The Tattoo Graft

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

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

There were those who didn’t make it back.

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

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

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

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

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

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

Eventually he started the Suboxone. It was indeed helpful.

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

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

It was he.

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

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

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

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

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

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

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

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

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

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

“Yes, sir,” he said. “Yes, it is.”

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

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

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

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

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

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

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

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

Time to be gentle. Time to be real.

“Not good?” I asked.

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

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

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

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

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

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

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

Then came last week.

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

The calm smile was back.

“You look good,” I told him.

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

“What happened?”

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

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

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

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

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

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

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

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

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

“Taps” and the Last Musketeer

It’s time to get this written.

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

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

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

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

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

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

Or . . .

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

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

For me?

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

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

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

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

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

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

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

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

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

So I made it.

I opened my arms wide.

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

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

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

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

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

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

“Of course,” I replied.

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

“Of course.”

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

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

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

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

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

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

It was Josh Groban.

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

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

Of course, Josh Groban. Of course.

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

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

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

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

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

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

Boundaries, schmoundaries.

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

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

Then it was his father.

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

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

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

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

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

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

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

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

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

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

From across the way the commands were barked.

Rifles clicked. Fired.

Clicked. Fired.

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

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

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

Porthos would have loved it.

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

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

And then it happened.

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

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

Athos handed Jack the flag. And he saluted.

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

Minutes later, the service was over.

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

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

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

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

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

“I know,” I replied.

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

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

He did.

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

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

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

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

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

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

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

“Yes.”

“Maybe I could come by on Friday?”

“Of course.”

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

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

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

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

Words that I now must write.

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

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

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

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

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

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

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

Because he’d watched a couple Harry Potter movies.

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

He knew something of that process, after all.

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

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

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

Cruciatus consumptus est, Porthos. Requiesce in pace.

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

Amen.

Goodbye, My Friend

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

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

My God, never again.

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

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

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

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

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

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

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

Ergo, your smile.

Goodbye, my friend. Goodbye.

 

In Memoriam, Clay Warren Hunt, 1982-2011

I have been putting off this post for several days.

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

But it’s time.

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

How lucky a father I am.

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

On Monday, I did.

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

Hunt_Wide_620x350

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

God, how many times have I seen those eyes.

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

But then there are the days I see those eyes.

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

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

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

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

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

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

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

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

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

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

Dear Doc/Dear Winston, 03.03.13

Dear Doc,

Dear Mom and Dad,

Just another day in Iraq, waking up wondering if today is the day I get to meet the Maker at this fuckin’ place.

I put a bullet in clip with HOMIS written on the side of it. Was thinking about you guys today, wondering what you’re doing.

I couldn’t sleep last night. The mortars just wouldn’t stop. It’s almost comforting, hearing the outgoing rounds blast out of the 120 (120 mm mortar round HEDP) (High Explosive Dual Purpose).

I lay in my bed thinking about being a little kid again. Where did the days go? Life is different here. I would try to tell you how, but I wouldn’t know where to begin.

I miss my baby girl. I will kill them all to come home to that sweet, innocent little baby. My heart is so cold, and she is like a spark burning deep in my chest. How will I ever tell her what I did here? I tremble at the thought of holding her. She is the only thing that scares me in this world. My breaths shorten at the thought of her.

Please don’t hate me for what I have done. I had no choice. I wished and prayed they would just stop and give up. I think to myself every time I pull the trigger, “Why don’t you just stop. Please. Don’t make me shoot you.”

But after awhile it turns to hate; the thought of one bullet not going through his chest upsets me.

Hope all is well. Maybe I will get to come home soon.

Love,

Your Son

Winston

__________________________________________________________

Dear Winston,

I’m sorry that it has taken me a few days to get back to you: I have been traveling this week, and life got away from me (much thanks to Chicago’s O’Hare airport, I might add, the number one exemplar of “chaos theory in action”).

I have pondered this letter often, however. After four years of working with the men and women who, like you, once served in combat, I still find myself surprised at how unprepared—how reluctant, even—I can be to experience the dramatic shifts in thought and emotion that you and so many of your brothers and sisters experience, sometimes hour by hour.

To feel at one moment a love for a child, a nostalgia for a family time, then to feel at the next a hatred that can easily conceive of killing, only to be followed by a sincere, pain-filled desire for all the hatred, all the killing to end, all of this happening day after day after day, on a busy city street in an Iraqi city, at a quiet kitchen table at your home, enduring another sleepless night: I have no clue, Winston. I have no clue.

