An Update, A Remembrance

Again,  the past few weeks have been busy ones, although this time with presentations as well as patient care issues–oh, yes, and Life.  In addition, though, I have been working on plans  to publish an e-book edition of the series The War Within, to be entitled  The War Within:  Different Veterans with PTSD, Different Missions to Recovery.  At this point, I am considering  publishing it on Kindle, and  I hope to have it available by  November 15.

I plan to keep the original series available here on the website for all who might be interested.  However,  some persons have  expressed  interest in having access to the material outside of the website as well.  Therefore, I am editing and streamlining the essays  a great deal, with a focus on  helping readers frame the challenges of recovery from combat trauma/PTSD as ones of redefining a veteran’s “mission.”   In doing so, the veteran’s  intensity and strength can then be re-channeled into endeavors that can be more worthwhile and rewarding.  I will be arguing again that extroverts, i.e., those who “recharge” themselves in the world “out there,” have very different missions–and therefore very different recovery paths–from those of introverts, i.e., those who “recharge” themselves in the world “inside.”

Still, both “missions” can still lead to the same endpoint:  a more full, more rewarding life post-combat.  If through these essays  I can help some combat veterans find a way to  reframe their challenges into ones that are more hope-filled and more productive, I will consider my efforts  to be successful.

Today, however, in addition, a remembrance:  for some unfathomable reason, earlier this week I began thinking about my elementary school teachers back in Des Moines, Iowa, where I spent my early years.  Given that over forty years have come and gone since those halcyon days of yore, I figured that some of them had passed away, so I went to the website of the Des Moines Register to see if I could find any of their obituaries–

–only to find that one of the most influential teachers of my life, Doris Elinora Stukenberg,  just passed away two weeks ago today, on October 18, 2012, at the age of 91. Her picture accompanied her obituary–and though older, I saw the woman I still remember.

It was 1967-69, my fifth and sixth grade years.  I was invited to join a gifted education program at a school across town from mine, and for both years Mrs. Stukenberg was my “basic skills”  teacher, i.e., all academic subjects except math (why the latter was taught separately, I haven’t a clue).  She taught us during tumultuous times:  Viet Nam and the Tet Offensive; the deaths of Martin Luther King and Robert Kennedy; the race riots of the 1968 summer, Detroit, Newark; the fists held high at the Olympics in Mexico City; the 1968 Democratic convention in Chicago; Richard Nixon’s defeat of Hubert Humphrey (and, never forget, George Wallace!); Armstrong and Aldrin on the moon the summer afterwards.

Only now can I appreciate the freedom she gave us to explore our ideas, to come up with crazy projects, crazy skits.  Dan Rowen and Dick Martin’s Laugh-In was hot back then, and in the sixth grade she let a group of us boys put on Cry-Out, which was so ridiculous, I suspect it was hilarious.  I remember trying to make crêpes suzettes, of all things, when we studied Europe.  During the fifth grade, my  mother was up all hours of the night making some crazy “float” of the state of Iowa, replete with some tower sticking up somewhere in the northern part of the map.  In class we watched this inane Spanish-language show on the local public television stations (which was dedicated to “educational programming” during the day), my very first introduction to ¿Cómo está Usted?, courtesy of this very odd Latina who was always about three beats behind everyone else on the show.  I also did some over-the-top report on Japan, during the sixth grade, as I recall, courtesy of some propaganda supplied by Japan Air Lines through an ad in the National Geographic, entitled Fifty New Views of Japan (or something of that ilk).  

One year Mrs. Stukenberg even called together a noontime  summit of the fifth and sixth grade gifted classes to settle our differences in The Great Foursquare Wars.  Hillary, Madeline, and Condoleezza, eat your hearts out.

Yet what I most remember was her encouraging me to write, no matter how long (yes, even then . . .), no matter how fantastic.  To this day I remember some semi-novella I penned that went on and on about  a flamingo and the Presidency and Ameranada and, well, you get the picture.  I recall  her as having an eternally bemused look, as if she just quite couldn’t believe what was coming out of these kids–and specifically, this kid’s–mouth.

She taught me a bit about tempering  the fine art of the smart-aleck.  She was quite kind and understanding during my father’s illnesses and surgeries.

In so many ways, this blog is an outgrowth of her belief in me all those years ago.  From what I could see in her obituary, she lived well and loved well, leaving behind a family and a legacy not only with elementary kids, but with college kids as well.

She helped me learn how to pave roads back.  May she rest in peace.

Hands and the Unfathomable

The consultation was an unusual one. A combat veteran was referred to me by another physician after the veteran had had some puzzling medical complications. The doctor was wondering whether “this gentleman’s problems might be related to his PTSD.”

Now, truthfully, if I’d just heard about this man’s symptoms in a case presentation, “PTSD” would not have been on the top of my list in (what we call in medical parlance) the differential diagnosis.

Apparently it was, though, for the veteran. For he had been the one to bring up the possibility.

When I first saw him, he appeared surprisingly chipper, given what he’d gone through medically only quite recently. He proceeded to tell me that although he was having problems remembering certain parts of his then-recent illness, he definitely recalled a time during it when he had felt “as if I were watching myself.”

“Has that every happened before?” I asked.

“Well, yes and no,” he replied. “Since I’ve been back from deployment, I’ve had some really strange experiences, but I have to say: nothing quite like this, certainly not during the day.”

“At night?”

“That’s been a different story, I’ll admit. Sometimes I’ve woken up and realized that I’d been wandering in some part of the house for who-knows-how-long, without a clue as to how I got there. And sometimes my wife says I start having these conversations with her in the middle of the night, going on and on about something or other dealing with The War, when I later can’t remember a thing.”

The man spoke with a certain assured air, if one could say such a thing about someone who was talking about being, at times, anything but assured about reality itself. He was a big guy, though in no way fat. True, he’d probably been a bit more toned, shall we say, in times gone by, but the adjective “husky” would have always been a mark of respect for him, never a euphemism. His dark hair was short, not in a military way, rather more like in the way of the decent guy next door who’d called to you over the fence some Friday evening to see if you and yours would like to join him and his for burgers and brats (and a bottle or two of Fat Tire).

“When were you over there?”

