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.