I do mean this: thank you for trying to give me a clue. I don’t like knowing what I have to know as a result of your having done so. I don’t like the gut shifts that occur within me as I read this letter, the psychic handball marked “raw emotion” that ricochets inside me, wall to wall to wall, the soul-imploding pain that I only dare to imagine to imagine as I consider, dear God, what if this were my son writing me this?

I’m sorry, Winston. I know that you volunteered to serve. But I, as a citizen of this nation, sent you to the Middle East with the promise that it would all make sense in the end. Nobody sent me to jail for refusing to pay the taxes that go to support the military.

I’m sorry that we, as a nation, are still not only struggling to make sense of it all, but, even worse, are struggling—why??—with the (what seems to me to be the obvious) notion, based on justice and mercy, that we owe you and your brothers and sisters. We asked you to give up your youth, give up the innocence that we still so easily cling to as we sip our morning, bad coffee and check out the local weather, all so that, indeed, we can make sure that we avoid the freeway jam to get to work, only then to pour ourselves another cup of even-worse coffee and gossip about the previous evening’s cable TV fare.

Thank you, Winston. I wish we all were living lives more worthy of the suffering that you and your brothers and sisters continue to endure, even last night, even now.

It continues to be an honor to work with you.

Doc

Dear Doc/Dear Winston, 02.25.13

Dear Doc,

I hate waking up and looking outside to see it gray and cold, rain setting in. It just feels like a day for a funeral.

I think about shit like that. When you have seen death like I have, it puts a damper on life, sometimes. You know that pain, the pain that hurts like hell, and you would do anything to take it all back or make it go away.

Well, after a while that goes away, but not mine. It stays and grows inside of me. It’s like I have hooks in my body and chains pulling at it all directions, and you can see fucking pain. You can see a little light at the end of a tunnel, but can never get close to it. And people keep telling you it’s all going to be okay, that they are praying for me and that they think about me and all that shit.

Well, I think about war, hate, life—why are we here? What is the purpose, or why do we continue to go on? You just keep going living in a life that is miserable. Why do I do it? I don’t know.

It’s hard when you want to live a life of war, filled with selfishness and anger. I now know why the Templars loved their lives, because they fought their whole lives and had God at the tip of their swords, striking down evil.

Winston

_____________________________________________

Dear Winston,

The writer Michael Howard wrote this comment on yesterday’s post:

“One of the real-life WWII characters I am writing about in my book survived Peleliu … In the early 60’s he would wake up his boy in the middle of the night to take him out on patrols. When I bounce the story off people who know nothing of PTSD, they tend to think it is fiction.”

Remember also what I wrote about you in Empty Chairs, Empty Tables: From Paris to Fallujah and Kandahar?:

“Yet also, had I not just spent the previous minutes with him, absorbing his words, not just hearing them, I could have looked at him and thought: grief that can’t be spoken? Seriously?”

In just these past two months, how our relationship has changed, hasn’t it? Gone is any distancing, defensiveness on your part. In its stead is the warmth, the humor that I know has always been you. True, if I pay close attention, I can notice still a hesitancy on your part, but quite easily I could chalk that up to the deference that a younger man can show an older man. Had I known nothing of you, I would have thought nothing of it.

Hence, my own words in that entry come back to smack me in the face:

“Just because a grief can’t be seen doesn’t mean that it can’t be spoken.”

Because of your willingness to speak your heart, Winston, I do so hope that at least a few more people can understand how the truism “Looks can be deceiving” can instead be a profound truth of combat trauma. Yes, a part of you wants to live a life of selfishness and anger, filled with righteous hate. Yet a part of you, night after night, searches for that little girl in your dreams, feels that pain of a father trying to heal the infected leg of a son, wants to understand why, why, why.

How appropriate perhaps it is, then, that you refer to the Knights Templar. Remember “Indiana Jones and the Last Crusade”? Remember the knight who stayed by the Holy Grail for seven hundred years, protecting it from those who would use it for their own glory and power?

The Knights were certainly no strangers to the atrocities of the Crusades, atrocities which continue to burn in the souls of Muslims and Jews to this very day. Yet somewhere there, within at least some of them, was a faithfulness, an honor, a duty that has lasted enough through the centuries to make a character in a fantasy-adventure film if not believable, then at least understandable.

I know that The War still can rage within you, filling you with all its annihilation, even its allure. And I know that you are there, perhaps, if I might say, a Templar in the best sense, one who has known all that War can do to a soul, one who wants to remain faithful to a vision that was good in its outset, even if complex and even destructive in its fulfillment, one who waits, hoping against hope.

That is the man whom I see.

Doc

Location, Location . . .

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.

The Killing Floor (Audio Version)

On April 18, 2012, I posted The Killing Floor, in which I described my encounter with a soldier who had written a song about his experiences in Iraq.  Since that day, the post has had, as of this writing, 889 hits.  The soldier’s words are direct, vivid–and tough.  Few have been able to read them without experiencing their power quite strongly.

Two days ago, this soldier sent me a copy of the audio of the song, and I gladly agreed to share it on the blog.  I have added it to the original blog, but given how many people have already found his written words so moving, I wanted to make sure that all would have an equal chance to hear them as they were meant to be heard.

If you thought you were affected by the words in print, then prepare yourself.  We’re moving to a whole other level.

In his truly amazing book, On Killing, Lt. Col. Dave Grossman writes the following:

“I [once] discussed some of the psychological theories concerning the trauma of combat with one crusty old segeant.  He laughed scornfully and said, ‘Those bastards don’t know anything about it.  They’re like a world of virgins studying sex, and they got nothing to go on but porno movies.  And it is just like sex, ’cause the people who really do it just don’t talk about it.’

” . . . Killing is a private, intimate occurrence of tremendous intensity, in which the destructive act becomes psychologically very much like the procreative act.  For those who have never experienced it, the depiction of battle that Hollywood has given us, and the cultural mythology that Hollywood is based upon, appear to be about as useful in understanding killing as pornograhic movies would be in trying to understand the intimacy of a sexual relationship.  A virgin observer might get the mechanics of sex right by watching an X-rated movie, but he or she could never hope to understand the intimcacy and intensity of the procreative experience.”  (emphasis in original)

This soldier understands Grossman down to his bones.  When you hear the song, you will know what I mean.

In re-posting the song, I do so for all the men who are in the spirituality group that I attend with the Chaplain here at our VA.  In just the few weeks I have come to know these men (including the writer of this song), I have been deeply moved by their honesty, their willingness to speak whatever truth they need to speak, their nearly-palpable desire to find meaning again in this world.  It is an honor to be part of their lives, and I have come to care deeply about each of them.  So in their honor–and in honor of those whom they loved, but could not bring back with them–I present you again:

The Killing Floor

Driving through the sand
In an 1114,
My men and I are true killing machines,
50 cal and a Mark 19.
We can take out anything.

Death is near,
I can feel it in my bones.
Contact right, coming over my headphones.
I look to the right, and what do I see?
I see this Iraqi man staring right back at me.
He raised his weapon, I had to blow him away.

I still think about him every day.

Was he a father, or was he a son?
I wonder if he’d ever even held a gun.

What are we fighting this war for?
It’s a one-man show on the killing floor.
The killing floor is what you need.
The killing floor is what you believe.

Have you ever heard a mother’s cry?
Have you ever seen a father’s tear?
Who are we kidding,
We’re killing children here.

Have you ever seen that father’s tear?
Or have you ever heard that mother’s cry?
That will tear you up from within.
Then I look at the killing floor again.

Beauty is within the selfless sacrifice.
Have you ever seen a dead soldier’s eyes?

What are we fighting this war for?
It’s a one-man show on the killing floor.
The killing floor is what you need.
The killing floor is what you believe.

One More Time Around, With Feeling

Often Thursdays are quieter days for me.  I only began working them in January, when I began working full-time at the VA; consequently not a lot of appointments have found me, so to speak.  The Joint Commission, the major hospital accreditation organization, was at our facility this week, but my section had finished its part of the evaluations, so in a sense, mid-morning that day was a perfect time to catch up on notes–or, in the alternative,  to stare mindlessly at a computer screen, wondering whether I have ever really slept adequately in my entire life, come to think of it.

“Hey, doc!”

It took a few seconds to shift my computer monitor reveries toward my doorway.  There stood a man I hadn’t spoken to in at least eighteen months, maybe more.

“Well, look at you!” I retorted.  It was indeed good to see him.  There’d always been this sotto voce warmth between us, as he would never, thank you very much, ever let himself actually show me too much excitement in this world.  His exterior had never been nonchalant, nor indifferent, nor certainly aloof.  It had merely been enigmatic, with a protective skin surrounding his psyche that certainly was thicker than paper, but not even close to being thicker than stone.  In the past I had seen his inner fire, true, but only in his eyes–and occasionally in his “you-know-I-could-blow-this-popsicle-stand-any-time-I-wanted-to” half-smile.

“Are you busy?”  he asked, no half-smile to be found.

