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.