“2003, 2004. Flew over on my twenty-third birthday, flew back on my twenty-fourth.”

I looked at him and said nothing. He looked back and did the same.

I’m in fact never quite sure what to say when I find out a combat veteran took part in the initial invasion of Iraq. I only imagine, knowing that I can never begin to imagine, knowing, therefore, that anything I have to say will only be trivial, at best.

“Not good?”

He snorted, thankfully in a resigned way, rather than the disdainful way that question deserved.

“You could say that.”

“What was your MOS?” (i.e., his assignment)

“Medic.”

Once again, I’m never quite sure what to say.  As I’ve noted before (e.g., in Kilroy Wasn’t Here), when I hear that a veteran was a combat medic, I try not to react too blatantly to other imaginings of mine, imaginings of gunfire, explosions, screams, hands being held for the final time. Rarely am I successful, though.

Twenty-three, a combat medic, in Iraq.

I wasn’t successful this time either. He noticed.

“Where were you over there?” I finally asked.

“You name it.”

In spite of the relatively terse answers, he was not at all wary or distant. In a way, it was as if he’d already been through this drill many a time before, so no need to get all worked up about it, after all. But then neither was he cool nor nonchalant. Instead, he very much exuded this feel of “if you’re willing to ask, I’m willing to answer,” a certain, pleasant-enough quid pro quo, if you will–one straight out of Hell, of course.

“How many close to you did you lose?”

He looked down, again in that tired, even matter-of-fact way.

“Four I was really close to,” he replied, as if both steeling himself for inner pain, yet somehow at the same time planning to be bored by it.

“Were you with any of them when they died?”

He looked back up at me, again not indifferently, yet, what, wearily, as if one more damn trip down the back alley of unspeakable memories was simply too much to ask of him today, too much.

“One.” He sighed ever so slightly, with a been-there done-that look on his face that could only radiate to the world that he would never finish being-there, never be finished doing-that, never. “One.”

It had been an officer, a man he had deeply admired, deeply cared about. It was awful. There were plenty more awfuls, though. Over the next five, ten minutes, he recounted some of them. He spared not a detail.

Clearly he cared deeply, about everything. Clearly he was struggling to find another ounce of energy to care any more, about anything.

“I was twenty-three. I saw things no twenty-three year-old, no one should have to see. I had to put my hands where no one–twenty-three, no one–should have to put his hands.”

It was the latter image, of course, that grabbed hold of my lower spine and squeezed with a vengeance. It’s been years since I medically invaded a body, drew blood, inserted catheters, dropped a nasogastric tube. Yet the physicality of the hand inserted where no hand should go: my own body reminded me that once I had been more than close to pulsating organs–holding retractors only, of course, while others far more daring than I invaded, inserted themselves further, deeper. Yet I knew that I could imagine such a scenario–hands as strangers in a strange land–far more easily than I would like to know.

He had stopped talking. He did not appear ready to cry, to lose his composure, nothing of the kind. Yet, still, his tiredness as way of life: the façade was beginning to crack.

“What’s the greatest sadness in you?” I finally asked.

Honestly, I have no clue where that question came from. Clearly he had been expecting it as little as I had been planning it.

He cocked his head slightly, almost as if he were taking a moment to admire my chutzpah, practically radiating one of those “well, who’d a-thought” looks. After five seconds or so, he finally said:

“You know, there was once a time when a question like that would have sent me over the edge. I don’t know quite how to say this, but . . . that question makes sense to me now. You know what’s my greatest sadness? The fact that I’m never not sad, no matter how I might appear on the outside, no matter what I say, no matter that I love my family more than anything. Please understand: I have happiness. My wife, my kids, they’re wonderful, they keep me going. But it’s as if I know one truth more than any other, a truth I couldn’t get rid of even if I wanted to: although I’m happy, I’ll never be happy again.”

“I mean,” he continued, “I shouldn’t be alive. You’ve got to understand how crazy it is that I’m sitting here with you. Good men are dead, and here I am. Over there, it got to the point that I didn’t care, period, didn’t care. I’d walk into the middle of a fire fight, thinking ‘so what’? Dead, alive, it didn’t matter. If you want to know the truth, I’m still like that, basically. I don’t want to die. I’m not going to hurt myself. I want to be alive for my family. And yet I can honestly say to you: I don’t care if I’m alive or not.”

I could say that I made no effort to calm him in all this, but that would give quite a misleading impression. He was quite calm, in fact. Or rather, should I say, he was quite calm and he wasn’t even close to being so.

Yes. That’s it.  Not even close.

“You know what?” he finally asked. “I was so messed up when I got back from Iraq. I hadn’t even heard of the term “survivor guilt,” but that was all I was, survivor guilt, all day, all the time, wandering, trying to figure out how I could muster the courage to carry out the only decent act left for me to do: die. But I couldn’t even kill myself. One time I had everything in place to do just that. But in the only minutes I realistically had to carry out the plan, the means I’d chosen just wouldn’t work. I tried, and I tried, and I tried, but nothing. And then once the chance passed, the means suddenly started working again, but it was too late. It’s like I’m being kept alive, even when I don’t care one way or the other. Yet I do care. For my family, I want to live. But I don’t want to live, see? Yet at the same time, I can’t even care enough not to want to live. Is any of this even making sense?”

“Yes,” was all I could reply. For, in listening to him, it did.

“You still in the medical field?” I finally asked.

“God, no,” he answered. “I lived enough of that as it was. I can’t even imagine doing it again. No, I want to become a counselor. People say I’m a good listener. They lean on me. That’s what I want to do. Maybe that’s how all of it will make sense one day. I don’t know.”

For a few seconds I looked at him, husky, sporting his brat-and-burger haircut, his smile still discernable behind that look of indifferent confusion, confused indifference.

“You’ll be good, you know,” I told him. I meant that.

Clearly he’d not been expecting that response either.

“You speak clearly, candidly, straight from the heart,” I continued. “You’re willing to live with your own confusion. That’s key in this job, believe me. I’ll have to say one thing, though.”

With that latter statement, his indifference vanished. Only plain old-fashioned confusion remained to face the music.

“What’s that?” he asked.

“Well,” I said, “if you’re planning to make it possible for others to live better, then you’re going to have to live better yourself. Even if you think that you don’t care, that you’re really not that into living: sorry, reality check. You do and you are. Your hope, that goal of becoming a counselor who will listen to another combat vet no matter what is remembered, what is said: they betray you, the real you behind all the indifference towards the next sunrise, the next cup of coffee, the next diaper change. Hate to break the news to you, guy, but it ain’t just your family who’s keeping you alive. You are as well.”

For the first time, his eyes went into lock-down, obviously determined not to let any lacrimal material even consider escape into the light of day.

“You’re probably right,” he finally said, his every milligram of emotional fortitude on full alert.

Truth be told, though, he looked–at least to me–to be more on the relieved side than anything else. Guess it’s not so bad to be found out after all.

In the end, I told him I’d be glad to work with him. He smiled.

“You know, almost all the psychology types I met in the service were worthless, didn’t have a clue. They really thought they could slice open a huge scab on your heart, muck around there for an hour or so, and then expect you to go home and be just as fine as they were going to be that night, as if to say. ‘OK, now that you’re all ripped up and raw, see you next week and we’ll pick up where we left off.’ Nuts, totally nuts.”

I smiled back. “Me too?” I asked.

He sat back, with a smile perhaps not quite yet ready to make an offer, let alone accept one, but, at the same time, a smile not exactly ready to pack up and leave the negotiation table either.

“Maybe I should start talking with someone again,” he mused, eyes still riveted to mine, while in no way giving me the pleasure of being right about one darn thing. “Who knows? Maybe that’ll help.”

I gave him my card. He took it. We’ll see what comes of it.

I can’t remember anyone being quite so graphic with me as he’d been when describing his experiences. A reference he made to a scene near the end of Kubrick’s The Shining, as a prototype for the setting of one of his rescues, was more than apt. And if I may be so bold: the horror of Nicholson’s imitation of McMahon earlier in that film had nothing, not a thing on the horror this guy saw coming at him day after day after day.

In being so explicit, so raw, I don’t at all think that he was giving me some kind of test, as if to see how well I could “take it.” No, sadly, I fear all was just as it appeared: horror had become so commonplace for him, so sleight-of-invading-hand in its routine manifestations during combat, each of the stories was simply another day at the office, as far as he was concerned.

An unfathomable day at the office, perhaps. But he reminded me of a truth so well-known, tragically, to so many men and women who once saw what their twenty-three, nineteen, thirty-five year-old eyes should never have seen: one doesn’t to have to reach a fathom into a body, a soul to get to a horror that can leave a sadness in its wake that can become so intrinsic, one can narrate a c’est-la-vie assessment of it and almost–almost–get away with it.

No, for that, just a simple hand-length will do.

Quite the Handful

I’d first heard about him several months ago.  His has been a complex story, and truth be told, he shouldn’t be alive.  He has had several near-misses, although there has apparently been much-heated disagreement among him and some of his treaters as to where “accidental” ended and “purposeful” began.  Still, he’s pretty much the straight-shooter: he readily admits that sometimes the latter is the only adjective worthy of at least a few of his tête-à-têtes, shall we call them, with the Great Specter from Beyond.

He came to me for Suboxone, the new opiate substitution regimen that has proven so helpful for many combat veterans who have struggled with addictions to painkillers and heroin since their return from The War.  Like many of his fellow veterans, he has endured chronic pain both of a physical variety and of an emotional one.  He has also long complained of very marked, almost continuous anxiety, an anxiety that, true, sometimes has had the quality of the hypervigilance so characteristic of the combat veteran who just can’t seem to get off guard duty, but at most times has simply seemed to be (to me, at least) a dramatic, post-combat upsizing of the chronic tension and energy that has been his hallmark since toddlerhood.

He has not been, what, particularly enamored with us at our VA.  He’s willing to admit, though, that he’s not always been, what, particularly enamoring himself.  When so much pain is ricocheting through a room as a combat veteran struggles with the acute emotional challenges of posttraumatic stress injury, both veteran and treaters can sometimes get caught up in the tornado-esque swirls of suffering.  We treaters do our best not to get so caught up, but indeed, we’re human, and humans catch emotions from each other, especially powerful ones, and since most of us went into the field precisely because we are good at experiencing the emotions of others, even the most calm and patient of clinicians can, at times, feel a bit unhinged in the midst of tense situations.

We had no such experiences together when we met, though.  He was pleasant, though (appropriately) wary.  I had no doubts whatsoever as to the sincerity of his desire to find a more satisfying solution to all his pains, for his relationships have suffered tremendously because of them.  I also had no doubts whatsoever that he can get quite ugly quite quickly, and both he and his wife had no problems whatsoever acknowledging that very fact.  He knew he needed help.  His wife knew it.  I knew it.  We came to a “meeting of the minds” quickly as to the medication.

But I will remember my encounter today with him not because of Suboxone.

Several months ago I wrote a post entitled Cluster B Traits.  Only one other post, The Killing Floor, has received more hits.  As of today, that post has been visited a total of 557 times.  In fact my new claim to fame is that if you Google “cluster B traits,” my post comes up fourth (some days, third) on the list after Wikipedia, Answers.Yahoo.Com, and another blog post!

I’m kind of impressed with myself, if do so say.

All these months later, I still have my reservations using that label (“cluster B traits”) with combat veterans.  My patient today, for example, has been the recipient of that label more than once.  He has, in fact, read page after page of his medical record, and he has more than noticed how frequently he has been given the honor of that quasi-diagnosis.

He has not been impressed.

Quite the contrary: he told me that he now finally understands why so many treaters at our VA have been, in his words, “less than supportive,” especially of his medical concerns.  “If you have a ‘personality problem,’” he said, “people just assume you’re trying to get something over on them.  I mean, that’s what I would think if I read that, you know what I mean?”

And . . . well . . . while I might say that he may be being a bit harsh and overgeneralizing with that claim . . . well . . .

I wouldn’t say that too vociferously.

Instead, I had him consider an alternative interpretation.

“But isn’t it a fact that you’ve felt this inner tension ever since you were a boy?” I asked.

“Yeah.  So?”

“So wouldn’t it make much more sense to call it for what it feels like, that is, lik too much adrenaline flowing through you all the time?”