“Not at all.  Come on in.”

“You sure?”

This was not some “after you, no, after you” comedy routine, believe me.  He was being quite deferential–yet seemingly quite uncertain as to whether I’d follow through with what I’d just said.

“Of course.”

He eased himself into my office, carefully closing the door behind him, and lowered himself into the chair next to my desk, adagio, poco a poco.

He’d gained some weight since the last time I’d seen him–not a lot, but he was admittedly heading into the stocky range, though quite admirably so, if I do say.  He had the same wire-rimmed glasses.  His hair was not much longer than it had been before, not military-issue, but not long by any stretch, more like “length of hair that would grant ready access into any middle-class home to check out a broken toilet.”  Come to think of it, that would have been a great title for a picture of him sitting here: Plumber in Blue.

How different he appeared from the man I’d first met in Spring 2010.  I first noticed him as he was walking down the hall with another physician for an intake, far thinner than he should have been, his countenance this odd mixture of the enigmatic and the panicked.  Within hours he was standing at another doorway of mine, this time solely panicked, pleading with me to speak with him.  It had been the heroin.  He couldn’t take it any more, he told me.  He’d already ruined his life (so he thought), for the authorities had him nailed.  His daughter’s mother wouldn’t let him see her.  He was just wanting all the dope-sickness to stop, all the pain.

But no talk of The War, understand?  He made that quite clear, thank you very much:  off the table, nichts.  Maybe one day, but . . . no.

“It’s been a while,” I say to him this week, hoping that he would pick up that I genuinely was glad to see him.

“Two years this fall.”

“When did you get out?”

“A while ago.  I haven’t used, though.”

This was anything but an innocent statement.  He was wanting me to notice, to be proud.

“Of course you haven’t.  You’ve been wanting to make this work, from the beginning.  We both know that.”

His smile flashed by so quickly, I’m still not sure I saw it.  He looked down and then made an attempt at a deep breath.

“I need your help.”

For the life of me, I couldn’t figure out why he’d be as reluctant to ask for it as he was seeming to be.

“What’s the matter?”

He filled me in on what had happened since I’d seen him last.  He had had to pay a price for some mistakes he’d made before we first met, a high one.  We’d talked about that a lot before he’d had to summarily disappear that fall, so I was familiar with the basics.  Suboxone had made the difference for him that summer, though.  But even then he’d known that he’d never get any after turning himself in.  He was right, of course.

But he hadn’t used.  That said it all, right there.  Not that there had been any dearth of opportunities where he had gone to do just that.  Don’t ever fool yourself on that account.

“I need to get back on the clonidine.  I ran out, and they won’t help me get any.  I’m going crazy without it.  You don’t understand.  Everybody around me’s using drugs.  I could have whatever I wanted.  I don’t want to do that, you’ve got to believe me.  But my nerves are shot, doc.  Shot.”

I’d never heard his voice that halting.  I’d never seen him that close to tears.

Clonidine is an old blood pressure medication that works by decreasing the body’s adrenaline responses.  The theory has it that taking medications like it will decrease the adrenaline surges associated with combat dreams, reducing the intensity and ferocity of the nightmares.  Sounds a bit hocus-pocus, I know, but it and a cousin medication, prazosin, have proved quite successful for these very tasks.

“Of course.  Be glad to.”  I hesitated, but I knew that eventually we were going to have to open the topic.  “The nightmares back?”

His jaw tightened, more as self-precaution than as warning.  Shifting his gaze to the floor, he nodded.  “As bad as they’ve ever been,” he whispered.

Might as well go for two, I thought.

“Have you seen your daughter?”

He was glad that I’d asked, I could tell, glad that I’d remembered her, remembered how her absence chipped away–no, sliced away–at his heart daily.  But it took a few swallows before anything could come out.

“I can’t even get her mother to answer my calls or texts.”  A couple more swallows ensued, eyes still downward.  “I deserve everything I’m getting, you know.  I messed up her life, my life, everybody’s life.  I just wish . . . she’d give me a chance to show her I’m trying.”

For some reason I felt compelled to scoot my chair closer to him, still a respectful distance, but one that felt more, what, real.

“You don’t have to go living like this, you know,” I said, consciously trying to be as gentle as I could.  “We can’t just make The War go away, but it can be better than this.”

For a few seconds, nothing, then “I can’t.  I just can’t do it now.”  Gone was the certainty of the past, though.  In its place, a familiar sound: words saying no, a voice saying please don’t take that answer.

“Should we think about getting you back on Suboxone?”

