore the byways of Milano and Bologna.

Or how about the life of her brother, who can reverse-engineer a yo-yo like nobody’s business, who found the meaning of life in his own–his very own–laptop that he doesn’t have to share, that is ready to bring him whatever latest YouTube thrill he craves, who still gets a tad peeved when the pay-per-view messes up his enjoyment of The Dark Knight, but who finds a way–eventually–to come to some detente with the Forces of the Universe, God bless us all.

Seasons of Life, Seasons of Love pass, day after day, month after month, year after year.

Five hundred twenty-five thousand six hundred minutes!
Five hundred twenty-five thousand journeys to plan.
Five hundred twenty-five thousand six hundred minutes
How do you measure the life of a woman or a man?

In truths that she learned,
Or in times that he cried.
In bridges he burned,
Or the way that she died.

Or alternatively, I could measure it in the lives of others who have passed through my life this week so far, ones whom I’ve known, ones whom I’m meeting for the first time.

For example, there’s the man mentioned in my very first post, New Year, Old Challenges. Once again, his situation has become “complicated,” and I find myself trying to track him down, all the while managing conflicting opinions from fellow treaters.

Or how about the man from Quite the Handful? His nightmares came back in full force this week, who knows why. Yet he’s afraid to go to sleep lest he see that seventeenish-year-old he had to shoot, still uncertain what the guy had been trying to do, night after night watching the blood not trickle, not gush, just flow out of him, steadily, flow. He looks exhausted. He bargains for sleeping pills.

But then there’s the man who was the inspiration for Will Do, Sir. Fortunately he’s doing great–well, sort of great, if it weren’t for his tendency still to say the wrong thing to his girlfriend at the wrong time, with his subsequent feeling guilty, his subsequent trashing of himself, repeat ad lib.

Or should it be the man from No Trouble At All? We too have been negotiating around medications. I don’t worry about his trustworthiness. Instead I worry about the depth of his symptoms, their range, their frequent ferocity. He’ll come in my office and fight back tears, but then assure me that overall he’s doing OK, but then call later because he can’t get his ex-girlfriend out of his head, but then assure me that overall he’s doing OK, but then tell me at the next visit that he desperately wants to contact his dead buddy’s family, but is afraid to do so, but then assure me that overall he’s doing OK, but . . .

What about the guy from Maybe a Letter? He didn’t show today. Is he OK? Will leave a message, but then . . .

No worry: the guy from Youth Remembered, Youth Blown Apart, Youth Renewed is heading out on vacation, one that he feels more ready to enjoy than he has at any time since his deployment. Good.

But . . .

. . .there’s the elder brother of that guy’s best friend, the one whom my other patient (the Youth Remembered patient) himself calls his “big brother,” the one whom my other patient followed into the military, same branch, the one who went to the Middle East six months before my other patient did, the one who only lost a couple of men in his unit, thankfully, yet the one who saw dead body after dead body after young dead body after old dead body, the one who is finally ready to admit that he drinks more than he should, to forget, that he has used pain pills more than he should, to forget, that he can’t forget what he tries to forget, the one who is about to lose his wife and two kids if he doesn’t get his life together, the one who calls me at the hospital on Tuesday morning to say that he’s driving down, right then and there, that his “little brother” said I wouldn’t make him feel stupid, that I’d take him seriously, the one who comes in shaking like a leaf in spite of his perfectly sculpted body that looks as if it would be up to the task of any lumberjack contest anywhere, the one who begs me, through tears that he admits he doesn’t care if I see, “Please help me. I’m going to lose everything. I don’t want to die. I’m ready to change. Please.”

Oh, yeah. Him. And then how about . . .

It’s time now to sing out,
Tho’ the story never ends
Let’s celebrate
Remember a year in the life of friends

Honestly, my life is not divided into hope at home and pain at work. Pain occurs at the former, hope definitely at the latter. The Will Do, Sir guy has indeed grown tremendously, has found much more love in his life. The Youth Remembered guy smiles more broadly than he once did. Maybe a Letter is fine, and we’re getting together later this week. No Trouble At All feels more understood than he has in years. There are indeed minutes, days, aspects of lives to celebrate, even after a War.

Remember the love!
Seasons of love!

La Bohème ends quite sadly, with Rodolfo belting a “Mimi!!” on a G sharp that pierces the soul. Rent ends more hopefully, although certainly not overly so, for if Rent stands for anything, it stands for hope having to be tempered with reality. Both are stories of love. Both are stories of love embedded in time.

I am a fortunate man. Although not without pain, my world is one of very deep love, for my wife, for my children and those they love, for family, for friends and colleagues who put up with me (although, admittedly, without having to make a decision about the accordion).

And, in a way, it is a world of love for my patients as well. “Love” in the context of therapy is always an iffy proposition, but if by the word we mean “meaningful connection,” “faithfulness,” “willingness to try, try again”? Then, most definitely.

The young often need to be reminded of the number of minutes in a year, reminded that their own numbers of minutes will have its limit. As I get older, I find myself a bit more able to remember the latter more effectively. Yet 525,600 is a big number. You can measure a lot in that time. Trust me.

Conical Combat Linkages

July 21, 2012 By in Culture at War, Living Life, Professional Relationships, Respect, Honor, Duty Tags: , , , , , , , , , 27 Comments

Sometimes it takes some days for an encounter with a combat veteran to sink in. Sometimes it takes some days just to decide how much I dare let it sink in.

I’ve talked of this man before, in Buddy, Got the Time? He’s sharp, insightful, witty. He can be cutting (hilariously so, I might add). He’s a Desert Storm vet.

He’s been trying to make his life work for over twenty years.

He’s been doing much better at that since we’ve begun working together. His combat nightmares have dramatically reduced. His relationships, though still, shall we say, on the complex side, have calmed, at least some. He has been able to work more regularly, and he has come up with some very doable, very challenging long-range business plans.

We hadn’t spoken for a few weeks, primarily because of my being in and out of town. When we did, I heard it in his voice.

“Been a tough couple of weeks, Doc.”

“What’s been up?” I respond.

“The nightmares. But they’re totally different this time. It’s weird. They’re not about combat. They’re about guys I knew back in Desert Storm. None of them died, but somehow I keep meeting them in my dreams. And these aren’t good meetings, Doc. They’re confusing, upsetting. There’s one dream I’ve had a good five times, and every time I bolt up after it and can’t fall back asleep.”

“What happens?”

“There’s this senior officer I served under. He’s just standing there, not even in his combat gear, looking at me. He’s covered in blood, sand, dirt. He’s upset, and he keeps talking, keeps trying to tell me something, keeps reaching out to me. But I can’t understand a word he’s saying.”

“What was he like,” I ask, “the real man, as a person, to you?”