That stopped him cold.  Apparently he’d not been expecting that from me.

“I’ve seen it with a lot of you guys in the military,” I continued.  “Ever since you were kids, you’ve had a motor running.  People usually called you ‘hyperactive,’ but that wasn’t quite right, was it?  It wasn’t so much that you couldn’t focus as it was that you couldn’t focus on the routine or the trivial.  If you found something that really interested you and allowed you to work out your energy, live it, love it, you could actually be quite focused.  True?”

He just stared at me.

Then I saw it.  His eyes began to well up.

He turned away from me slightly, looked down.  He brushed the edge of his right hand against the edge of the corresponding eye, swallowed.  Still he still looked down.

“Isn’t that true, though?”  I asked again, though a bit more genly this time.  “That it’s always just been so much to handle on the inside of you, that the military took care of that, gave you something meaningful to do with all that, rewarded it?”

He looked up.  Whether he was fighting the tears or just not caring what happened anywhere north of his lips, I couldn’t quite tell.

“I wish other people understood that,” he whispered.

“Not even your wife does?” I asked.

He was still looking right at me, every microfiber of muscle still.

“I don’t know,” he finally said.  “I think she tries, but I don’t know.  Nobody else does.  You don’t know how I fought to stay in the military.  They tried so hard to med board me out, and I fought it and I fought it and fought it, until finally I had to go.  You don’t know what I’d give to get back over there.”

“Because it all fit over there, didn’t it?”

“God, yes.  I loved what I did.  I was good at it.  I didn’t want to kill people, hurt people, destroy things.  I didn’t try to do it.  But I protected myself, protected my men.  We did what we had to do.  We saved a lot of lives over there.  Now I’m just here.”

“And inside you, the motor keeps running, on and on and on,” I said, myself whispering now.  “And it’s eating you alive.”

He just nodded.  What else could the guy have done.

He’s quite the handful.  Always has been.  Yet character-disordered?  Cluster B traits?  Oh, sure, I could make the argument as well as colleagues could: the veteran’s longstanding difficulties, his interpersonal challenges, his “persistent unwillingness” to look inward and “fix” it, whatever that it might be, “tame” it, “reflect” on it, “soothe” it.

Unwilling?  Or unable?

Yes, he loves his energy, his adrenaline, his push, push, push into the world, now, again, again, harder.  He feels alive with it.  He feels real.

But he’s no fool.

He knows that we don’t cotton too much to such energy back here in the civilian world, even if we say that we like our boys or girls to be “Army tough”, Semper Fi.  You leave that out on the playground, child, you hear?  Run that out of you and then get back in here and get to work.

You go do your military thing, man, woman.  Run that out of you.  “Thank you for your service,” we’ll say.  Shoot, we’ll even give you a parade or two (the Fourth’s coming up, you know).

Then get back in here and get to work.

And we wonder why he turns to pain pills to ease the pain.  All that energy, we say, if he would just use it right, ‘tis a pity .

Use it?  Really?  Where?

You gonna put up with his constant edginess, Mr./Ms. Civilian?  You gonna give him that opportunity to punch that bag, run that ten miles, pump that iron–even if maybe you might lose an hour of work out of him to let him do so?

You gonna tell him he’s a good man, that even when he’s a handful, yes, even when you’ll exhale quite the sigh of relief whenever he’s bounces out to do whatever it is he needs to do “get that out of you, boy, go on, go, go, go!, you’ll tell him that  you’re so glad that he’s here, that you wouldn’t want him any other way?  (Well, all right, most times . . .)

They just want to be understood, you know, these men and women with that Army-tough, Semper-Fi drive, energy, passion.  They know they’re a handful.  They know they’ve got too many hormones and neurotransmitters hurtling through their arteries and veins, banging on the doors of their neurons as if there were no tomorrow, ordering every cell within the vicinity to “move this sucker, baby, and I mean now!”

They know they’re not “normal,” i.e., not like most of us on the remainder of the bell curve.  You think you’re gracing them with some eye-popping epiphany when you label them “hyper” or “emotionally dysregulated”?

Actually, I’ve found them to be quite a forgiving bunch, if you want to know the truth.  You can label them whatever, from my experience–just as long as you can smile and like them, give them the space they need, the passionate direction they need to allow them to burn up a few of them inner chemicals so that, maybe, tonight?  We could just chill a bit, you know?  Be friends?  Talk?

“Now, true,” he or she might then say, “I’ll do most of the talking, but . . .”

Please don’t blame them for their bodies’ chemical composition.  Please don’t abandon them to some poor spouse or some few kids who cannot deal with this all on their own, who are are just going to need a break every once in a while–and not just talking every few weeks here.

It takes a village, a village that’s willing to adjust its work schedules, willing to say up front “We understand.  We’ll work with you.”   Willing then to do just that.  I can’t help but wonder what would happen to those veterans’ “Cluster B Traits” if that were to happen.

Well, actually, I don’t wonder, but then . . . I’m one of those types, you know, unwilling to call pathology when I see it, unwilling to set limits that must be set in order for an individual to learn to function in society, after all.

Yes, indeed.  I am.

A Love Remembered

This post will not be an easy one.  And it’ll be a long one.  I’ve got too much to get out of me.

For starters, I am not a couples therapist.  Let’s get that on the table right off the bat.

Next, I was (I’ll confess it) well-trained as a youngster shrink, so it’s like: I know what I could be doing if only I were to have the fortitude to do it.   For those in the know, I have the basics down for the Milan School of family therapy (everything sounds better in Italian, and it was all the rage, baby, all the rage back in the eighties) and for Bowen systems theory (one of the old warhorses of the industry).  I’ve done my Generation Whatever part: I’ve read Harville Hendrix’ Getting the Love You Want, which is holy writ in my neck of the words (and, yes, for good reason).

On the bright side, I have recently (through the VA) been trained in a couples communication method called PAIRS (which stands for Practical Application of Intimate Relations Skills).  It is, without a doubt, the most sane method of skills training for couples that I have ever found, hands down.  It is not a couples therapy method.  Instead, it is a highly-structured way of communication-skills building that is quite dramatic in its impact.  Through the Chaplaincy departments of many VA’s nationwide, it is increasingly becoming a must-do program for couples struggling to find their way back from deployment(s).  I can’t recommend it highly enough.