His head jerked up, and his eyes grabbed mine, seemingly clutching for dear life.

“I can?”

Had I not been so dense at the moment, I’d have picked up the cues by now.  But dense I was, so I was still at a loss to explain his reticence.  After all, he’d always been reliable as a patient.  I’d never worried about diversion.  Suboxone stopped his cravings and stabilized his moods.  We stopped it only because he had to leave the area.  So why would he ask that question?

“Of course” was all I could manage to say.

In the end, we both determined that it was unlikely that he’d be able to take Suboxone while living in his current housing.  Within a month, however, he would be returning home, and we could start the medication back then.  He felt that the clonidine would hold him until then.  When I wanted to discuss any psychotherapeutic/counseling services, though, he bristled.

“I’m not going back and having people tell me ‘drugs and alcohol, drugs and alcohol.’  I know I have a problem with drugs and alcohol, but that’s not the real problem, and I can’t seem to get anybody to get that.”

Only then did it dawn on him what he’d just done: he’d admitted his problem with PTSD, its primacy in his life, and, to his chagrin and yet relief, his need for treatment.  To someone who gets that.

We stared at each other for some fifteen, twenty seconds, must have been.  His eyes began to moisten, but I could see the fire reigniting within them, even if gently.  There, they seemed to be saying, you’ve gotten your satisfaction, your admission.  Fine.  So don’t push your luck and ask for tears as well.

Understood, soldier.  Understood.

We briefly considered various options, finally agreeing that an intensive, dual-diagnosis program might be his best option.  I warned him that our local program was anything but for lightweights, but assured him that the leader was always willing to slow matters down when necessary.  He seemed genuinely relieved.  His eyes were still moist.

Soon we made our arrangements to get together after my time off next week.  He was in better self-control, so he quite rapidly bid me goodbye, promised to see me in a few, stood up, turned toward the door, move on out, baby, move on out.  As he did so, I offered him my hand–more like required it–and he ever-so-briefly paused to shake it dutifully, his gaze basically still fixed toward the door and his imminent liberation.

Then I made a conscious choice.  I didn’t let go of his hand.

He turned back to look at me, puzzled far more than irritated.  One more time our eyes met.

“It’s good to see again,” I said.

He breathed in deeply, I suspect still plotting out the mad dash for his escape.  But then suddenly he calmed, regained the lacrimal glimmer in his eyes, and his been-there-done-that half-smile returned.

“Thanks,” he whispered.  A brief pause, and then “It’s good to see you, too.  I don’t understand hospitals, so I had no idea how I could get back to you.  I’m . . . I’ll see you in a couple weeks.”  Within seconds, he was gone.

Two things, one my cluelessness, one his.

As to me: at the time I had no idea why I scooted forward or why I held on to his hand.  This is a bit dangerous for a therapist.  In a way I confess this precisely to keep myself on the straight and narrow.  I can’t save this man.  I can’t even give him a nanosecond’s thought that I think I can.

Yet at the same time, if a part of me doesn’t in some way reach out and say, “it’s good to see you,” he’ll never know that it is.

And he needs to know that.  More than anything.

For ultimately it is his cluelessness that is the problem.  In my cluelessness, my constant wondering “why is he so hesitant?”, I forgot his cluelessness, his day-in, day-out self-lie: nobody would ever in his or her right mind reach out to me.   I’m a crazy combat vet.  I thrash around at night, moaning on the good ones, screaming on the average ones.  I’m a junkie.  I’m a worthless procreator.  I’m a worthless son, a worthless brother.  Better men than I are dead.

It wasn’t just hospitals that this man didn’t get.  It was me.

Plumber in Blue.  I was so glad to see him.  You cannot even begin to know how hard he is trying.  He is indeed surrounded by drugs 24/7.  Opiate addiction changes most people’s bodies, makes them a hunger-machine for a fix, causes every single neuron south of the neocortex to demand–now, baby!–one more swallow, one more snort, one more injection.  Yes, clonidine will help him, but believe you me: what’s getting this man through this–what is going to get this man through this–is the inner soldier who did not die over there, who still wants to live out of respect for those who no longer do, who wants to be so much more than a sperm bank, who wants a family, a life, honor, hope.

It was good to see him.  Round Two has begun.

Resilient Tears

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

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

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

“How are the nightmares?”

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

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

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

You might hear the veteran catch his breath.

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

“How many did you lose?”

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

That’s when the first tear appeared.

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

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

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

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

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

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

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

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

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

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

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

“See you next month.”

“See you next month,” I replied.

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

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

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

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

Or more.

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