“He was like John Wayne,” he answered, his voice brightening slightly. “He even sort of walked like Wayne did. He was a man of few words, but he knew what to do, when to do it, and he knew how to lead. He could be calm when no one else was. He took charge. He was quite the guy, almost like a big brother to me. And that’s what’s so strange: in my dream, he looks so lost, desperate, trying to tell me something, I know it, but I can’t understand a thing. It’s not him, Doc. But it is.”

“How long have you been having the dream?”

“The last two weeks, I’d say.” He paused. “I’m trying to think if there was anything that went on then. I really hadn’t thought about that before right now.” He paused again.

“Anything?” I finally asked.

Still no words, but then, slowly, “You know, that’s right. That BBC show, about the guys in Afghanistan. Yeah, that’s it. It really upset me.”

“What happened in it?”

“It’s not so much what happened as what was happening. These guys had taken direct hits. They’d lost several men. But you know what they were doing over there? Helping Afghans learn to farm. Can you believe it? It was agriculture class. And guys were dying for it.”

His voice had become more distant. I could almost feel him in front of that television, open-mouthed, furious, but too shocked to do anything about it.

“I mean,” he continued, his tempo picking up, “that’s crazy! Crazy! There’s a f***ing war going on, we’re sending these guys to battle, and for gardening? Look, I understand: the best thing we ever did when I was over there, the one thing I’m still proud of, is that we completed a big public works project that saved the lives of I-don’t-know-how-many people. I get it: we’re trying to help the locals, show them we’re not horrible people. But what, Doc, what?”

I hadn’t heard him this animated in quite a while.

“What–”

“What the f*** are we doing over there?,” he continued. “Where has all this death, this destruction gotten us? What is it about these politicians? None of them served. What do they know? My job was to watch out for young kids like those kids over there who are plowing fields or whatever they’re doing–and getting killed! I was a kid myself. I mean, if you want us to do good works, send us to do good works, fine, we’re the best, we can do that. But to send us over to fight, to kill, to die–and then to garden? Are you, like, for real, man? This is crazy, Doc, f***ing crazy.”

He was on a roll. I couldn’t have stopped him had I even wanted to.

“And you know what else? I just remembered this, too. It was around that time that I had this really serious talk with my daughter. She told me she wanted to talk to me as an adult, not as my little girl. So we did. And you know what she said to me?”

I couldn’t even utter a mere “what?”. Clearly he had too much to say, right then, now, now.

“She said that she’s sick and tired of people telling her that she should have known me before I went over to Desert Storm, that she should have known the man I ‘used to be.’ She looked right at me, Doc, and she dropped the F-bomb. I’m not kidding: I’d never heard her say that in her entire life. She looked at me and said, ‘Don’t they f***ing get it? You’re my Dad. You’re the man I’ve always known. I don’t care what you were like before. I care about who you are now. I care about you trying to care of yourself, trying to take care of us. Why can’t people just let you be who you are?’”

Silence. On both our parts. It was one of those silences that I dread, a silence that dares me to say one, single word, a silence that shakes me at my core, demanding that I say something, anything, all the while laughing at me because it knows there is nothing to say, nothing to do except feel the silence shake me, shake, shake.

Then I thought it. I waited a few moments. I asked it.

“Is that what your officer is trying to ask you? Why did we do all this? Why did this happen to us, back then, now? We’re covered in blood, sand, dirt, we’re just . . . why?”

For at least fifteen, maybe even thirty seconds, he said nothing.

“Doc, ” he finally said, in a whisper that shouted, “I’m proud that I served my country. I’m proud that I made people’s lives better when I could. I’m proud of the men I served with. I honor the men I sent home to be buried. But, Doc, some days, I just don’t know, I don’t think I can take another g**d***ed minute. Do they know what they’re doing, do they have a clue, these politicians, these bureaucrats? Do they know what they’re creating? This is gonna take years, Doc, years to clean up the mess they started! And I’m just talking about the men and women who are coming back! And why? Why? For vegetables? Are you kidding me? Vegetables?”

I can’t fully describe to you how it is to sit with someone who feels that, says that, lives that so deeply. It was not the first time for me to be in such a position, but he was so passionate, truthful, precise. Like so many combat veterans whom I have served, he both despises war and acknowledges its inevitability, even, as is the opinion of many, its necessity. He’s no pacifist, but he’s no warmonger. He believes that what he values can sometimes be insane. He believes sometimes that he is insane to value what he values. Yet that is who he was. That is who he is. That is who he hopes he will always be.

“After war, Doc, nothing connects in a straight line. There’s no direct, uncomplicated connection between you and your spouse, your kids, your family, your coworkers, clients, nobody. It’s almost as if I’m back in engineering class. Life doesn’t develop linearly in any way whatsoever, but almost, what, geometrically. You know, a lot of the guys you see probably wouldn’t put it that way, but that’s really it. Everything multiplies, expands, spins, and the line, it becomes like a cone, a vortex, and you can’t even figure out which end is the tip.”

After a few seconds, he then chuckled.

“What is it?” I asked.

“Maybe you can blog about this one, eh, Doc? What could we call these things? How about ‘conical combat linkages’? We could do CCL for short. Yeah, that’s it. Conical combat linkages. Vortex after vortex after vortex.”

By this point, I’m simply stunned. I haven’t a clue what to say. The word vortex is living out its meaning inside my head, swirling, like the Charybdis that nearly swallowed Odysseus, like the tornadoes that periodically stroll down our Midwest alley.

“I’m so sorry,” I finally say. Stupid. A stupid thing to say. I’m ashamed of myself before the last syllable has the audacity to pass through my vocal chords. Stupid, stupid, stupid.

He’s a good man, though. He actually laughs. I haven’t heard this voice at any point in this conversation so far.

“Doc,” he drawls–and I mean, drawls. “It ain’t your fault, guy.”

I thank him.

And I wonder.

What do I believe about war, about peace, as a citizen of this country, as a Mennonite by choice, as a psychiatrist by trade, as one guy listening to the heart of another guy, that guy’s heart gritting its teeth, letting its jaw drop in incredulity, in exhaustion, left saying nothing? How many times have I said it in this blog–and yet how many times have I truly, truly asked myself: what venti, nonfat lattes did you give up, Rod? This War ain’t your fault, guy?

Really?

Maybe it wasn’t such a stupid thing to say after all.

The linkages swirl, between me and this veteran, between him and his ex-wife, his children, his siblings, between me and the next man or woman I’ll interview the next time I step into my office–”next in line, please!”– between me and a nation, between me and a faith tradition, a family tradition, between me and a wife, three children, a world. Conically. Combat half a globe away geometrically expands all my linkages, all our linkages.

The vortices will demand our attention. They’ll get what’s due them. That’s the way of vortices. Even Odysseus found that out. Pay now. Pay later.

Whether or not you eat all your vegetables.

Not Yet, But Maybe . . .

July 17, 2012 By in Living Life, Professional Relationships Tags: , , , , , , , Leave a comment

I talked about this combat veteran in an earlier entry, One More Time Around, With Feeling.  I first met him a couple years ago.  In the interim he had struggled with difficult circumstances.  He had called me a couple months back to see if I would be willing to work with him again.  He’d been surprised that I so easily said yes.

We’ve been in touch since then, though infrequently.  He had found clonidine to be helpful (a blood pressure medication that can reduce some symptoms of opiate withdrawal).  He had been reluctant to consider Suboxone again, although I could never quite figure out why.  Then yesterday he called me.

“Can you see me today?  Everything’s falling apart.  Everything.”

This is not a man who would stoop to sounding desperate even if he were so.  Yet his vocal chords did not allow him the luxury of anything even close to coolness in his words.  I heard the message.

“Of course,” I replied.

He came in about an hour later, accompanied by his girlfriend–well, at least she had been his girlfriend, but he wasn’t sure if she still was, and he wasn’t even sure he cared whether he was sure if she still was, and she, for her part, didn’t . . .

Enough said.

Initially he brought her with him into the office, but within microseconds all three of us realized that little was to be gained by this exercise except for another entry for their scrapbook of crummy times.  I suggested that he and I speak alone.  She wasn’t pleased, but honestly I couldn’t tell whether she was displeased with me, with him, with herself, with all the above, with whatever.  She left.  Thankfully, drama was minimal.

“She lied to me,” he said, his voice as steely as a hanging judge’s.  “I can’t stand that.  I’ve always told you that I’ll never lie to you, and I won’t.  She’ll try to manipulate and say she didn’t, but I don’t care what she says: she lied.”

This line of discussion wasn’t going to get either of us anywhere, and I believe he knew that as well as I did.  I will vouch for one statement, though: I believe it when he says that he wouldn’t lie to me.

He might have lost his job a few days before.  He wasn’t sure.  He had been too upset to check.  He had been living with his parents, and it was likely that his mother was going to demand that he leave the house, for reasons complicated and anything but new.

His struggles hadn’t just accumulated overnight either.  Whatever few chunky-ish pounds he’d previously sported, they were no longer there.  Food had not apparently been a priority.  From a physical standpoint, he looked quite good, even, as strange as this might sound, dashing.  From an emotional standpoint, though–well, he was right:  everything was indeed crashing around him.

But he hadn’t used.  He was proud of that.  “Check my urine,” he said.  “You’ll see.”

He was right.

But he had hoped that he would get to see me, prayed that I would pick up the phone earlier that day, because he had been afraid that if something were not to happen fast, he was going to use.  He wanted back on the Suboxone.  He wanted back on anything that would do something to make all the emotional pain abate, even if slightly, even if momentarily.

I had to say it.

“I know that you’re struggling with the opiate dependence, but clearly: your depression’s back.”

In a previous encounter he might have stiffened at that comment, just enough to let me know that he wasn’t going to let some hot-shot doctor label him that easily, thank you.  None of that today, though.  Not a facial muscle moved, in irritation, in relief.

“I don’t have a clue what I feel,” was all he could answer.

The Suboxone part was easy; we discussed the dosage at which he’d previously been able to maintain his sobriety.  We decided to do one task at a time: get the Suboxone started first, then think about whether an antidepressant might be helpful.  I told him I suspected it would.  He didn’t even make a move to disagree with me.

We talked about housing options.  He was unsure whether he’d have to leave his parents’ house or not.  He has always been quite close to his father; it had always been his mother who had been his periodic nemesis.  He was going to speak to his father later that evening.  He promised to let me know if he needed something from me.  He assured me that he knew that the emergency room was always available to him.

Then we just looked at each other.

There was no defiance, no begging, just heaviness, a face that could have been on the verge of a sob had he been anybody but himself.  It didn’t feel as if he were trying to keep that sob at bay.  He was just too tired to deal with it.

He looked so sad.  He broke my heart, seeing his sadness encase him like a second skin, so familiar, so alone.

So once again, I had to say it.

“This isn’t working, you know, the posttraumatic stress injury, the holding it in, the nightmares, everything.  It’s going to take you down.  You have no more strikes left.  You’ll become a statistic, another one of those combat veterans, defeated, imprisoned, alone.  The opiates are too ready and willing to do just that.  You know that as well as I do.”

He just stared at me, blinked, stared.  He swallowed.  His eyes then did the nodding in agreement for him.

“Please,” I finally whispered.  “You’re a good man.  You are trying.  Please.  Please.”

He swallowed again, looked down.

“I’ll come back tomorrow if I can, Wednesday at the latest.  I will.  I promise.  She’s got an appointment she’s got to get to now.  She’ll be freaking out if I don’t get going here.”

“You two going to be OK in the car together?”

He looked up, sporting the closest thing to a smile I’d seen in I-don’t-know-how-long.

“It’ll be fine.  I don’t care what happens, if you want to know the truth.  If she makes me get out of the car in the middle of the street, I’ll be fine, whatever.  I’ll get home.  I’ve always had to take care of myself.  I’ll do it again.  I won’t use any drugs.  I’ll make it.  I’ll be back here.”

“Talk to your Dad,” I finally said.  “Let him know at least some of what’s going on with you.”

He nodded and then simply said, “I will.”

He got up and stood before me.  In another life he could have been a model, not the pretty-boy type, mind you, but the J. Crew type, maybe in the winter jacket section, woods behind him, self-confident enough to have the camera snap his picture, but no posing, pal, none, leaving you, oh, casual peruser of the catalogue that you are, with no doubt whatsoever that he could whip up a more-than-decent-enough campfire and take care of himself just fine, thank you, long before you’d ever know that you really are as untalented as you look.  You’d be welcome to join him, of course, if you were to so choose, but don’t expect a second invite, understood?  Then as he sits down on the log just behind him and takes a swig of whatever ecologically-sound water he had stuck in that backpack of his, he’ll half-smile enough at you to remind you one more time–because, you know, he’s really not totally as über-cool as he looks : yes, you really are more than welcome to join him.

If only he weren’t so sad.

He offered me his hand.  I took it.  Unlike the last time, I did not linger with it.  He turned toward the door, sighed, uncertain, apparently, of how much drama awaited him on the other side, opened the door, and with a “See you,” he was gone.

He doesn’t lie to me.  He’ll be back.

The Dad in me sometimes just wants to take these guys by the shoulders, look them straight in the eyes, and then . . . and then, what?

Just look at them, I guess.  Make no promises except the promise to remain as faithful as I can for as long as I can.  Not waste his time or her time or my time with anything ridiculous like “I’m so sorry” or some other such nonsense.  Let, instead, my eyes speak as honestly as they can for me.  Hope to God that he or she’ll get the message that needs to be gotten–the message that I mean what I say

And then let go, I guess.  Not leave.  But let go.

“See you,” would be all I’d be able to say at that point.

And all I can hope is that he or she would say “See you” in return.

We keep going.  No Plan B.

Youth Remembered, Youth Blown Apart, Youth Renewed

July 14, 2012 By in Living Life, Professional Relationships Tags: , , , , , , , Leave a comment

For the past couple days, I’ve been attending a conference in Boston, where I lived for just over five years in the late 1980′s.  My family and I have periodically visited New England since then, primarily for conferences on Cape Cod, but I haven’t been back in the area for eight years.

My, how things change.

My cab ride from Logan Airport that took me through the South Harbor area of the city was completely mystifying: where did all this come from?  There before me were all the fruits of the “Big Dig” that had been gearing up around the time of my last visit, the road project of road projects that took part of Boston’s famous “Central Artery” of I-93 underground.  Good Lord, how do you spell gentrify?

And then I get to my hotel, right off Chinatown, in the Theater District, and, like, where am I?  Although this area was cleaning up when I was living here, still there were remnants of the old “Combat Zone,” Boston’s red-light district here and there.  I kid you not, there’s a W Hotel down there.  A “W”!  I see the South End from my hotel window, a conclave of row houses formerly on the godforsaken side, though, true, getting trendy even twenty-five years ago, but–I mean, that’s the South End?!  Verily, God hath returned.  In quite the glory, I might add.

But then I walk up Tremont Street, and the Boston that has always been Boston greets me:  there’s a great breeze coming off the Commons;  Park Street Station remains abuzz, even at this quite early hour; Park Street Church continues its Calvinist, stern watch over the whole scene, the Statehouse just up the hill.   I end up at Government Center, with the ornate Courthouse, where I did part of my child psychiatry training, just out of my view.  And I’m sitting under the famous Steaming Tea Pot of Government Center.

But under that Tea Pot, where I’m typing?  Instead of the eatery of old that had once stood at the heart of all Bostonian–it’s now a Starbucks.  I just finished a cinnamon chip scone that I could have snarfed down just as easily in Indianapolis.

Life does, indeed, move on.

And as I remember and readjust, I recall: when I lived here, I was the age of most of the men and women whom I’m now serving.  My worst memories at age twenty-seven were of this bizarre anesthesiology resident I had to endure as a medical student.

But even with him, the bodies I saw woke up.

Today I also recall a patient whom I’ve talked about before.  His story does not differ markedly from those of others.  He was blown away.  His buddies were blown away.  He lived, in a manner of speaking.  They didn’t, period.

His struggle with opiate dependence has been a hard one.  It has only become harder as we have begun working together.  Although one might think that one should feel better when working with a psychiatrist, in my combat trauma line of business, sadly I cannot guarantee (initially) such a course.

He has relapsed on both pain pills and heroin, more than once.  He always tells me when he has done so.  He is terrified that I’m going to kick him out of the Suboxone program, send him back to the streets until he finally decides to “get serious about his recovery.”

He is a challenge.

I’d forgotten how much Boston is a city of the “fit young,” something so very noticeable in the minimalist clothing of summer.  He could easily have been one of these young men I now see at this early morning hour, he on the slender side, true, but he still with a gymnast’s physique, striding before me, backpack in place, button-down Oxford open-collared, heading off to the Financial District, dreaming of a one-day corner office.

Instead he’s just grateful to modern medicine that he has a body to drape anything over.

I had to be honest with him: I found myself in a quandary.  I told him that I was not going to stop his Suboxone (I can’t be deterred that easily).  Yet both he and I knew that with every prescription he took (and, no, I don’t think he’s selling it), he was taking from me a flaming torch that he could add to the fire of painkillers in his bloodstrem to end up with a grand finale conflagration of respiratory failure.

We’d been here before in my office, post-relapse, post-confession, his gaze averted.

“It’s as if a part of me is getting stronger,” he told me, “but another part of me is determined not to change.”

Hmm, have I heard that story before?

He’d been having girlfriend problems.  It was complex (isn’t it always?)  It’d reached a point, however, at which I’d had to ask him to consider that both he and his girlfriend were trapped in a cycle of recriminatory despair that didn’t appear to be benefitting either of them, shall we say.

“I just can’t stand to see her sad,” he said.  “I love her so much, but we’ve got to be away from each other for a while.  But she gets so sad.  I can’t stand to see people hurting.   It hurts me so much, I keep on doing what ends up hurting me even more, even when I know I shouldn’t.”

I’d heard this story before as well.  From him.

It was an old story for him, one that long predated his combat experiences.  Clearly he’d been a sensitive kid who’d nonetheless managed to grow into a kind of cool kid as well.  Had he gone to college, he’d have been invited to one of the cooler fraternities on campus, no doubt, and then he’d have become the guy who was always laid back, funny, loyal–the quintessential “decent guy,” the one you tell your darkest secrets to when you’re drunk, the one you even admit the same secrets to once you’ve sobered up.

But he wanted to go into the military.  He wanted to prove himself.   He was well-liked by his peers, well-liked by his superiors.  He rose up the ranks quickly.  He ended up in some impressive spots–and I mean, impressive.

He took that decent-guy heart of his to the Middle East.  He was devoted to his buddies, his men.  The man who had always felt deeply felt over there even more deeply, more intensely than he had ever imagined.  Those guys were his life.  He just knew what they needed.

He is one of only a handful of survivors.

“Have you ever noticed,” I asked him, “that whenever you start feeling better about yourself, you get this incredible urge to use?”

He looked down.

“I just don’t get it.  I know that I can do more with my life.  I really feel that, deep down.  But it’s just so hard, my girlfriend, all these feelings.  It’s just so hard.”

I decide it’s time to return to the story.

“It’s so hard, isn’t it, to feel hopeful, strong, when all of them are dead.”

He looked back up at me, eyeball to eyeball.  He said nothing.  He didn’t appear angry, anxious.  His look wasn’t a blank one, though.  It was as if both of us were suspended in time, staring at each other, without feeling, yet with every feeling imaginable.

The first tear trickled down.

“You have to understand,” I told him.  “For all you guys, you had never felt closer to anyone than you did to the men around you.  You were in each other’s souls.  And when one of you died, he took a part of your soul with him.  But for you–it was even harder.  You feel the hearts of others so much more naturally than most.  When you entered a guy’s soul, you entered it.  You’d do anything for him, would have done anything for him.  But he died.  And you’re alive, in better shape than anyone who had seen you on that Med-evac would have ever imagined.”

