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.

Will the Real Me Please Stand Up?

He came in without an appointment, first to our Access Center, then directly to me.  It was time:  he had to get off the dope.  He couldn’t live like this any more.

When persons first come to me in my role as the doctor who provides Suboxone, the remarkable medication that helps many opiate addicts find a second chance at life, they are never in good shape.  To start on Suboxone, one needs to be in the early stages of opiate withdrawal, which is anything but a fun state:  gastrointestinal disturbances (nausea, diarrhea), temperature dysregulation (hot and cold flashes), severe muscle cramping–in short, a generalized state of ick.  None of my patients first encounter me with a bounce in their step–with the ill-temper of a bouncer, maybe, but never with a bounce.

He presented as quiet, even a bit timid.  I could still feel the Marine in him, though:  the occasional flash of the “can we get the point, please?”  The disgust of a drill sergeant with a new recruit (i.e., himself) who just can’t seem to get it.  But all things considered, he was respectful and cooperative.  He merely wanted all this crap over with.

Good news:  since then, a lot of the crap is over with.  He is feeling better.  Physically.

Also since then, I’ve heard from others that he has not always presented himself thus.  He has in the past had a far more confident air about him.  He has made an impact on people that has been quite lasting.

Eventually I asked him about this.

“You know,” he told me, “I’ve thought a lot about what you said in the beginning, about how a lot of guys feel as if a part of them died over there.  That’s what happened to me too.  Ever since I’ve been back, it’s as if I’ve been trying to create this new person for the world, somebody who people would like, somebody who doesn’t get all angry, who’s put together, confident, ready to take on the future. Lots of people think that’s who I am.  So I keep trying to make that guy–but it isn’t working.  The foundation just isn’t there.  I keep asking myself what I’m doing wrong, and I can’t come up with any answers.  I don’t know what to do.  I’m lost.”

“How has love been for you?”  I eventually ask.

He drops his head. “You wouldn’t believe the number of women I’ve dated since I’ve been back.  And I’ve just been awful.  I reach a point, and I  get bored, and I disappear–well, all except my current girlfriend, though.  She’s stuck with me through all this drug stuff, encouraged me.  She really loves me.  I say I love her, but I’m afraid I don’t.  I’m afraid I’m going to hurt her, really badly.  I don’t know if I’ll ever be normal.  All I want is a family, a house, a career–to help people.  That’s it.  But I’m so self-destructive.”

Fortunately he has not recently had any thoughts of suicide.  But he has indeed more than once contemplated swallowing a gun.  It’s serious.

His story is an all-too-familiar one.  His best friend in the world was blown up right next to him.  He shouldn’t be alive–literally.  In any previous war, he’d have become another name etched on a memorial.  His picture is right next to the dictionary entry for “survivor guilt.”

Yet that’s not all he is.  He is a guy, for example.  We guys are not that hot at closeness.  We know we want it, but we’d all prefer that we wouldn’t have to get all caught up in that mess, you know what I mean?  Come on, women in our lives:  you know the drill, don’t you?  I mean, we’re still here, right?  If we didn’t want to be, we wouldn’t be.  Right?

He’s also a guy on the verge of life.  A talented guy on the verge of life.  You know, I’ve been able to feed and clothe my family off the notion that somehow–don’t ask me how–intense, thoughtful men should be able to figure out where they can put their ambition, do so while also being confident but not obnoxious, while being a regular “guy” your buddies would want to hang out with, while also being a decent partner and dad who can be comfortable and supportive at home, at all times, all the while rising to become the top of their game–and doing all that easily and happily.

True confession:  I bought into that once myself.  I think my therapist was able to remodel a whole wing of his house as a result.

My therapist enjoys that wing, I’m sure.  Lucklily, in the process, he also–finally–got me to see that maybe I too could start getting real and yet enjoy life as well.

The point of today’s post is the same as the one over the past several posts:  never, never, never fall into the trap of believing a combat veteran when he or she tells you–no, believes with all his or her heart and mind and repeatedly, repeatedly tells you, if you’d only listen, numbskull–that he or she is all-PTSD, all-the-time.  Never.

For the guys, certainly:  never, never, never let them think that if only they’d not gone to war, they’d have breezed into love and work like all the other “normal” men around them.  (If ever LOL was to find its utter fulfillment, it would that last statement, believe you me.)  Never.

“Listen,” I eventually said.  “Did losing your best friend in the world and not even knowing it until long after he’d been in the ground, all because it took you that long to recover enough to open your eyes–did that change you forever?  Yes, it did.  Will love be hard because you never want to hurt like that again, never want to feel the pain of someone for whom you’d die in a heartbeat having the gall to die before you had a chance to prove that?  Yes, it will.  Are you lost because a big part of you believes down to your core that a loser like you, daring to breathe while others far better than you are mere memory, should never be allowed to find a way anywhere, ever?  Yes, you are.”

“But you’re more than that.  You don’t feel it, but your not feeling it doesn’t make it false.  Even if you’d never boarded that plane heading over the Atlantic, you’d still be terrified of closeness with a partner, uncertain whether you could ever make something of yourself, fret over which way to turn now, whom to trust, what to do next.  You think you’ve been creating this “actor” as if he were some figment of your imagination, smoke-and-mirrors out of whole cloth, the phony of phonies, hoping against hope that no one will catch you in the act?


“You’re a guy.  You’re a guy who’s seen some really bad things.  You’re a guy who’s lived some really bad things.  You’re all that–and you’re not.  Our task ahead of us is not going to be an easy one, but we can’t shirk the mission:  you’ve got to become more able to tease apart what’s PTSD and what’s normal-guy-ridiculousness.  Every young buck has to be tamed, at least to a certain extent.  And you, my friend?  Let’s face it:  you’re quite the young buck.”

