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.