Still, I ain’t the guy for marriage counseling.

For starters (second round), I’m not good at dealing with more than two psyches in a room.  Because of the way I’m made, I absorb too much of a couple’s conflicting emotional lives at the same time, and my talent that is usually my strong point–an ability to experience quickly the nuances of a person’s interpersonal style–becomes my absolute point of weakness.  Honestly, I can listen to a combat veteran go on indefinitely about the horrors of war, but to have a couple bring before me the nitty-gritty of the horrors of their daily life–and then live it out right there in front of me, in stunning, surround-sound technicolor, no less?

I’m toast, period.

Even when I have a technique at hand which can bypass that immediate emotional turmoil (e.g., the PAIRS method), I still find myself afterwards, in my own head and soul,  embroiled in the complexities of a couple’s relationship.  Perhaps because I’m a man, I do find it relatively easy to see the perspective of even the greatest jerk of a male partner.  But sorry, guys: even with that said, I can more than easily understand why the female partner is often two micrometers shy of kicking your sorry-butt out into the street, partner, and don’t even bother looking back with that hang-dog look of yours!  But then I can understand why the man might be so sick of the “you never even try to understand my feelings,” but then the woman might be so sick of the “I just need some time to myself,” but then . . . you’ve got the picture.

But you know why I really don’t like working with couples?

Frequently, all too frequently, it can just be so painful, so God-awful, soul-wrenching painful.

The couples who already started out on shaky ground?  Not easy, but tolerable.  You made a mistake.  You move on.

But the couples who once truly loved each other, who truly, truly handed over to each other their hearts, their souls in a way that only the young can, those first “real loves” of high school or college?  To watch such a couple truly, truly have to face each other, hackles down, guns holstered, and ask each other truly, truly: can we go back there after all this?  Or are we going to have to release each other into the future, hand back to its original owner the heart that we had once treasured so deeply, that we now know, if we give it back, we will almost certainly never have again, no matter how many children we might have together, no matter how many years it’s been, no matter where the present might take us?  To remember, down to our deepest beings, what once had been, what had not been fake, no matter how much we wish it might have been so as to make our current lives that much easier, to grieve, to mourn in front of each other a death of something we had once both stitched into our hearts–stitched, what are we saying, more liked wove lovingly into the warp and woof of the thing: the death of our relationship, our future?  The death of the us of us?  To take back strand after strand every thread of that weaving, destroy a pattern that once truly, truly was there, but which can no longer ever be again and then to say, with tears that we truly, truly don’t want to shed: goodbye?

Just shoot me now.

And, oh, BTW: for those of you who might have forgotten, I signed up for a job in which daily I meet one-half of couples who often had stood before each other with precisely those heartfelt loves of loves, knowing full well that the one before me (usually the man) might never return for Chapter Two of the saga, who practically surgically implanted their hearts into the soul of the other, with the deepest of truly of the deepest of trulies.

And then the terror of what they had done hit them, him in a godforsaken wasteland, her in a might-as-well-be-godforsaken apartment, pregnant, or with one baby, two, each wondering–like every other couple who has ever lived on the planet since, what, the Neolithic Age?–what the heck did I do?

And given that many had never known a parent, a loved one who had ever been able to answer that question in his or her own life, and thus had never known a single soul who, yes, knew that these things can be gotten through, just call me and we’ll figure it out, kid, don’t sweat it–so yes, given all that:  bad things then happen.  Mad escapes into spicy-hot relationships that promised–what?–anything but the truth of the truth?  Silences that bring meanings heretofore never fathomed by humankind to that simple word cold?  High dramas of high dramas that put to shame even the most Daytime Emmy-winning performances of the greats of the great soaps–or even better, if you ever got past high-school Spanish, of one of those absolutely insane Argentine or Mexican telenovelas?

Oh, yes, and even if all that can be avoided, there’s this slight problem of . . . the return of a different man than the one who had left.

And so it begins, lights, camera, action!: “You don’t understand my feelings!” “You don’t know what I went through!”  “You don’t know what I went through!”  “Well, at least she understands me!”  “Well, at least he understands me!”

And then the truth truly, truly hits them: when one has truly, truly loved, truly, truly been woven into the soul of another, one does not truly, truly let go of that like some washcloth that’s gotten a little threadbare.   So . . .

Then let’s see if we can truly, truly make each other so truly, truly miserable that, truly, truly, we’ll not have to deal with what Life has brought us, what we have done, what we have not done, and . . . and truly . . .truly, truly . . .

Oh, God.

It had been heroin that had finally gotten him.  His wife had told him that she’d had it–although, as I read between the lines, it was most likely that she’d had some, what, issues of her own to deal with that, what, had not been?  Still, whatever, he was willing to admit it: he’s an addict, through and through, weak, a loser, unable to control himself, just loving the high, living for it, heck with anything else in the world–you only live once, right?  She should have left him, yes, that he knew.

Oh, small detail for later: she isn’t his first wife.

He’d tried Suboxone on the street once.  It had helped.  But he couldn’t afford the price.  Then he heard that the VA was making it available to vets.

Enter . . . me.

OK . . . well, now that he’d just divulged that torrid tale of libertine squalor and self-degradation, I did have to, well, ask one question–well, I mean, I didn’t have to, I guess, for he seemed quite happy to leave it at that, but, well, you know me, inquisitive minds just have to know, especially when The Enquirer isn’t there to help me out . . .

“What was your MOS?”

Silence.  All appropriately guilt-ridden confessions screech to a halt.  He looks down.

Infantry, such-and-such company.

“Where?”

He names off places.  As I recall, no four-star accommodations for infantrymen in a single one of them.  Pretty good medical facilities, though, from what I’ve heard.

Further silence.  Head still down.

“Had you used in high school?”

Throat cleared.  Head still–yeah, you got it.

“Uh, no, sir.”  Pause.  “I was, sort of, you know, a big fish in a small pond.”  Eye contact made.  “I mean, don’t get me wrong: I wasn’t an angel, but .. .”  Head back down.  “No.  I didn’t.”

