The Slide Show

Truth be told, he and I never should have met in the first place.

Working at a VA associated with a major university has its perks, the most glorious being–residents!  Believe you me:  I am more than thankful to have the opportunity to work with young psychiatrists-in-training, not only because of their energy, their intelligence, their curiosity–but also, yes, I admit it, because of their being on-call in the hospital every night.  We staff psychiatrists have it nice as a result, I do grant you.  Even though we’re on call for a week at a time, four to five times a year, it’s all by beeper.  The men and women slogging it out in the trenches at 2AM are half my age.  They might beep me at 3AM to discuss a case, but, hey:  I fall back asleep easily.  Hallelujah.  For residents and for sleep.

In the latter part of 2010, however, it was not always so.  For reasons too complicated to explain, the staff psychiatrists had to serve as the first-call person on the weekends.  Poor us, I know.  Still, another glorious perk of Med Center VA life?  Having  very competent social workers working through the night in our emergency department, triaging and making life livable for all.  Sweet.  Plus, since we are able to access our VA computer accounts via a secure website, we doctors were able to manage all other matters that fall from the quiet of our homes.  Sweet x 2.

I did, though, cover one particularly memorable weekend:  ten admisions to our inpatient service in the span of two days, with two discharges.  None of the admissions was easy.  None of the discharges was.  By late Sunday evening, both I and the very competent, always-faithful nursing staff had just about had enough, thank you.

It was about 9:30 that evening when the ER social worker called me.

She had interviewed a young man who was struggling with acute drug intoxication issues (among other quite complicated matters, it should be added).  This social worker is quite savvy, yet she was struggling to know what to recommend for the man.  Given his impulsivity, she was quite concerned for his safety.  Still, he had “a way” about him, she told me, that made her wonder whether it might not indeed be OK to release him that night to his family, with outpatient care to be scheduled within a day or so.  I remember her words well, listening to them as I was while sitting in an easy chair in our family’s spare bedroom:  “It’s times like these that I miss having the residents here.  Sometimes that was all it took:  having an MD sit with the patient and convince the guy face-to-face that he’d be better off if he’d just come into the hospital for a while and get himself settled down.”

She was right.  I knew that.  I too was not pleased with the thought of this guy’s just going home in the condition he was in.  I knew I was on solid ground to ask the social worker to contact hospital security and then tell the patient that he was going to have to stay, whether he wanted to or not.  I knew that our VA police, our ER staff, and our inpatient staff were all quite competent enough to make that happen with only the minimal Sturm und Drang.  Nevertheless, I also knew:  Sturm and Drang there would be.  The kid was “strong and wiry,” according to the worker, and “he wouldn’t go down without quite the fight.”   “Code Orange” is what we call such a melee in our neck of the woods.  No good comes from such high drama, for anybody, certainly not at 10PM on a Sunday night and certainly not with an already overworked nursing staff (two admitted patients were already on one-to-one nursing monitoring).  I knew that.

Still, I’ve got the initials behind my name.  All I had to do was to say the word, hang up, and go back to reading my Kindle.  The inpatient doctor would have had to have picked up the pieces in the morning.  Wouldn’t have been the first time.

“OK,” I finally said.  “I’ll be there in a half hour.”

I have colleagues who still roll their eyes on hearing that–and rightly so, I might add.  Their knowing half-smiles say it all:  only you, Rod.  Only you.

After arriving and then enduring the knowing half-smiles of the ER staff, I walked into the young man’s room.  He was lying on his side, facing the wall.  He barely turned his head to look at me.  He wasn’t hostile, but believe me, he wasn’t impressed either.  “I don’t know, man,” was about all he could say.  “I don’t know.”