He was still looking at me, several tears having already followed the first, quiet, his whole demeanor floating almost, on a sea of sadness.

“It hurts so much, you know,” he whispered through a swallow.  “Sometimes I don’t think I can make it.”

I had to ask.

“Any thoughts of hurting yourself?”

He shook his head, though not vigorously.

“I mean, I can’t say it doesn’t cross my mind sometimes.  But . . .I could never hurt my family like that, my Mom and Dad, my siblings.  That would be too awful.”

So I decided to go for it.

“You do realize, don’t you, that in trying so desperately to rescue your girlfriend from her pain, a part of you is trying to rescue those guys?  It’s as if your body can’t let go of trying to get it right this time, make sure no one around you ever hurts like that again.  So that you don’t have to hurt like that again.”

He looked down.  Very slightly, he nodded.

“We’ve got to face this together,” I continued.  “It’s not going to be helpful in the least to deny it.  As you begin to feel stronger, more solid, a part of your body is going to demand that you get back to those drugs.  Yes, you’re going to want to use initially to reduce the tension.  But you know as well as I do that within minutes, you’ll just be hurting, loathing yourself, one more time, one more crummy time.  No, you don’t want to feel that way, be that way.  But you’ve got to face that a part of your body is demanding you never have what those men could not have.”

For a few seconds, silence, then a quiet “I do feel better, you know.  I do know I can get better.”

I leaned forward.

“That’s why these drugs are so dangerous.  The stakes are getting higher.  Pretty soon your body’s going to have to take some desperate measures if you don’t get a strong enough support network around you.   You’ve got to let a few people take care of you.  You’ve got to let me take care of you.  You’ve got to let your parents take care of you.  You’re not strong enough to take care of yourself yet.  The part of you that wants to live has got to give in to us and let us sit with you, not leave you alone, let you know that we’ll do what we can as long as we can.”

He looks up at me.

“I . . . I just don’t want them to worry about me, my parents.  I . . .”  He fell silent.

OK, time for the big guns.

“Look: I’m a father.  I can tell you this without a doubt.  Your parents know when you’re suffering.  It ain’t a secret.  And nothing–nothing–is harder for a parent than seeing a child suffer and not even be able to try to comfort him, sit with him.  Nothing.  You’re not making your parents’ lives any easier by not talking with them about your pain.

“One of the best acts your Mom or Dad could do for you is simply sit with you when you’re hurting, scared, ready to run out and use.  Even if you guys just watch some stupid TV show, even if you just sit on a couch and say nothing, you won’t be alone.  You need to let them–let me–comfort you so that one day, finally, again, you will be able to comfort yourself as well as any of us humans can.”

For a good thirty seconds or so, we sat in silence, his head down, my body now back upright in my chair.  Slowly he looked up at me.

“Will you talk with my parents if I bring them here?” he whispered.

“Of course,” I whispered back.  “Of course.”

I finish writing these words much later in the day, as I fly out of Logan, heading back to Indianapolis, the Boston skyline ablaze before me for the few seconds before the airplane wing covers it, hurries it to short-term memory, its ultimate recollective fate unknown.  When I was much younger, I almost ached as I would fly away from Boston.  My life had changed there in so many ways.

Yet now I am no longer young.  I have created a life a good two hours away by direct flight, two days away by car.  It is a good life.  My youth may not be renewable, but my own hope, my own passion is.  It will return as I go home to my family this evening.  It will return as I go back to the hospital on Monday.

My patient is slowly starting not only to believe, but to feel in his gut that his youth, though partially diverted into several years of horror and pain, can still be renewed, renewed in his own hope, in his own passion.  Forces deep within him, gut urges will keep trying to draw him back into a part of his psyche that had barely been holding on with life supports.  He will have to take the risks of depending on us.  He will have to take the risks that, just as with his buddies, something could happen to us.  He’s going to have to learn to soothe himself again.  He’s going to have to trust that we’ll do our best to help him do that–and that we’ll do our best to remain available for that very task.

Life would have been so different had my wife and I stayed in Boston.  For one thing–I’d have never met this man.  True, I’d have met many others, sat with many others.  But not him.

I am glad to be flying home, as a husband, as a father, as a psychiatrist given the opportunity to work with a very renewable, very aching, very hopeful-to-be-hopeful young man.

Life can be hard.  Life can be good.

Treatment Plans

July 12, 2012 By in Professional Relationships Tags: , , , , , , 2 Comments

Yesterday I had the memorable experience of sitting with a group of colleagues at my hospital to hear a discussion of how to use treatment plans as therapeutic tools.

For the uninitiated: everyone who is receiving treatment in modern hospitals and most modern practices (especially those that are dependent upon insurance reimbursement) should have a “treatment plan” that spells out the specific goals and objectives that should be pursued in the treatment. It should be an ongoing reflection–a snapshot in words, if you will–of where the patient has been, of where he or she now is, of where he or she should be heading. Otherwise, how would you know that the treatment has been successful, right?

Or even worse, otherwise we might end up with a nation full of Woody-Allenesque treatments lasting decades, going nowhere, costing money that should be more effectively applied to more effective tasks in this effective world of ours, in effect.

This is a big whoopie deal in my profession right now, and I believe it’s supposed to be accepted dogma that not only are treatment plans necessary, but that they are also morally superior to any treatment that is conducted more along the line of “two people deciding together how matters should go as those matters unfold.” These days, if you’re not pro-treatment plan, you’re a nobody, a loser, a dinosaur, or worse: a therapist who keeps people dependent in order to line his or her pockets with filthy lucre, dropped by some poor soul who had been under the delusion that he or she had actually been benefitting from said filthy-lucre-engendering relationship.

In other words, combat veterans deserve the best, and the best, no doubt, no contest, no quibble, nothing, nada is–treatment plans!

Being against treatment plans is akin to being against motherhood–or better, being against air. Treatment plans are not just good: treatments plans are, period.

So let me set the record straight to the universe-at-large: I’m all for treatment plans.

I’m even for the idea of treatment plans as being therapeutic. Just as I’m pro-air, I’m pro therapists’ talking to their patients about what the patients are hoping to accomplish in therapy, about their working together to achieve those ends. You go, Mom!

My thought for the day is merely this:

We are now seeing a generation–a big generation–of patients, i.e., combat veterans, most of whom, for the most part, would never have darkened our doors had they not gone to War. I’m not just talking about stigma or about War creating problems that otherwise would not have been created. I’m talking about a big number of people who, even when faced with problems, would under any other circumstance have never thought for an instant about speaking to a professional about such problems.

I say it over and over: you don’t volunteer for the military during a time of war because you are a Herman Milquetoast. You have energy. You have passion. You are a warrior. You’re someone for whom the act of volunteering for the military during a time of war makes sense. You do. You make things happen. You join a group of people because they are making things happen–and you want to make things happen.

Combat vets do not want to come see us mental health professionals just because of stigma. They do not want to come to see us because they know that therapy and their passion do not easily mix. They do not want to come see us because they know that what they have seen, what they have experienced, what they have done cannot be encapsulated with even the slightest hint of relevance into measurable goals and objectives.

Believe me: if those experiences could have been so encapsulated, they’d have long done it. On their own. And then done something about it. We mental health professionals are the last ones they would have needed to–or even thought of–consulting about that project.

The passion, the horror of what they have experienced has not been seen by my profession in these numbers for years. Years.

That means that all of our regulations, all of our best practices, all of our plans for efficiency, all of our practice models based on business models for running banks and airlines that cannot afford a margin for any error, all our data have never been systematically worked out on a big group of real men and women who cannot be compared to any group of similar “clients” from the past forty years–the very years during which we’ve been making our regulations, formulating our best practices, etc., etc.

Why in the world we think that a focus on “doing” in mental health is going to be the salvation for these men and women is beyond me. News from the front: these men and women never would have been ones to sign up for a Woody Allen psychoanalysis. We don’t have to worry about their sitting around forever and doing nothing.

We do have to worry that they will not know how to sit long enough with that passion, with that energy, both now directed with a vengeance against their very own souls, their survivor guilt, their grief, their actual guilt, their shame, all long enough to let metabolize what needs to be metabolized, cried through what needs to be cried through, accepted what needs to be accepted, all in order to find again that even after War, life can be worthwhile.

And even more–and what nearly breaks my heart to say–we have to worry that we have spent so much of our time and energy training a generation of mental health professionals how to be goal-oriented doers, we may no longer have anyone left who has the emotional fortitude to accomplish the one goal that these men and women cannot accomplish on their own: to listen to and sit with the pain of War long enough to allow it to move to the periphery of the combat vet’s soul so that Life can retake its rightful place at the center.

What a combat vet needs in his or her treatment plan is the following, right at the top of the list:

Goal: To Put Life Back in the Heart of the Client

Objective 1: Improve the Veteran’s Ability to Regulate Emotion

Intervention 1: Standard Evidence-Based Treatments

Intervention 2: Medication as Necessary and as Tolerated

Time Frame: Eight to Twelve Weeks, with Follow-Up as needed

Objective 2: Strengthen the Veteran’s Ability to Find Purpose and Meaning Again in Life After Having Witnessed and Participated the Ultimate in Meaninglessness

Intervention 1: Listen to How Bad It Was

Intervention 2: Wonder Out Loud With Veteran About How Anything Good Can Come Out of All That

Intervention 3: Believe When They Cannot that Such Good Can Indeed Come

Time Frame: As Long As It Takes

Show me a mental health professional who can write me that treatment plan? I’ll show somebody who’ll have already had more referrals from me than either of us can count.

Saint Crispin’s Kindergarteners

July 7, 2012 By in Culture at War, Respect, Honor, Duty Tags: , , , , , , , , , Leave a comment

In yesterday’s New York Times, columnist David Brooks wrote a fascinating piece entitled Honor Code, and even at the writing of this post, almost twenty-four hours later, it remains the most e-mailed article of the day for the paper.

Using an ingenious example, King Henry V of England, or rather his literary embodiment, Henry V, as immortalized by Shakespeare–ingenious on Brooks’ part, in that Shakespeare had already given his audiences a glimpse of a much younger Henry in two earlier plays, Henry IV, Parts I and Part 2, as the, shall we say, wild “Prince Harry,” or (as he’s more affectionately known by his portly, somewhat wayward, older friend, Falstaff) “Hal”–Brooks makes a passionate argument that modern education (and perhaps even modern social mores) takes passionate boys and turns many of them into angry, confused, and self-loathing “problems” (or as we in the mental health field might say, “clients”).

The guy pulls no punches.  We in the medical and mental health fields take our customary hits, given our semi-acquiescence in the apparent outbreak of attention deficit disorder (ADD) among our young, especially the boys.  In truth, he provides a succinct, quite plausible narrative that had Henry indeed been raised in the finest schools of modern America, he might easily have become a male poster child for my well-Googled bugaboo, Cluster B Traits.

One can easily argue that Brooks overgeneralizes, and I suspect even he would admit that on occasion he leads his argument down a more showman’s path.  ADD, for example, does exist, and I can provide you the references on request.  Yet the article ain’t Number One for nothing–and I tell you, if you work daily with combat veterans, you know exactly why it is.

I’ve discussed this topic already in a several earlier posts, most recently Buddy, Got the Time? and Quite the Handful.   Brooks, however, through Henry, adds an interesting embellishment, quite appropriately using the word people, and thus describing passionate boys and passionate girls.  He writes:

Schools have to engage people as they are. That requires leaders who insist on more cultural diversity in school: not just teachers who celebrate cooperation, but other teachers who celebrate competition; not just teachers who honor environmental virtues, but teachers who honor military virtues; not just curriculums that teach how to share, but curriculums that teach how to win and how to lose; not just programs that work like friendship circles, but programs that work like boot camp.

For those of you who might be a bit rusty on either your British history or your Shakespeare, wild young Prince Hal grew up to be thoughtful, charismatic, and brave King Henry, leading a relatively small “band of brothers” (hmm, combat vets, sound familiar?) to an amazing victory over the French at Agincourt on St. Crispin’s Day.  In the play, he agonizes over the role of the king, of the one who himself is only a man, yet who must make decisions that will affect the lives of many men.  Finally he stands before those men, all vastly outnumbered by the French forces, and Shakespeare has him speak the words that so many actors have endeavored to inhabit with passion for hundreds of years:

And Crispin Crispian shall ne’er go by
From this day to the ending of the world,
But we in it shall be remembered,
We few, we happy few, we band of brothers.
For he today that sheds his blood with me
Shall be my brother; be he ne’er so vile,
This day shall gentle his condition.
And gentlemen in England now abed
Shall think themselves accursed they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin’s Day.

Some today indeed see those words as glorifying the bellicose, the worst of the human spirit.  Perhaps they are right.  Some see today’s emphasis on the mutual, the ordered as finally attaining the humane, the best of the human spirit.  Again, perhaps they are right.

Yet every day I sit with men–and women–who desire peace in the world, in their lives, but who are anything but “peaceful” by nature.  They have a warrior’s energy.  They had a warrior’s energy in kindergarten.  They didn’t do circle time well.  They were often the outsiders, the problems.

Indeed many of them do feel that they are still “outsiders” in a world, a nation that tells them to live mutual, ordered lives after training them impeccably well in the bellicose, taking complete advantage of their passion and fire when necessary, demanding complete extinguishing of both when later deemed “necessary.”  They are more than aware that they’ve had to turn in the title “soldier” upon arrival onto US soil and then head off to the next debriefing station to pick up their new title:  “client.”

Brooks has an excellent point, one made not only by him, but by others: in a globally-interrelated, technological world, the mutual and the ordered may indeed flourish.

Yet, friends and neighbors: we have warriors in our midst.  Many of them were made to feel “problematic” as children.  Many finally found that life could have coherence and even meaning when their warrior nature flourished in the military.  They did not want to kill, but they did so if they had to, not for sport, but for the protection of those they loved.  They grieve those who died unnecessarily.  Warrior certainly does not equal monster.  It shouldn’t even necessarily have to equal client.  End of story.

So I get passionate when I think that we are taking one percent of the population, a percent that we allowed to volunteer and fight, exposing them to horrors on our behalf (and don’t you dare give me that “not my behalf” bit: did you give up lattes and/or Bud Light to stand against George or Barack?), with our then now doing nothing to find a way for them to fit into our society.  Talk about the ultimate bait and switch: You’re a problem!  No, wait, you’re a hero!  No, sorry, you’re a problem again.

Brooks is right.  We do have to rethink “problematic” boys–and girls.  We do have to rethink problematic combat veterans.

For many of us, then, we have to keep writing, keep pounding on doors, keep shouting.

His Majesty, Henry the Fifth of England, would have done no less.

And, boy, when he was a kid?  Let me tell you. . .

Independence Day

July 4, 2012 By in Culture at War, Living Life, Respect, Honor, Duty Tags: , , , , , , , Leave a comment

Life takes interesting turns.

Just a year ago, I had no idea at all that I’d be working full-time at the VA or that I would be writing a blog about my experiences.  I had not met many of the very fine people I have had the opportunity to meet through the blog and other social networking outlets.

I certainly did not think about Independence Day in the way that I do now.

As I’ve said in previous posts, I’m not patriotic in the usual sense of the word.  I remain very distrustful of the Nation-State as a whole, and while I have no problems with the notion that leaders, whether civilian or military, might be decent people as individuals, I cannot similarly say that they always act decently when they act together “for our benefit.”  I simply cannot muster excitement for “The United States” as an abstraction–and therefore as an abstraction symbolized by a flag passing in front of me or a song, ridiculously difficult to sing, no matter what your voice, one only passably accessible for a bass-baritone in the key of A flat.

Yet that same flag, that same song as symbols of concrete realities, of real men and women with real histories, real tragedies, triumphs, hopes, men and women not proud of aggression, but not ashamed of it either, men and women who leave behind “Just In Case” letters for spouses, children, parents, just in case, facing at the ages of eighteen, twenty-five, thirty-five, even forty-five the reality that each of us hopes will remain existential for the foreseeable future, thank you, the reality, however, that they can no longer afford to hand a number and then tell it to take a seat and wait its turn along with graduation gifts, wedding cakes, baby blankets, and anniversaries silver and golden?

As some of you who have been following the blog may remember, on Memorial Day–on Decoration Day–I placed a flag at the grave of the father of one of my patients, the grave of a man of a different era who did believe in an abstraction, but who also lived out the actual ideals of that abstraction in his concrete life, no matter how imperfectly, no matter how simply.  Today I think of names–Danny, TJ, Mike–and I imagine flag-draped coffins, nothing abstract whatsoever, folded, delivered, held.

Today I also remember my son playing his oboe, standing out on a football field (yes, I know, oboes and football fields don’t jive, but trust me), having memorized the song indeed in A flat, glad that the flutes will double him in case he misses a note or two in the parts when the brass take a rest.  I remember standing in a corner of the grandstands, just a few people around me, mainly band parents (it was a junior varsity game, after all), as the de rigeur drum roll began, three beats and then come in on four.

And I remember thinking of Danny, TJ, and Mike, the fallen comrades–no, soulmates–of three of the men I’m privileged still to listen to, to serve.

The musical progression is well known, thanks, in no small part, to basketball and rising flags at Olympic Games:  E flat, C, A flat–a low note for many people, yet quite comfortable in my range–a dotted eighth note, sixteenth note, quarter note, all followed then right up by the major chord, do, mi, sol, do.

What I cannot remember is the last time before this one that I had sung the National Anthem.

You must understand: I am a better-than-average singer.  I’ve done my time in the choruses of Turandot and Tales of Hoffman for our Indianapolis Opera Company.  If I sing just at half voice in your average crowd, I’m noticeable.

While I did not sing full voice (it wasn’t about me, after all), I didn’t whisper.  I couldn’t.  I had just remembered Danny, TJ, and Mike.

At that point the politics just didn’t matter to me, Lyndon Johnson, Richard Nixon, George Bush, Barak Obama, Robert McNamara, Donald Rumsfeld, Henry Kissinger, Hillary Clinton, none of them.

I was not unaware of the song’s militarism.  I was not unaware of the suffering of the Iraqi and Afghan people.

And I was aware of six young men, three dead, three alive, three of whom never saw their twenty-fifth birthdays, three of whom have yet even to reach their thirtieth.

All I have to do is keep the back of my throat open and imagine the sound rising to the top of my head, and I can take that E flat at the end of the land of the free, more with a short i sound than a long e one, and hold it out four counts, no need to push the volume, just fill the head with air and relax.  It’s that simple.

And the home of the brave.

Yes, each of those six men were.  Three still are.

The standard applause and semi-whooping done, I started to walk down the steps toward my son’s pick-up point.  As I passed, the woman just to my left, two rows down, looked right at me.

“Wow,” she said.  “And you knew all the words and everything.”

We live in a complex world, filled with children who die unnecessarily, no matter where the nation, men and women who grieve a life partner, whether only of a few months or of many, many years, men and women barely out of adolescence–or long, long past it–who grieve a guy from Dubuque, a woman from Tallahassee.

I can only plant a flag for a kind, often sad father.

And sing.  As well as I can.  For Danny.  For TJ.  For Mike.

Routine, So They Say

July 1, 2012 By in Living Life, Professional Relationships Tags: , , , , , Leave a comment

He’s not a combat vet.  So why write about him, right?

Actually, he’s the childhood best friend of another of my patients who is a veteran of the early invasion of Iraq.  They served in different branches.  They give each other no end of grief about that.  Well, no, what am I saying:  his friend gives him no end of grief.  I’m not sure that my patient gives anyone grief.

He’s too good-hearted.

He grew up in a very working class neighborhood of Indianapolis.  He did not have it easy.  He never knew his biological father.  He still remains connected with the stepfather of his childhood, although that man has long moved beyond my patient’s mother into another relationship, with a woman who’s not exactly that enamored of my patient.  His biological mother?  A long story, very long.

He’ll admit it: he has not exactly lived a life worthy of being enamored of.  Certainly the mothers of his children have not been.  It’s been ugly.

It was heroin, with painkillers thrown in for good measure.  He was a heavy abuser.

He also has recently been diagnosed (by someone other than I) with bipolar disorder, a mood disorder formerly known as manic-depressive illness.  Some in my profession believe the diagnosis is thrown around a bit too freely these days.  They have a point.

My patient, however, is the real deal, although of a more depressed type.  He cannot take standard antidepressants, as they cause his mood to shift into a very painful state of hyperactive mood shifts and racing thoughts.  His moods do respond relatively–stress on the relatively–to standard mood stabilizers.  Still, he has a rough go of it.

Yet his desire to get better is nearly palpable.  He’s hurting down to his core to try to get better.  And when I sit with him?  His core finagles its way right into mine.

I often talk about the problem of “countertransference,” i.e., the challenges I as a treater face when I experience within me the strong emotions of my patients.  Today marks the thirtieth anniversary of my beginning my career as a psychiatrist.  Thirty years ago I was standing at the VA Medical Center in Durham, North Carolina, across the street from the then newly-built Duke University Medical Center North Hospital.  Countertransference got to me more than once as that young, quite-insecure doctor back then.

It still does.

My patient is slender, but now well-built.  I suspect that as a much younger man he was, to put it mildly, lanky.  He has a Southern drawl typical of persons who grew up in his area of town, and he reminds me so much of those boys from Hillsborough and Butner and Rocky Mount who would make their way over to the Durham VA so many years ago.  He’s very deferential, with a good-old, Andy-Griffith “aw, shucks” way about him.

I suspect he was not at all that likeable when he was high.

But in the past, when he would get so sad, think about his life, the mistakes he made, that he continued to make, when he would regret actions taken, would miss his children so, so much: heroin made it all go away, even for just an hour or so.

There are only so many tears a man can shed–especially when he has to shed them alone.

It was about three months ago that he came to me, practically dragged to my door by his buddy.  He was a wreck.

“I’m so sorry, sir,” he kept repeating.  “I don’t mean to be like this, but I just can’t stop.  I shake and I shake and I shake.  I want to stop the drugs.  I hate my life.  I hate myself.  I want to see my son again, and his mama said she won’t let me see him if I don’t clean up.  I’m so scared.  Please help me.  Please.”

His wasn’t the most straightforward of cases medically, and I made some clinical decisions that some colleagues might frown upon.  (Lord, everybody’s got an opinion, don’t they?)  Yet he stabilized fairly quickly, and he was clearly relieved.

He lives, though, quite a ways from our hospital.  He long ago lost his driver’s license.  His father works constantly.  His stepmother can’t drive.  His buddy is his only means of reliable transportation, and the friend can’t get out there to my patient’s place very often.  We’re not exactly in a situation that allows for a lot of close follow-up.

But he does stay in touch with me.  And last week, he let me know that he was not doing well.  By hook and crook, he managed to bum a ride to the hospital, but he was about three hours late for his appointment.  He was panicked that I wouldn’t see him.

“I get so scared,” he told me.  “I miss my son so much.  His mama is just beginning to talk to me again, and I can’t mess up, I just can’t.  But I just sit in my room and cry.  I hate it.  I don’t want anybody to know.  I don’t want to kill myself.  I want to live for my kids.  But I don’t know what to do.  I can’t work.  I’m alone most of the time.  My parents are always thinking I’m going to start using again.  I haven’t, I swear.  I don’t want to.  I’m staying away from all those people.  But it’s so hard.  It’s so hard.”

He was doing everything he could not to weep, and to give the boy his due, he was succeeding.  Hearing him say those words, though, in that Kentucky accent, all caved in on himself, even though he’s actually quite muscular and attractive, in a farm-boy kind of way–he ripped my heart out.

“Who calms you,” I finally asked him, “when it gets this bad?”

I was afraid of the answer to that question.  I almost didn’t ask it.

He looked up from the floor that he had been staring at so long.  The word puzzled has ne’er been so well embodied.

“Excuse me, sir?” he whispered.

“I said,” now whispering myself, “who can calm you when it gets this bad?”

He swallowed.  He didn’t want to say it.  I didn’t want to hear it.

“Nobody, sir,” he finally said.  “Everybody’s just mad at me.  I did it all to myself, sir.  I’ve got nobody to blame.  I just . . . no, sir, there’s nobody.”

“Who’d you live with growing up?” I asked him.

“My mom, sir.”  He paused.  “When I was wasn’t in a foster home.”

I didn’t ask more.  I knew enough.  He didn’t volunteer more.  He knew all too well.

I can’t begin to tell you the number of stories there are like his.  The VA’s full of them.  Mental health centers (what few are left) are full of them.  Emergency rooms are full of them.  It’s routine, so they say:

Child, usually a boy, is caused trouble, causes trouble, all in an endless cycle of in-home/out-of-home/run-from-home.  Sometimes he finds stability in the structure of the military, but ghosts come back to haunt within days of discharge.  Eventually he makes himself clear enough to a person who’s ready enough to listen, and the pattern emerges: the dramatic mood shifts, the family history of substance use and emotional chaos, the boy’s, the man’s own personal history of the same, obediently re-enacted as the next generation’s example of all the forefathers’ (mothers’) chaos and suffering.  Medications help stabilize him.  He gets better.  But still, there has been so much pain endured, that is yet enduring.  There’s only so much a poor, little pill can do, after all.

Many guys with this story just blow up, over and over and over.  My patient’s buddy struggles with that.

He, however, is the opposite.  He just caves in on himself, over and over and over.

Heroin used to help, that’s for sure, even allowed him to muster up some good, old-fashioned obnoxious sneers and threats when he was high, a sort of “jackass’s relief,” if you will, from all his misery, his self-condemnation, allowed him to spread his misery around to all who dared venture into his vicinity.

Now he’s clean.  Now at least he’s not jonesing.  But now he’s hurting, 24/7.  He doesn’t want to die.  But he has no clue how to live.

Thirty years ago today, I was the age he is now–a little younger, in fact.  We grew up in the same city, in some ways even in similar cultural worlds.  Now I sit with him, old enough to be his father, same city, worlds apart.

I want to fix everything for him.  I want to fix him.  I can’t.  I know that.  He knows that.  I do my best.  He does his.  We’ll keep trying.

No combat trauma today.  Just life’s routine trauma.  So they say.

I wish.

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