OK, I think, might as well go for it.

“Your first wife, she was your high-school sweetheart?”

Still looking down, he begins to rub his forehead.

“Yes,” he whispers.

“How soon before deployment did you get married?”

Still rubbing.

“Not too long.  We had a really nice wedding, though.  Then we both got scared, knowing I was heading off, so, well, we thought, should we?  And then . . .”

“And then what?”

Throat cleared second time, slight chair fidget, not dramatic, head still down.

“The night before I ship out, I tell her, go ahead, might as well check a test, and . . . sure enough, there it was, positive.”

“And you left the next day.”

“Yes.”

“So what happened then?”

“They let me come back a week before her due date and stay until a week after, but . . . she was late.”

Silence.

“Meaning . . .?”

“Meaning my daughter was born the day after I left.  They wouldn’t let me stay any longer.  She just couldn’t understand that.  She thought I didn’t try hard enough.  She . . . she never forgave me.”

“How old were you?”

He looks up.  The glisten is in the corner of his eye.

“Nineteen.”

Silence.

“So what happened then?”

He looks back down.  “It all went to s***.  I came back.  We had another daughter.  I had to go back and then I came back.  We’d split up, and then we’d get back together, split up and then back together.  We couldn’t stand to be with each other, and we couldn’t stand to be apart, and . . .”

“And what?”

“And I was awful, I mean really awful.  I tried to hurt her.  She tried to hurt me.  Back and forth.  God, I was awful, awful.  She should hate me.  I hate me.”

“So?”

“So eventually we divorced, and I met my current wife, and everything was going to be much better, and then it wasn’t, and . . .”

“And what?”

Throat cleared, round three.

“My first wife and I just couldn’t stop being awful to each other.  We live in a small town, see?  Everybody knows everything about everybody.  We all went to school together.  I mean, people would stop me in the grocery store and ask me why I was being so awful to my first wife.  And I just wanted to tell them my side of the story, but they didn’t want to hear if if they didn’t believe me already, so I’d just say ‘F*** ‘em,’ and I’d go on, but then I’d have to get back at her, and then she’d get back at me, and she’d follow me around town when I had the kids, and then I’d text her to tell her to go f*** herself, and then–”

“This was all while you’re already married to your second wife?”

“Oh, yeah.  And then my second wife and I began having problems, and–”

“Has your first wife remarried?”

Pause.  He’s looking right at me now.

“She’s marrying this guy this summer.  Or that what she says, at least.  She is.”

“So, is that making things calm down a bit?”

Now the boy g0t riled.

“Are you sh**ing me?  It’s just gotten worse.  I mean, you’ve got to believe me:  I know, I brought all this on myself, I’m not innocent, but I have been trying not to be so mean and provocative, really, but then I hear her voice, and I get . . . I don’t know, it’s like I go crazy, and I say things I don’t even really mean, just to hurt her, and then she says things right back to me, and it hurts so much, and I just–”

“You still love her, don’t you?”

All right, brief interlude: that was big-time risk to say that.  I knew it.  Colleagues, feel free to label it a mistake, an acting-out, whatever.  But you see, I couldn’t help but notice this pattern: as things got worse between one of them and his or her new love, the two of them got along better.  As the new couple got along better, the old couple got along worse.  You don’t need a college degree to figure this one out.

That stopped him cold.  I knew it would.  That’s why I did it.  It took him about thirty seconds or so to compose himself.

“Yes,” he finally whispered, head back.  And believe me: it was a whisper.

“And she still loves you, doesn’t she?”

He shakes his head, clearly not wanting to say what he’s about to say.

“She’s hinted at that more than once, yes.”

Now I try to compose myself, not because I’m sad, but because I know what I’m about to say.

“You’re not going to move on in your life and in love until you deal with this.  And even if she refuses to deal with it, you’re still going to have to.  You’ve got to believe me: stuff like this can last a lifetime.  I’ve known couples who’ve remarried, started new families, yet have gone to their graves still holding on to that first one, screaming at the top of their lungs that they’re long over that jerk, that witch, and yet going off like a Roman candle every time the other’s name is mentioned.  Ten, twenty, thirty, even forty years–it don’t matter.”

Still looking down, he’s fidgeting more, rubbing his hands together.

“Did you ever talk with her about what happened over there?’ I ask.

Now he starts rubbing his forehead again.

” No, not reall- . . .no.  I didn’t know what to say.  I . . . I’ve talked a little bit to my current wife, but not even that much with her, I . . . I just don’t know what to say.  I don’t even know what to say to myself.”

“You do know, don’t you, that the heroin’s not just about having a good time?”

Still looking down, he nods his head.

“As long as I’m working,” he replies, “I don’t have to think about The War.  But the drugs were getting too bad.  I was going to lose my job if I didn’t stop. And it’s a really good job.”

“And your current marriage?”

He looks away from me, toward some far-off spot.

“I think that’s pretty much over.”

I couldn’t help but notice–although I at least finally had the decency to keep it to myself–that he was not as emotionally, shall we say, vigorous saying that as he’d been describing another relationship that was, allegedly, long, long “pretty much over.”

“There’s nothing like a first love, you know,” I finally say to him.

He shakes his head, looks back down, finally smiling a bit.

“She was always so strong-willed.  That was what I liked about her.”

The pain in his gut was about ready to slice open mine.

“You’re going to have to stop this nonsense, you know,” I finally say.  “And you can’t do it with any thought of getting her back.  You and I both know that you’re going to be hoping to do just that, but that’ll get you nowhere, and you’ve got to face that, even though you’re going to be feeling otherwise.  You’ve got to stop your part even if she never does.  Even if she tells you that you’re a fool for thinking she’d ever want you back for even an instant.  Even if she stabs you repeatedly in your heart, your soul, your mind.  Even if she makes you look like the biggest wimp in the whole town.  Don’t matter.  You’ve got to stop.  You’ve got to let what happens happen.  And then you’ve got to deal with it.  If you guys do get back together, it cannot be like before.  You’ve got to face what happened to you.  She’s got to face what happened to you.  You can’t run any more.  She can’t run any more.  You’ve both suffered too much for too long.  You both know that this hell each of you has been experiencing these past umpteen years has gotten both of you exactly nowhere.  If you do decide to get back together, you’re still going to have to go through hell, but now in a way that’ll actually get the two of you somewhere.  And if she moves on, whether she weeps or not, you’re going to have to.  This is a death.  You’re going to have to stand next to the grave of that first love, even if all by yourself, and you’re going to have to put her heart in that grave with that first love.  And even if she refuses to release your heart back to you, you’re going to have to move forward without that part of your heart.  And it’ll hurt like hell.  And you’ll have no clue how you’ll do it.  And it’ll just be like being back in the military: you’re going to have to do it anyway.  But you don’t have to be alone.  You don’t need to be by yourself any more.  I can’t save you from this.  But as long as we’re both here?  I’m here.”

A few moments of silence.  He takes a couple deep breaths.

“I think I’m going to have to go, I . . . Can I see you next week?”

“Of course..”   Now I’m whispering.

He looks up at me, eyes far more than glistening.

“OK.  I’ll be all right.  I just . . . I just need to go.”

“OK.”

We shake hands as he stands up.

“Thank you,” he says quietly, and then he leaves.

Shoot me now.  Just shoot me now.

Inside, Outside, Anywhere

Last Sunday, the New York Times Sunday Magazine ran an article entitled “Post-Traumatic Stress’s Surprisingly Positive Flip-Side.”   It was an interesting piece describing what’s called “post-traumatic growth,” a concept exploring how one can grow more resilient out of an experience of life-changing trauma.   The piece described a program that the Army is implementing that encourages troops to approach difficult situations with an eye toward viewing the situations as neither good nor bad, but rather as opportunities for change and positive outcome.

In addition, this past week I met a veteran who had survived significant combat trauma and who, as a result of physical injuries he had sustained, developed an addiction to painkillers.  It does appear that with the use of Suboxone, a modern opioid substitution agent, he will gain a new chance at living life without resorting to the illicit use of substances.

The veteran had already undergone standard treatments for PTSD, including the “prolonged exposure” therapy that many practitioners are now using to help combat veterans process the emotions they are experiencing as a result of their combat experiences and, at least to some extent, to help them integrate those emotions and their associated memories back into a coherent-enough narrative of the veterans’ lives.  He had found the treatment to be helpful, and he told me that he felt that he was “doing fine” vis-a-vis his war experiences.

He was a burly, friendly chap, although understandably embarrassed by the extent to which the opiates had become the center of his life.  He had gone into sales and had been successful, although he had found the whole rigamarole boring, truth be told.  He certainly had a saleman’s air about him:  focused on the pragmatic, with a certain bottom-line no-nonsense.  He has his demons, to be sure:  his addiction did not arise from nowhere.  Yet I had a sense that his usage stemmed more from boredom–as well as from the desire to avoid withdrawal symptoms–than it did from terror.  We’ll see what the future brings.

It is an intriguing question, though, one that is even now confounding, yet captivating researchers:  why do some veterans leave combat with extensive, long-standing psychological sequelae, even after the “best” of “best-practice treatments” (essentially everyone has challenges in the short-run), while others do not?  Is “resilience” and ease of “post-traumatic growth” a state to be learned or a trait to be appreciated?  Do “some got it and some don’t?”

Certainly I don’t have the answer, and I cannot be too bold generalizing from my experiences, given that mine are clinical experiences, i.e., the people whom I meet are already suffering.  I do find myself wondering, though, what might be the relevance of an old Jungian concept that became popularized through the Meyers-Briggs, a common measure of personality typing: extroversion versus introversion.

Colloquially, these terms are about sociality, the life-of-the-party versus the wall-flower.  In this sense I’m describing, though, the words deal more with the cognitive than the interpersonal.  Extroverts “think,” if you will, from the outside-in, while introverts do so from the inside-out.  Extroverts make sense of the world initially (and preferentially) via looking outward, making things happen, seeing how matters fit or do not fit together.  Introverts, in contrast, make sense of the world intially (and preferentially) via looking inward, contemplating, rehearsing.  Extroverts are capable of inner contemplation, and introverts are capable of external focus.  Yet each has his or her major and minor.

When trauma hits extroverts, it hits them in their minor.  The memories, the emotions:  they haunt and they demand.  Yet they reside in “foreign territory,” if you will.  The extrovert keeps being drawn back inward to a place that never did feel that comfortable.  When they work in therapy, they seek to be freed from all the inner focus of trauma so that they can return more reliably to the familiar world of their major:  the world out-there.   Extroverts find hope in escaping the War’s clutches and going back “home.”

For introverts, however, trauma bores right into their major, colonizes an inner world that had always been their home, making what had once felt so comfortable (or at least familiar) so very, very uncomfortable and unfamiliar.  Focus on action, even on internal action (e.g., “stepping back” and re-examining emotional and cognitive responses), is fine as far as that goes, but it always seems somehow beside the point.   Introverts find that the War has taken up residence in their “home” and that therapeutic “escape” takes them away from where they had once felt most real.

Extroverts have a point:  the world “out there” has far more options for freedom from War’s memories and pains.  Yet for us introverts, “out there” just isn’t home.  We can live there–and even live there rather successfully.  But we are always expatriates.

In my role as a Suboxone provider, I see many combat veterans who have completed “standard” PTSD therapy and who have benefitted greatly from it, usually with far less emotional upheaval and far more insight into their pain.  Yet in a real way, the thoughtful, internal ones, the ones who always prided themselves in their capacity for looking inward, not as navel-gazing (these are military folks, after all), but rather as preparation for action:  they still struggle.  “Home” has been invaded by an interloper who has taken these veterans’ most prized possessions–their memories, their emotions, their linkages between the two–and forever altered them, not only distorting them, but also robbing them of the healing, restorative power they had once had.   Looking outward may help, may even help greatly.  But sorry, extroverts:  ultimately your restorative, out-there “home” feels more to us introverts like a consolation prize than like a gift.

Perhaps because my style is the introverted one, I find myself so much more “captured” by the combat veterans who struggle with their inner demons within their beloved, internal home.  In a very profound way, I feel the adage:  there, but for the grace of God, go I.

It may not  be the most resilient of options, but it’s what I have.  May both introverted combat veteran and I “grow” all the same.

Once a Warrior . . .

Over the past year or so, I have had the privilege of working with a man who experienced combat in a conflict prior to the current one.  He’s brilliant.  He’s well-educated.  He’s dashing.  And when we met–he was in deep pain.  PTSD had long been his companion, day and night.

As a result, he always struggled to “live up to his potential,” i.e., to the standards he held for himself, the standards that he knew, deep down, he was capable of approaching, even of achieving.  Yet as the years wore on, it became harder and harder not only to approximate such standards, but even to remember what they had been.  His professional life suffered, greatly.  His personal life suffered, greatly.  When we met, he admitted that his periods of darkness had become so frightening to him, he feared that, yes, eventually he would not survive them.

He’s been a delight to work with these past months:  funny, self-deprecating, quick on the draw.  Yet how hard he has been on himself, for so many years.  Through the years certain life scenes, quite uncomplicated ones, have caused him literally to double over, often so much so that he had to pull over his car or lean against the side of a building to catch his breath–or, perhaps better, his soul.   He still remembered who he had been before the conflict.  In some way, he knew that man still lived inside him.  Yet only in some way.  In other ways–quite powerful ones–he had no clue who put his pants on every day.

He hated the man he had become.  He knew he was making his family miserable.  He was making himself miserable.  Yet all the vocabulary, all the books he’d read, all the logical prowess he possessed:  none of it stopped the dreams, the sheets soaked with sweat, the constant tension of being in Target–Target, of all places!–the fears that, dear God, it’s Fourth of July again, I can’t take it, the explosive pops, over and over, I can’t take it, I can’t take it!

We have spoken many hours.  He’s been a straight-shooter.  So have I.  It’s gotten blunt sometimes.  How many times have I said to him, “you’re not going to like what I’m about to say.”  “Just go ahead and tell me,” would come his answer.  So I’d say it.  And always he would reply, “you’re right.  I don’t like that.”

In the last few weeks, though, I’ve heard a change in his voice.  He and I have decided that the best word to describe this change is a sobering.  He’s not sadder.  He’s not angrier.  He’s not more anxious.

Instead, he’s sobered by the reality that he can no longer deny to himself, the reality he’s known, without fully knowing, for years, the reality he’ll never not know from now on:  he’s a warrior.

“You know, Jung was on to something,” he’s said to me, “those archetypes we have to have in our lives to understand what the heck’s going on in the world.  There is an archetypal warrior, you know:  the one with the strength and the will and the energy to go out, defend, never give up.  And I’m one of them.  I can’t be anything else.  I can’t”

Furthermore, he and I both know the hardest truth of all:  there are few places for the warrior in our society.  He remembered being told at the time of his debriefing at the end of his military career, “After all you’ve done, you can do anything!”  Unfortunately that was all he was told, in the course of less than thirty minutes, done.  “Go into business,” everyone later kept telling him.  “You know how to lead.  Do it again!”

Yet he couldn’t stand the the politics of the corporation when the only outcome of such politics was the sale of some product.  “I don’t get off on ‘closing the deal,” he’d tell me.  For he knows better than most:  “closing the deal” is often not at all the same as “getting the job done.”  He’s not afraid to compromise.  But there’s only so much of politics he can take.  He barely tolerated it in the military–and at least there, he had some vague notion of how theoretically good was to come out of the ridiculousness.

What am I going to do, he’s wondered.  I don’t fit in.  Everybody looks at me and sees so much I could do.  But my energy gnaws at me.  I always want something bigger, something more real, more alive.  Nobody gets it.

And he’s right.  Nobody–except fellow veterans.

True, Jung got it, in his way.  Joseph Campbell got it, even became a PBS superstar because of it.  Long before them, even Plato got it.  There was a place in The Republic for warriors, he wrote–an ambivalent one, true, but still a place.  Reason is needed to tame the warrior’s passion, he told us.  But reason plus passion is by no means a recipe only for war crimes.  A warrior can do good, at least for some.  Sometimes for many.

My guy knows well who Plato was.  On a multiple-choice test, he can even match The Republic with the guy’s name,I’m quite certain–and not The Merry Wives of Windsor, for example.  The boy can even spell Achilles, believe it or not, so he knows darn well how the warrior spirit can go out of control.  He’s seen the bodies firsthand, after all.  He’s heard–and seen–the broken promises.

Veterans get it.  So he’s decided that he has to give back to his fellow veterans.  He has to do what he can to make it easier for these young men and women coming back.  And have no fear whatsoever, friends:  he’ll find a way.  With that brain, those looks, that charm:  boyfriend will find a way, and a good one at that.  He’s the least of my concerns.

As professionals, however, we have to remember that for many veterans, the military never fully leaves them.  And many veterans are not as gifted as my patient is.  It’s not just the structure of the military all these veterans long for, but even more the passion.  They know that being a warrior can mean going berserk.  In fact, many combat veterans fear–just like many civilians fear–that “berserk” is the only state a warrior can achieve.  They see no viable options for their passion.

We must not be similarly fearful.  We need to be doing what we can to encourage our workplaces, our professions to be accomodating somehow to that passion, to allow that passion to find a place that will be fulfilling, while not being foolhardy.  In spite of what some might claim, few of these guys are wanting to sit on their butts and collect disability for a lifetime.  They want meaning.  They want to matter again.  It’s hard to do that sitting watching the History Channel 24/7–or languishing in a cubbyhole, for that matter (remember Mr. Incredible, all you Pixar fans?)

If we don’t push our colleagues to make room for that passion, it ain’t gonna happen.  Sorry, but I don’t see this as being that intellectually or morally complicated.  We sent those kids over there, bottom line.  Even if you didn’t believe in the war from the get-go, I don’t think many of you were that revolutionary about that belief to threaten your access to a caramel latte in any way.  As the law would say:  in this court of equity, we’ve all got dirty hands.

We’ve got to get moving.

But you know why, in addition,  it might be worth it, for all of us to find spots in our worlds for this passion?  Since my guy’s been sobering to his warrior soul?  He’s been having fewer nightmares.  Significantly fewer.

I can’t claim causation.  But it’s an interesting correlation, is it not.

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