He eventually did turn to face me.  It had been Afghanistan, I finally learned–that, and a quite, quite complicated life pre-deployment.  Bad, the whole scene, really bad.  He just couldn’t take it any more, the waking up screaming, the never-ending newsreel of blood and body parts in his head, the absolute certainty that it would never end, that it never should end, given what he’d seen, what he’d done, halfway around the world, just the other side of town.  He wasn’t going to kill himself, or at least not really.  He just didn’t care.  About anything.

His family had brought him in.  I sat with them for a good half-hour or so in a secluded corner of the waiting room.  I still can see his father, fighting back the tears that he was too worn out to hide:  “We just don’t know what to do.  I love him more than anything, but . . . we just don’t know what to do.”

When I went back to the patient and told him what his family had said, he looked genuinely shocked.  “You mean they’re still here?” he asked.

“Yes.  They’re worried.  Big time.”

Wiry and strong as he was, he dropped his head and began to cry.  “I’m so terrible to them,” he finally whispered.  “They love me so much.  I don’t deserve it.”  Slowly he raised his head.  “OK.  I’ll stay.”

By the time all the admission dog-and-pony show was over, it was about 1AM.  I was about to head out of our inpatient unit when I saw him sitting by himself in our day room, clad in the standard-issue hospital pj’s, staring at the floor, strong, wiry–and anything but.

All right.  I’ll confess it to the entire world.  Here it goes, ready?

Sometimes the Dad in me takes a gut punch whenever I look at these guys, see that far-off look in their eyes, watch their slow breathing, their mouths slightly opened, with just enough shortness of breath to remind both of us that it can all be so tiring, life.  Death.  These are the sons and daughters of my peers.  Each one of them could have been mine.

There.  I said it.

It’s called “countertransference” in the lingo of my trade, the all-too-human feelings that arise in us all-too-human treaters in our all-too-human work.  It can be a problem.  It’s not always, not by a long shot.  It just happens.  I’m no neophyte to this.

Still, it had been a long night.  For him.  Strong, wiry, lost–him.

I went over and sat across from him at the table.  He looked up, a bit confused, even.

“You don’t have to stay, you know,” he said.

“I know.”  We just looked at each other.

I launched into my spiel, the one about feeling so intensely, so deeply that a group of men can almost think the same thoughts simultaneously, not quite knowing where one of them ends and the other one picks up.  About love.  About having a part of your soul ripped out of you when you realize your brother of brother’s not there any more, not even in one piece any more, never again to laugh, cuss, get drunk, stare at a computer screen, reading an e-mail.

“Were you in the military?” he finally asked.


Once again, he looked genuinely shocked.  “So how do you know all this?”

“You guys tell me.”

It was his first smile of the evening, skeptical though it was.  “You actually listen?”

I wasn’t quite sure what to say.  I suspect I smiled as well.  “Yeah, that’s sort of the point, you know,” is what I think I finally said, something like that.

The smile disappeared, yet replaced not with a frown, but rather with this look of puzzlement that had a sort of “well, who’d-a thought . . .” quality to it.

“Thanks, man,” he finally whispered.  We shook hands.  I went home.

It’s been a long road since then.  Really long.  Good stuff.  Not-so-good stuff.  He’s told me more than once:  “I think about that night a lot, you sitting there with me at that table.  I really do, man.  I really do.”

It had been a while since I’d seen him.  Stuff.  Not-so-good kind, at least recently.  He looked good, though, better than I’d seen him in a while.  He was so proud of himself, of all the work he’d been doing trying to get his life together, of his dreams to help other veterans.  He was wearing a well-worn Indiana University soccer outfit, still strong, still wiry.  He has one of those “Yeah, I know, I’ve been bad, but you still like me, don’t you?” smiles.

He’s right.  And he knows it.

He handed me a CD.  “Here, man.  I want you to have this.  It’s pictures, from Afghanistan, different stuff.  Just us mainly messing around, you know.  Not really any combat.  I just want you to have it.”

“Thanks.”  I took it.

After he was gone, after I’d written my encounter note, I opened up the D: drive of my laptop and pressed the CD down into it.  My photo program opened up the first picture.  He  was lying on a cot, shirtless, clearly just waking up, clearly not that impressed with the photographer.  I hit the slide show button.

My photo program eases one picture into another, like moseying along through the family album, giving you a few seconds to prepare yourself for the ridiculous look on whoever’s face is about the grace the screen, a sort of retrospective, “This Is Your Life” quality, know what I mean?

It was his smile.  Over and over.  He’s quite photogenic, actually.  Combat fatigues, physical training outfits, swimming trunks, goofy T-shirts, posing with local troops, robed men at fancy hotels, cute kids, even with President Bush, no lie.  There was this family wedding picture.  He was in a tux, holding what looked to be the ring-bearer, his hair slightly longer than Army-issue, sun-bleached just enough.  Went well with the smile.  The whole look.

I didn’t cry.  Yet there was something inside me, that Dad something again.  It’s a sincere smile, his is, one of those “you gotta love me” types, one of those that says–not shouts, mind you, just says–“Here I am, world.”  Here I am.

God, I wish he didn’t know what he knows.

Please, dear God.  Let him find peace.

Dream and Weep

About a year ago, Dr. Ghislaine Boulanger came to the University of Indianapolis to give a presentation on adult-onset trauma.  Dr. Boulanger is a psychoanalyst who has endeavored to broaden the psychoanalytic understanding of PTSD beyond the traditional focus on childhood trauma.  As a result of her work with Viet Nam veterans, witnesses to the 9/11 attacks in New York City, and survivors of the Hurricane Katrina disaster in New Orleans and the Gulf Coast, she has written eloquently of the complicated psychological meanings of the tragedies and/or horrors that can completely alter adults’ lives.

Dr. Boulanger is brilliant, engaging, warm, and deeply committed to helping professionals learn to work more effectively with adult sufferers of PTSD.  Very graciously she agreed to serve as a consultant to me last spring as I began to consider moving into full-time work with the younger veteran population.  The conversations we shared together were to me very rewarding, challenging–and sometimes just downright painful.  She is no stranger to the profound emotions we professionals can feel whenever we take seriously the lives of those who have had their innocence ripped from them.  She warned me: this was not going to be easy.

I thought of Ghislaine today.

I have worked with a young veteran who repeatedly experienced horrific encounters while serving on deployment in the Middle East.  He has struggled to make his life work since his return.  He has met only limited success.

He comes in regularly to see me, even though (by his request) we do not delve deeply into his past experiences or into the current thoughts that those experiences trigger within him.  Yet he appears to enjoy our spending brief periods of time together, chatting about his family and his hopes for their better future.  I enjoy spending time with him as well.

As soon as he sat down this last time, though, he told me, “I brought something.”


He pulled out his phone.  “A song.”

Never having been good at the poker face, I clearly amused him with my perplexed surprise.

“I listen to it a lot,” he continued. “Try not to be around anybody when I do.  Freaks people out.  But sometimes it just comes up in my playlist.  Can’t help it.  It’s about what goes on inside my head.  You want to know what PTSD is?  Right here.  This song.”

I hesitated.

“Glad to listen,” I told him.

I’m still not quite sure I meant that.

So he turned on the mp3 player in his phone.  Immediately he smiled sheepishly.  “Better turn this down.”

Good thing he did.

Of course I had never heard the song before, never even heard of the group who played it, given how pop-culture clueless I am (ask my kids).  After it was over, he told me that it was entitled Dreaming, by the Armenian-American hard rock group System of a Down.  He had discovered their 2005 album Hypnotize in a book of random CDs he’d found somewhere in his basement.  He can’t remember where all the CDs had come from or from whom he’d received them.  But it was this album, this song that finally–finally–enabled it all to make sense for him.

The following are the words, as presented in AZLyrics:

For today we will take the body parts and put them on the wall

For treated indigenously, digenously
Human right is private blue chip, pry
For treated indigenously, digenously (We’re the prophetic generation of bottled water, bottled water)
Human right is private blue chip, pry (Causing poor populations to die, to die, to die)

You, you went beyond
And you lost it all
Why did you go there?
From beyond You saw it all
Why did you go there?

For treated indigenously, digenously (We lost consumer confidence in casual karma, casual karma)
Human right is private blue chip, pry (Confetti, camouflage, camouflage, the flage, the flage)
For treated indigenously, digenously (We’re the prophetic generation of bottled water, bottled water)
Human right is private blue chip, pry (Causing poor populations to die, to die, to die)

You, you went beyond
And you lost it all
Why did you go there?
From beyond You saw it all
Why did you go there?

She lost her mind
Someone kicked her into the back of the line
She lost her head
When they called and said that they thought he was dead

Dreaming of screaming
Someone kick me out of my mind
I hate these thoughts
I can’t deny

Dreaming of screaming
Someone kick me out of my mind
I hate these thoughts
I can’t de-

For treated indigenously, digenously (We lost consumer confidence in casual karma, casual karma)
Human right is private blue chip, pry (Confetti, camouflage, camouflage, the flage, the flage)
For treated indigenously, digenously (We’re the prophetic generation of bottled water, bottled water)
Human right is private blue chip, pry (Causing poor populations to die, to die, to die)

You, you went beyond
And you lost it all
Why did you go there?
From beyond You saw it all
Why did you go there?
Na, na-na-na

Dreaming of screaming
Someone kick me out of my mind
I hate these thoughts I can’t deny

Dreaming of screaming
Someone kick me out of my mind
I hate these thoughts I can’t deny

You will take the body parts and put them on the wall

And bring the dark disaster

I could say that the lyrics in italics were pure cacaphony, for I had no clue what they were as I listened.  Yet cacaphony is not exactly the right word, honestly:  that implies a disorder that aggravates, making you wonder why you’re wasting your time listening to this junk.  No way was I wasting time on this.  No way.  The sounds slashed me, creating a column of bleeding x’s right about where my soul should have been, almost goading me to come back for more–if I dared.

The words not in italics, though?  Crystal clear, shattered-ly–no, ground-to-a-powder-ly crystal clear.   Why did you go there.  Dreaming of screaming.  Someone kick me out of my mind.

Dreaming of screaming.

I’m not quite sure when it happened.  Given that I was struggling at times to understand the words, I had bowed my head and closed my eyes to concentrate.  Maybe it was the first dreaming of screaming.  I don’t know.  But I felt it.  I felt the tear inching its way toward the surface.  It was giving me a choice.

You can stop me now, it seemed to be saying to me.  Or you can let me go.  You pick.

Oddest thing, it was, not at all something I’m accustomed to, this–how should I put it–challenge my emotions were offering me.  What was worse:  the front part of my brain, that part that is charged with keeping a lid on these emotions?  It almost seemed to be delighting in my being forced to make a decision, as if it were saying to me, “So, what is it:  gonna do it or what?”

I really did contemplate sending the tear back to its pool of origin.  I really did.  For the briefest of seconds, that seemed not only easiest course of action to take, but (oh, even better) the most therapeutic.

Yet it was as if my frontal lobe with its logic and my limbic system with its emotion were together bolting right straight toward me, sputtering  in one voice, “Don’t you even dare, pal.  Don’t.  You.  Even.  Dare. ”

What makes you so special, hot-shot, they seemed to be sneering to me, that you don’t have to suffer this kid’s life.  Seriously?

In the end, I had to agree with them.  Didn’t want to, at least in a way, but you know, so what, really.

So I fished, rather than cut bait.

From that moment on, I really didn’t contemplate the actual tears much.  Mind you, there was no sobbing or drama, so it’s not as if major intervention would have been in order.  My eyes just trickled.  One trickle after the other.  After the other.  She lost her head, when they called and said that they thought he was dead.  One after the other.

My God, I could only think.  This is his mind.  He told me straight way.  This is it.

My God.

The song over, I looked up.  He too was looking down, he at his phone, turning it off, staring at it for those few seconds.  Then he looked up at me.

He clearly hadn’t been prepared for what he saw.

I knew I had to act fast.

First, I smiled, not broadly, just–smiled.  He seemed so young to me all of a sudden, as if he’d just stepped off a skateboard rolling down Tenth Street, flipping it up into his hands with his right foot as he had begun walking up the front steps of the hospital.  He’s slender, not a big man.  He was wearing a stocking cap pulled down over his ears, just edging over the top of his Shaggy-Rogers-scraggly beard.

I turned to get a Kleenex, biding for some time.  As I did, I simply said, “You seem surprised that it affected me so.”

Kleenex in hand, I quickly dabbed the couple of tears in the corners of the eyes, brushed over the one trickle-track still left on the right cheek.  I looked back at him.   I was still smiling, as I recall.

I imagined wanting to take him by the shoulder, assure him that all was going to be OK, somehow, OK enough, at least.

“I am,”  he replied.  Then he paused.

“I’m sorry,” he then said.  His voice betrayed a shame that was about ready to vortex out of control.

“Sorry?”  I quickly answered back.  “What you mean?”

He swallowed.  “I’m sorry I upset you.  I didn’t mean to.”

It was the opening I needed–didn’t have a clue what actually to do or say, mind you, but it was my time, I knew it.  I just shot from the hip.

“Please don’t feel sorry,” I told him.  “I’m not upset at all, not in the least.  It’s just what I do, you know:  feel.”  Another pause.

And then something else just popped out.

“You  need that from me, you know, feeling.  You doubt that you can touch anybody, really matter to anybody.  I guess we both need the tears.  Like, to prove you wrong.”

For a few seconds, nothing.  Then he smiled the saddest smile I’ve seen in a long time.  “Why would anybody want to take anything I say seriously,”  he whispered, almost rhetorically, as if he were commenting to a group of bystanders on the strange utterances of this man seated  before him.  His voice caught.  “I mean, I’m a nobody.  Everybody knows that.”

For a few more seconds, nothing as well.  I of course knew, at least at some level, that he’d thought that way of himself long before he’d climbed into that plane headed for Kuwait.   This was an old, old story.  Still, it did take me aback for an instant, hearing him say that so plainly, matter-of-factly.

“Tears say differently,” I whispered back.

He smiled a little less sadly, as if he’d decided that he just didn’t have it in him to go another round and prove me the numbskull that I am.

“Maybe,” he replied.  “Maybe.”

Then he looked back down at his phone.  “Let me show you something.”

With a few clicks, he smiled at his handiwork, and then pointed the phone back toward me.  In its middle was this picture of a boy, probably around four, five tops, smiling the Cheshire-cat grin of Cheshire-cat grins.  It was almost a Precious-Moment kind of picture–if it weren’t for the fact that the kid had the orneriest look on his face that you could imagine.

I looked back up at him.  His fatherly smile was not broad, but it was no longer sad.

“That’s why I’m alive,” he said to me.  “That’s why.”

I sit in a quiet corner of my house, typing away.  My son is not far off, checking out some DSi-computer link with all his might and all his soul.  My younger daughter is asleep upstairs.  My wife is in the room next to my daughter’s, half-devouring, half-perusing the latest mystery downloaded onto her Kindle, still not quite yet ready to give up and head to bed so early.  My elder daughter is living the high life as a freshman up at Goshen College, probably right about now watching some Netflix golden-oldie with her boyfriend and the rest of her cronies, who knows.  So normal.

We have no clue, I, my family, you, your family.  None of us over here does.

Dreaming of screaming.  Someone kick me out of my mind.

The tears were real.  As is he.  We keep going.

No Plan B.

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