He did look away–very briefly–on that one.  Yet I caught that hint of a smile.  Good for him.  We’ve got something to work with.

The combat veterans we work with desperately need a narrative to add to the “I’m just War” story they tell themselves day in, day out.  Good news, folks:  there is one.  It’s called “human trying to make it in this world.”  Their PTSD will complicate that narrative–but it will not obliterate it.  Never, never, never let them go on thinking that.  Never.

Your reward?  The combat veteran’s “real me.”

It’s worth the effort.  For both of you.

I can hardly wait to see it in him.

It’s the smile.  Gets me every time.


In so many ways, it was just another day.  I had not expected to see him.  He had, however, spoken with a colleague about his concerns about his painkiller usage, so the call had come:  could you see him?  He’s in bad shape.  He really seems sincere.

I said I’d be glad to.

When I walked into the waiting area, I saw a soldier’s soldier.  He looked like a high school wrestler who had aged rather well, thank you, hairline ever so slightly receding, strong facial bone structure.  He was looking at something in front of him that, I would estimate, must have been about twelve miles from where we were.  His whole demeanor was resolute–sort of, not really, but yes, really, it’ll be OK, but . . .   It’ll be OK.  Yes.

When I introduced myself, he looked me right in the eye as he popped up, ever the straight, good soldier he was, not rigid, but solid, putting out his hand confidently, sort of, not really, but yes, but . . .

“Thank you for seeing me.”  He spoke with definitiveness, yet vulnerability, as if both to assure me that all was going to be fine as well as to assure me that he was desperately needing my help, this was not a drill.

“Good to meet you,”  I replied.  We shook hands, again his grip both soldierly solid and humanly tentative.

His story was a familiar one.  He had injured himself in the Middle East.  He had begun opiates to ease the pain.  He came home, and the PTSD symptoms started.  He had seen a lot of war up close and personal.  The images continue to haunt day and night.  The painkillers did make them go away.  Somewhat.  Not really.

He’d reached a huge daily dosage.  He was desperately seeking it from whatever source he could.  A few days before he looked at his child and realized that he could barely focus on the kid, not because his eyes were weak, not because he was high–but because he could only think pills, pills, pills, God, where will I get the next pills.

As he told me this, I could see the tears gather, but he was a good soldier.  He didn’t let them go.  He sat rigidly and narrated his tale.  He sat limply.  He appeared in control.  He appeared desperate.

He loved his child.

We talked about Suboxone, the opiate substitution product that has helped so many of these veterans.  He was anxious to start.  Our converstion, though, had taken its toll on him.  He stood up to go out of the room.  He was not crying.  Sort of.  Not really.

But if he were to take one more step toward the door, he was going to start sobbing.  I knew it.  He knew it.

“It’s no problem, your staying here and pulling together a bit if you’d like,” I said.

At first he looked at me blankly, but within seconds came the smile of relief.  “Thanks,” he whispered.  He sat down.

Deep breaths, he took.  Sort of reminded me of the breaths you take before you’re about to try to shimmy up the rope on the obstacle course, I can do this, I can do this, I can do this.  Deep breath.  I can do this.

He looked at me, eyes resolute, eyes ready to release their torrents.

“I hate this,” he said.

I don’t know why I said it to him.  It’s not my usual opening statement when starting the guys on Suboxone.  I just felt:  I need to tell him.

“You know, the problem is that you guys came back with someone else in your soul.  The war.  The war’s there.  It’s not going away.  You know that.  I know that.”

He nodded his head ever so slightly.  “I know,” more of a swallow than a response.

“But the real problem,” I continued, “is that you guys feel that only the war came back, that the war is all you are, that you disappeared over there and only the war came home, full of rage and pain, the war-is-hell war, the war that makes you too horrible for anyone to love, to care anything whatsoever about.  Am I right?”

He nodded.  This was one determined man.  Breathe.  You can do it.  Breathe.

“You’ve got to trust me on this,” I said to him.  “You’re still there, inside you.  While I in one way don’t know you from Adam, I do know war when I feel it.  I feel the war in you.  But I feel someone else as well.  I know you don’t.  But you’re going to have to trust me.  You and the war are too entangled.  We’ve got to disentangle you.  It won’t happen just like that.  But it’s possible.  You’re not gone, the you that went on deployment.  He’ll never be alone again.  But he’s not gone.  Believe me.”

That was when the first tear began to respond to gravity.  He was still breathing, ready for the rope, trying to stop gravity’s pull on that tear simply out of sheer will.

“I can’t take the war out of you,” I continued.  “You wouldn’t believe me if I told you I could.  You will always have to live with it.  But you are not it, and once you can begin to feel that more consistently, you will be able to begin to find a way to live with it.  There’ll always be some pain, but it doesn’t have to hurt like this forever.  Once you get disentangled, it’ll work better.  Trust me.”

He swallowed.

“Really?” he whispered.


He closed his eyes and looked down.  A few pre-shimmying breaths again.  Then he looked up, first at nothing in particular, then at me.

“Thank you,” he said.

“Sure thing.  See you tomorrow, to adjust the dose?”

He nodded.  “Yes.”

I nodded.  “OK.”

He stood up, soldier straight.  One more breath.  A very resolute, very warm smile.  He gave me his hand.  I shook it.

He came the next day.  We adjusted the dose.  That’s how it goes with disentangling.  Steady.  Keep going.  Breathe.


%d bloggers like this: