Goodbye, My Friend

Mere hours ago, one of my patients died, not by his own hand, but suddenly, unexpectedly, far too young, far too soon.

Words fail me. Yet at the same time, I cannot let this night pass without my having typed at least a few such words onto a screen, into cyberspace, for him, whose smile I will never again see.

My God, never again.

Goodbye, my friend. For indeed we were not just “doctor and patient,” were we? It matters not that in another few hours, in the very next daylight I will see, I will write my final note in your chart, does it, for you were never just another note, never just words under federal protection.

These very words that I type, at this very moment: God, I wish you could see them.  I wish I could see you seeing them. I wish we could laugh about them.  I wish I could hear you say, “Jesus, Doc, lighten up, why don’t you.”

I promise, my friend, that one day I will.  The memory of your smile will help me do just that.

But for now, I have to ask you to give me a few hours, a few days, as long as it will take.

May somewhere, somehow, not just my memory of you, but you—you—know: it was never just a job.

At this very moment, you cannot know how glad I am that I can write that.

But then on second thought: maybe you always did know that.

Ergo, your smile.

Goodbye, my friend. Goodbye.


Combat Veterans and “Closure”

A few days ago, Max Harris wrote the third of his blog posts (from Every Day Is a New Day) about his losing to death his therapist, Dr. Joseph Casagrande.  In my two previous posts, I shared Max’s frustrations and anger.  Today I share his grief, just he shared it with all of us:

I went out to the cemetery today.  I had learned late Thursday night that Doc does have a final resting place and it was less than a half hour from my house.  Needless to say, after spending Friday getting everything sorted out with the VA (that’s another post for another day), I was exhausted and couldn’t make it out to the cemetery yesterday.

So I went this morning.  Talk about surreal.  There I was, not a soul in sight anywhere.  I was standing in front of his grave marker, solemn and contemplative, head down.  No cars drove by the cemetery in that moment and the snow started to come down very heavily.  It felt like one of those moments you read about in books or in serious dramas.  Yet this was real life.  This was MY life and, for some reason, it just felt right that I should have solitude and quiet in that moment.

And then it passed and the emotional pain hit like someone ripping off a Band-Aid.  Intense, searing, yet short lived.  I was left with the dull throb of missing someone I would never see again, but being there – seeing Doc in his final resting place – gave me the closure I needed desperately to fully move on.  I didn’t realize how badly I needed it until that moment.  It made me wonder why I needed that closure, that finality, so keenly.

I thought about it on my walk back to the car, on the ride home and a good portion of the early afternoon.  And then, it hit me.  I needed this because I never got closure for all of the death and violence I experienced over in Iraq.  It made me think about all of the other veterans with PTSD that were suffering just like me and it made me realize:  If there is ONE THING that can trigger us and bring it all back into our consciousness, it’s having someone close to us die and not getting the closure we need to move on.

In retrospect, I recognize now that a lot of the anger I have felt for the past few days was not anger felt but, rather, anger remembered.  Grief.  Not felt, but remembered.  Helplessness, intensely remembered.  I recognize now that this event, the unfortunate circumstances surrounding Doc’s passing and the way in which I was informed, has been a blessing in disguise.  It may take it a while for me to fully accept that, but I know I eventually will.  What I have gained from this experience is how losing someone I care about will affect me in the future.  It also equips me to support my fellow veterans if they find themselves in the same position.

So take heed.  If it is in your power, do everything you can to provide adequate closure for veterans with PTSD.  Don’t blindside them.  Do what you can to be compassionate and try to leave them feeling like they are in control of the situation and how they choose to grieve.


The combat veterans whom I serve often ask me “When will it end? When will I be able to move on?” They—and I—often struggle to understand what, at any particular point, that “it” is: the emotional instability, the nightmares, the flashbacks, the guilt, the grief?  All the above?

If only the latter, if only.

There is a part of the brain called the hippocampus.  Among its various functions, it serves as the “cataloguer,” if you will, of our life’s experiences.  It is the part of the brain that allows us to remember an event and actually remember it, i.e., put it in the past, in a particular context, one that began and then ended, one which no longer abides with us today.  The hippocampus is our own personal scapbooker, of the good times, of the crummy times, one of the main producers of our episodic memory, the this/then-that/then-that of our existence.

For the most part, the hippocampus turns off when we experience trauma, when Reality overwhelms us with the fire and brimstone that ignite our emotions into a wildfire worthy of any California hillside.  No time to catalogue in such a situation: it’s time to move!

Unfortunately, as a result, such memories then hang around as vivid videos inside our heads, as if we’d been transformed into a smartphone that could transport us back to Hell with the mere tap of a finger.  They’re not downloaded off the phone, if you will, into our brain-laptops, into file folders marked “War” or “Attack” or “Earthquake,” with each segment named and stored as a WMV file, ready to be watched at any time, true, yet just as ready to be shut off by a click on the Play button.

Ready—and able—to be “closed.”

The “closure” of grief and the “closure” of trauma are not, in quite important ways, synonymous, even though both processes are ultimately about loss: the former of someone real, the latter of a fantasy, a hope-against-hope that “it will never happen to me.” It is precisely because the experiences are indeed both about loss, though, we can see how they often find their ways to plow together into our souls like the proverbial Mack truck.

Max, like so many combat veterans, is once again having to catalogue the world:  Dr. Casagrande is gone; his buddies and the Iraqi civilians are gone, whether they “left” a month ago or, as Max noted recently, ten years ago this month. There is a comfort in cataloguing, in filing a memory, an emotion into a neuronal cabinet so that it isn’t just sitting around ready to be stimulated at a moment’s notice.

Sadly, though, neither the cabinet drawers of “grief” or “trauma” have the common courtesy to stay closed.  They have this tendency to fly open at the most inopportune of times:  a song heard on Pandora, a film clip on the History Channel, a photo on page five of the local morning paper.

Once they have been downloaded and filed at some point, though (all metaphors wonderfully mixed), they can be filed back, even after they’ve popped out here and there.  There is comfort in that.  One doesn’t have to live in the mind-cinema from Hell, in other words, stuck on the front row, all that horror careening toward your senses, larger than life.

That theater at least can be closed, hallelujah.

I’m glad that you had that time in the cemetery, Max.  I’m glad that Dr. Casagrande can be “filed,” while never filed away.  May his “folder” pop open at all the right times, causing you to remember once again his warmth, his wisdom.  May he rest in peace in Pennsylvania, and may he continue to bring you peace wherever you might find yourself.

In Memoriam, Joseph J. Casagrande, PhD, 1943-2013

In several past posts I have talked of Max Harris, a former Army Arabic linguist who has bravely written of his struggles with combat trauma /PTSD in his blog, Every Day Is a New Day. Below is Max’s most recent post.

I have had the honor of working with Max as a friend and fellow blogger  over the past year, and I have especially been glad that he had been able to find a solid, meaningful therapeutic relationship with his psychologist at his local Community-Based Outpatient Clinic (CBOC) in Allentown, Pennsylvania. I was quite saddened, therefore, to learn of his therapist’s recent passing–and especially saddened at how deeply the doctor’s death has impacted Max.

Below is Max’s tribute to his therapist, Dr. Joseph Casagrande. It speaks for itself, both in his pain, his frustration, and his hope. I gladly reblog it to share with others the work that this dedicated clinician did with Max and with other men and women who have served in the military. May Dr. Casagrande’s work and compassion continue to be an example to us all.


I try to keep the tears from hitting the keyboard as I write this. I found out today that I lost a man who held a special significance in my life. In his honor, I want to share what I knew of the man.

Read His Obituary Here: Dr. Joseph Casagrande

I never even knew his first name. We just always called him ‘doc’. I didn’t even know him for very long, but Doc Casagrande had a huge impact on my life. About a year ago, when I was out on short-term disability and learning how to cope with my PTSD, I found out about his Cognitive Processing Therapy (CPT) Group and asked to join it. That’s when I first met him. We met one on on and he asked me pointedly whether I was committed to learning the tools I needed to learn to better my life.

That should have been the first clue that this doc was different. I went to my first group session two weeks later…and my life was changed forever.

Over the course of the past year, I have taken control of my life. I still have horrible nightmares, I still get triggered. I still have to fight the depression, the anxiety. The difference is that I have acquired, through emotional growth and a considerable amount of emotional pain, how to better cope with these symptoms of PTSD. I learned these skills in my CPT group and at the direction of Doc Casagrande.

He was an amazing man. He never wore his heart on his sleeve but his passion for helping veterans came through in his straightforward attitude and brutal honesty. He told us what we needed to hear, no matter how difficult. This was his gift to us, he taught us to look at our behaviors and beliefs unflinchingly, to never back away from a problem. Doc always knew what we needed to hear and talk about the most and directed group discussion. He didn’t drone on and monopolize group time. He asked pointed questions and, throught his direction and the support of the other veterans in the group, each of us learned more about ourselves and what we could do to make changes for the better.

Four weeks ago, Doc wasn’t at group. Neither was anyone else. When I asked where everyone was, I was told that Doc was out sick. Concerned, I let it ride. Two Wednesdays ago, someone else was leading the group, a clinical social worker (for more about this group session, click here.) By this time, Doc Casagrande had already passed away. No one said anything. When I asked about Doc, the social worker evaded the questions with ‘I don’t knows’. Growing more and more concerned, I went to group today and noticed that the room was empty again. I didn’t wait around. I left and drove around for a little, thinking. In the end, I came back just after the group was ending and I ran into another doc that I have worked with and asked him for a no-bull explanation as to what was going on. The doc stared at me, stunned. The look in his eyes told me everything I needed to know but the doc said. He passed away. I found out that Doc Casagrande had passed before the last group session that I had been to and I felt the lights grow dim. My world took on a much more threatening glow.

As I said in my previous post, ‘The VA Screwed Up, Big Time.’ I was angry and very distraught. My grief was eating me alive. As I have had many times in the past when I have worked with Doc Casagrande, I felt a moment of clarity. The grief is still there and still profound. The fact that I never got the chance to say goodbye, to have closure, will haunt me for quite some time. What that moment of clarity gave me was resolve – to continue to do the work he would have wanted me to in order to make the most of my live. And to make a difference for others. That moment of clarity showed me that, while I was robbed of my right to honor the man after he died, I could live my life – the live he had made possible – in his honor. To live my life as he lived his: with compassion, honesty, integrity, and unflinching resolve to do the right thing.

It is with this in mind that I share with you my vision. I want to take what he has taught me and make a difference for veterans with PTSD. As I move forward with creating my non-profit, I will be needing a physical location. In his honor: It will be named the ‘Joseph Casagrande Center’

I ask for your support in making this a reality. Please help me and others that knew him honor his memory and his mission.

In Love and Grief,

Max Harris

Taking Him On Home

I met with Athos last week, one of the “Three Musketeers” whom I had described in an earlier post, Merry Christmas, Reality Notwithstanding. Athos is the second of the two men I have had the chance to work with, the quieter one, the Tobey Maguire/Nick Carraway to my first patient’s, Porthos’, Leonardo DiCaprio/Jay Gatsby, as you might recall.

The third musketeer, Aramis, was the man they each mourn to this day.

“I sent the link of your blog post to my Mom,” Athos told me before either of us had even had a chance to consider sitting down. “She wanted me to tell you ‘Thank you for taking care of my boy.’”

As he finally did begin to lower himself into his seat, he flashed a hint of the smile that, no doubt, keeps him his “Mom’s boy” even to this day. Even after all that has happened.

“Well, tell her ‘thank you’ as well,” I replied. “It remains my pleasure.”

“I haven’t sent it to Aramis’ folks yet, but I’m planning to,” he then said, a bit sheepishly, even though at the same time definitively, if such a combo could be possible.

“You stay in touch with them?”

“Oh, yes. I talk to them a lot. I’d spent time with them, gotten to know them. I mean, at his funeral, it was like I was there in his place, like a son, you know?”

“They let you come home for his funeral?” I asked. That’s not the usual practice, after all, not by a long shot, especially during the period of the conflict in which Aramis was killed.

Athos hesitated a bit, as if he hadn’t quite been expecting my query.

“Yes, I . . .” His swallow betrayed less an impending tear than more an impending dread, the dread of here we go, one more time, remember, one more time. “Yes, I came home with him.”

For a moment, I couldn’t quite place the scenes in my mind again, Aramis’ death, Athos’ and Porthos’ positions, their responses.

“You were there, weren’t you, when he died?”

“Yes, sir.” He swallowed again.

“Porthos too, right?”

“Yes, sir. We were both right there. We’d all gone by the spot earlier, and we were on our way back. Somehow we missed those guys the first time through. They must have just sat there as we walked past them that first time, I guess, I don’t know. But then they opened fire, just like that. I mean, man, I went down for cover, but Aramis just charged ahead, shooting right at them. They hit him five times, last one through the head, the one that killed him.”

I didn’t pause. I’m not sure whether I felt his momentum or dreaded it.

“You saw it all?”

“Yes, sir. I just started shooting. I’d never shot at anybody before. I just shot and shot and shot. Then I started to run out to him. I heard somebody shout at me to get back, and all I can remember doing was shouting back, ‘F*** you, I just lost my best friend.’ Then all of a sudden, I felt a hand on my shoulder, and I whirled around, and there was my sergeant. He just looked at me, only could have been seconds, and he just said, not yelled, ‘I know, but not now, not now,’ and he pulled me back.”

Now there was a pause.

“You know,” he continued, in his mind perched on some rock thousands of miles away, in heat so real to him even I could almost feel it, “we couldn’t get his body out for about twenty-four hours, so we just stayed with him, Porthos and I, we couldn’t leave him. It was hot, it was . . . it was bad. The medic had covered his face, you know? So that . . . we didn’t see it. I took his gun, all his stuff. His blood was still all over everything. When the helicopter came, I climbed in one side and Porthos climbed in the other, his body in between us, and we were off to get him on the Blackhawk to get him out of there.”

“But what was even more crazy,” he then said, “was that when I got out of the helicopter, I just started walking–I mean, I didn’t even know which way was up, you know what I’m saying?–and then out of the blue this airman leaps right on me and starts screaming at me that I’d about walked into the propeller. And you know what, Doc, you know what?”

I figured that he was going to say what he finally did say. And even though he saw that I had already had it figured, no matter: he said it anyway.

“I wouldn’t have cared if it had.”

He meant what he said, of course, yet I have to say this as well: there was something less definite about him that day we spoke, less miles-away, less certain, as if somehow futile was slowly easing its way out of the centerpoint of his vocabulary.

Then after a few seconds, “And it was right after that that the big guy pulled me aside and asked me.”

“Asked you what?”

He snorted, although hardly at all, truthfully, and certainly not at all one of contempt, but more like one of a person’s somehow still not quite believing that what happened actually happened. He looked right at me.

“He asked me if I wanted to take Aramis on home, back to the States, to his family. And I didn’t hesitate for a second, not a second. I just said, ‘Yes, sir.’” Slowly his gaze left mine, wandered past my head, toward the window, out. “Yes . . . sir,” he then whispered.

I’m sure the next silence was only seconds long, but with his looking through the window, he pushed me back a good six psychic inches from him, not too far, mind you, but far enough to privilege me only with the sharing of his story, but not with participating too closely in it. He was in a world that was his and Aramis’s, theirs alone.

“When they put him in the plane to take him back, I just crawled in and lay down next to him. I didn’t leave his side the whole way. We’d heard that the escorts sometimes would do s*** like putting their feet up on the bodies. No way, man. No way.”

Those last words were not spoken to me, were no mere descriptions of what was or was not going to happen. Those words were a vow, spoken to a best friend who, though not hearing, would nevertheless know that Athos had not only had his back, but finally also his whole body, to the end, the very end.

Then, all of a sudden, he smiled, just enough to bring us both back to my office, to each other and to each other’s gaze.

“You know, Doc: that’s when I found out what happens when you’re lying on the bottom of one of those planes as it’s coming in for a landing. I mean, the presssure?” He gave me a are-you-kidding-me look well worth the price of admission. “Not good, Doc, not good.”

Freed from the reverie of his final one-on-one trip with his “bestest buddy,” he returned to a more steady, though still thoughtful narrative pace. He talked of his time with Aramis’ family, the funeral, the motorcade to the national cemetery, the graveside service.

“But you know what I’ll never forget?” he then said. “I’d just gotten out of the limo, and I was like standing there, not even sure where I was, who I was, nothing. And so I look up, and there he was, the big guy, the senior man himself, looking right at me. It took me a few seconds, but then I saw what he was looking at: I had something hanging from my uniform. But before I could even react, all he did was walk toward me, take a pin off his own uniform, and then pin mine back together. He put his hand on my shoulder and just said, ‘There you go, son. There you go.’ And he squeezed my shoulder and walked on. I . . . I couldn’t believe it.”

We talked more, about Aramis still for a while, but soon we were talking about his own girlfriend and his (quite funny) memories of trying to keep Porthos in line while they were back in the military. By hour’s end, he had already stood up to leave, our plans for our next meeting having been made, when he paused and looked right at me.

“I don’t know if I’ve ever told anybody all that, Doc. But, you know: I made it through without crying. That’s . . . that’s a start, Doc. That’s a start.”

With that, he walked out.

A week later, the pictures in my mind that I cannot shake are two. One is the picture of a young man, barely into his twenties, lying on the bottom of a cargo plane next to a box, vowing to remain faithful until the landing at Dover, protecting another man’s honor that, in one way, was only a memory and that, in another way, was the only bit of Aramis that no one–no one–would ever take from him. No one.

The second is of a senior officer looking into the eyes of a young enlisted man, quietly saying, “There you go, son. There you go.”

There is no glory in War. Only days before that officer took Athos’ shoulder, a family over in the Middle East had buried another man, a man perhaps who had died with hatred and malice in his heart, a man perhaps who had, instead, merely died wanting only to get these armed strangers out of his country. I will never know.

I do know that Athos, Porthos, Aramis, each believed he was “born to protect.” Each believed that 9/11 was an Act of War. Each believed that their mission was part of a greater mission to assure that 9/11 would not happen again. What others believed or to this day believe about that mission, that never was the point. They believed honorably. They acted as men, real men capable of rage and love. Their commanders saw them as men, real men capable of respect and even worthy of the title “son.”

One of them did not come home alive.

He did not, however, come home alone.

For it was, to the end, as Alexandre Dumas put in the mouths of his famous trio, “One for all, all for one.”

All for one.

Empty Chairs, Empty Tables: From Paris to Fallujah and Kandahar

This past Thursday morning, I opened up my e-mail on my iPhone to find the following:

Songs That Stab

And now so soon once more again
The rock has turned in its due course
And “empty tables and empty chairs”
rings from ear to soul.

The poet is the writer of A Soul’s Walk, a blog that I follow regularly for the author’s inspired ability to link words that quite often ring for me from ear to soul. Periodically he writes about war, noting in one entry that “I have known a lot of people who are now dead.” I have always had the sense that he is no stranger to the painful consequences of combat.

He wrote the day after I had enjoyed my one (albeit two-part) Christmas request of my family: a). to go see the movie Les Misérables on its opening day, and b). to do so without my children’s complaining. While my son did remark that he had not planned on there being “so much singing,” I am pleased to report that I succeeded in getting both halves of my wish.

Les Misérables, originally produced by Cameron Mackintosh from a French musical adaptation of Victor Hugo’s novel, is a story of loss, justice, mercy, and redemption. In an earlier entry, 2K, 1 by 1, I referred to one of the centerpiece songs of the musical, sung by Jean Valjean (Hugh Jackman in the current movie), “Bring Him Home.” The poet in A Soul’s Walk  refers to another such centerpiece song, “Empty Chairs at Empty Tables.” I can only assume that he had seen the movie on Christmas as well.

I have no surprise whatsoever at his response.

Eddie Redmayne, a British actor and singer who was once an Eton classmate of Prince William, in the movie plays the role of Marius Pontmercy, the wealthy young man who joins the student revolutionaries as they try to establish a Republic amidst all the political intrigue that arose in the twenty-some years since the fall of Napoleon. Marius falls in love with Valjean’s foster daughter, Cosette, and Valjean goes off to protect Marius before an emotionally climactic scene of the novel and film, the Paris Uprising of 1832. (Valjean sings “Bring Him Home” at that point.)

In the Uprising battle that ensues, Valjean does indeed rescue Marius, while all Marius’ other companions are killed by government forces. Soon afterwards, Marius returns alone to the tavern at which he and his companions had dreamed their revolutionary dreams, the place now in shambles, bloodstains still on the floor. There, he sings the following:

There’s a grief that can’t be spoken
There’s a pain goes on and on
Empty chairs at empty tables
Now my friends are dead and gone.

Here they talked of revolution
Here it was they lit the flame
Here they sang about tomorrow
And tomorrow never came.

From the table in the corner
They could see a world reborn
And they rose with voices ringing
And I can hear them now!
The very words that they had sung
Became their last communion
On this lowly barricade . . .
At dawn.

Oh, my friends, my friends, forgive me,
That I live and you are gone
There’s a grief that can’t be spoken
There’s a pain goes on and on.

Phantom faces at the window
Phantom shadows on the floor
Empty chairs at empty tables
Where my friends will meet no more.

Oh, my friends, my friends, don’t ask me
What your sacrifice was for
Empty chairs at empty tables
Where my friends will sing no more . . .

To call Redmayne’s performance a tour de force is not to give the man his due. The director, Tom Hopper, had filmed the movie with the actors’s doing all their singing during the actual takes, with orchestration added later. Therefore Redmayne had not been constrained by the stage singer’s need to belt out a song for the back row, over a full orchestra, whether live or recorded.

In theory, the sentiment of “Empty Chairs” is one worthy of any Verdi or Puccini.

In practice, though, it is the song of a young man who had never been prepared by his family for the worst that life can bring, who was saved finally not by that family’s money, but rather by the happenstance of his having fallen in love with the right woman at the right time, who had then provided him the right father-figure who was willing to take the risks that his patrician grandfather would never have dreamed of taking, Valjean, a reformed convict who covered himself with the excrement of Paris and faced his deadliest adversary just in order to “bring him home.”

But isn’t that what music does all the time, though: turn dumb luck into high drama?

That, Redmayne certainly provided. Unlike the song of any Marius I had ever heard, his began a capella, orchestrated by a stillness that, nonetheless, within a matter of only a few guitar and violin notes plunged itself directly into his chest, expelling his tenor voice with the quiet ferocity of a heart being ripped right down the middle, musical phrase by phrase, whispering, weeping, belting out to the back row, collapsing, until finally he and we, the audience, were left helpless before the final murmurs of a lone cello, wending its way up the scale, from bass clef to treble, into a fermata of grief that neither he nor we could escape.

If it was indeed a grief that can’t be spoken, it certainly became one that could be sung.

For many combat veterans, however, themselves often the happenstance recipients of happenstance rescues at the right time: if only it were that easy.

The young man came into my office the day after Christmas. I had met him on several occasions previously, yet that day’s visit had all the makings of one to turn out either ominous–or trivial. During the weekend before Christmas, he had been caught up in a high drama of his own involving other veterans with whom he had been living, several of whom I knew well. Accusations had flown. Searches had been undertaken. Outrage had been expressed. By all.

He came to see me because he needed his Suboxone, the opiate antagonist medication. Fortunately there had been no misuse of the medication whatsoever. (At least one does not need literal chemistry to have explosions that can make life more than memorable.)

I opened the door to find him in the hall, dressed in casual, post-Army chic, well-prepared for the blizzard that had been howling around him only moments before he had stepped into the building. His hunter’s cap was well-ensconced on his head, yet his facial smoothness (not softness) was worthy more of Marius standing tongue-tied at the gate before Cosette than it was of any ersatz lumberjack. He still had hints of a boyish smile, with eyes that I suspect had once even twinkled.

He was ex-military, though, through and through, one of those types I often see trekking down our VA hallways, a man who could have chosen the life of the “pretty boy,” had he so desired, but instead had thrown himself into perilous situations, because of which it is now clear to all that you wouldn’t want to mess with him, yet a man who at the same time can’t quite yet give up his birthright as “he-with-the-genes-to-make-girls-swoon.”

“Hi!” he said.

He was a bit more chipper than I thought he should have been–but that says more about me than it does him. After all, some of his drama had invaded my Christmas weekend, too.

“Come on in,” I replied. (“Countertransference, Rod,” I whispered to myself internally, those pesky feelings that patients can sometimes engender in us therapists. “Live with it, pal” was my only self-retort.)

We chatted a bit. To his credit, he was taking seriously what had happened to him the weekend before. Truth be told, knowing many of the actors who had been involved, I believed his version of the whole saga. Unfortunately for him, though, he had squared off against an adversary who is much more skilled at camouflaging his anger than my patient is, so my patient had far-too-readily swallowed the latter’s bait, along with the proverbial hook, line, and sinker. Ugliness ensued–as did my patient’s eviction.

I have to admit: I’d have probably reacted the same as he had.

Perhaps that was why I was a bit irritated: if I’m willing to play the there-for-the-grace-of-God card, I guess I expect a little reticence in return from my co-conspirator-in-fantasy.

This was not, however, the first time that my patient had pulled a “What, who, me?” line on me. That very morning, for example, there had been a bit of a song-and-dance about whether he’d given a urine specimen for a drug screen.

He’d turned up dirty, of course.

He’d partied down the after the Great Drama, having been sent out on his own. I actually believed him when he told me that he had done it more out of anger than he had out of a desire for recreation. No reason that spite and fun can’t go hand-in-hand, after all. Still, in the matter of only about twenty-four hours he’d managed to anger not only his “landlords,” but also both his estranged wife and his parents, so he was counting on an all-forgiving relative to grant him shelter until he could arrange a place of his own.

So I took the risk–and given countertransference, I mean risk: I decided to talk with him about his attitude.

For the non-therapists out there: I cannot overstate how dangerous this decision was. “Confronting the patient with reality” always sounds great in theory, and, granted, it usually plays well on TV-psychologist shows, whether fictional or “real” (LOL). The technique, however (if one dares grace it with that name) is fraught with perils. Such “therapeutic confrontations” often end up being no more than self-justified hissy fits on the part of peeved therapists.

My only saving grace, if any, was a simple one: I really like this man.

And I can never forget the symptom he’d reported to me at our first meeting: at night he often awakens to the crying voice of an Iraqi girl. It has often seemed so real, he has had to search his house before he can settle himself back down just to consider returning to sleep, a reprieve that he is rarely granted.

“I want to tell you something,” I began, “but it won’t be easy to hear.”

Because of his smooth facial features, it was hard to tell whether any apprehension was registering in him. His eyes did widen ever so slightly, though. Not his usual.

“Sure,” he replied, without a hint of swagger, yet without one of tenseness, either.

“It’s important that you know that I believe in your sincerity and in your desire to bring some kind of peace to your family, whether or not you and your wife stay together. But you also need know: you often appear as far less than sincere. Frankly, you can often come off as a guy who depends on his good looks and charm to get him out of any mess he’s finagled himself into.”

For a few moments he just stared at me. He looked neither like a man who’d been caught in the act or like one who was about to harangue me with the excuse du jour. He just stared.

Finally he whispered, “I know.”

After another few moments of silence, I whispered back, “That’s not who you really are, so . . . why?”

He swallowed, shifted in his chair, looked down, then began rubbing his hands.

“It’s so hard,”he said after another hard swallow had barely begun its way down his throat. “I mean, if I don’t keep going, keep acting like everything’s OK, keep telling everybody to stop making such a big deal of everything, I . . . it all comes back.”

“What comes back?” I asked.

He looked back up at me, no tears, yet no defensiveness, either. I had to wonder, in fact, whether his face was what Thoreau had been referencing when he had written of “quiet desperation.”


“As in?”

He took a breath, as if to steady himself.

“Houses all blown up. Tanks running over the cars. The people I killed, Doc. My buddies, picking up their body parts, putting them in bags, there never being enough parts for one bag, never . . . enough.”

The stillness of my office reminded me of the stillness of Marius’ tavern.

“We have to face it,” I finally whisper. “It’s not just going to go away.”

He just looked at me, then “I don’t know what to do. I don’t know . . . what to do.”

As I looked back at him, I thought of Valjean’s words in his song: “He is only a boy.” Yet my patient had seen too much. The baby face was gone.

But he was still Marius, wasn’t he–or perhaps better, a male Éponine, the girl who had loved Marius from afar, who had wandered the streets of Paris “On My Own,” much as my patient had had to wander through his adolescence living on his own. Like the ill-fated Éponine, he had tried to make his way in a world that at one point had seen him, like the young Éponine, as “pretty” and “entitled,” a world that, however, no longer allowed him, as it did not the older Éponine, that luxury.

“I know I’m just running away, Doc,” he finally whispered. “But if I don’t run, I . . . I can’t stop seeing the pictures in my head. I look down at my daughter and . . . “

That was when the tear came, demanding both of us to give it enough time to trickle down his cheek with the respect it deserved.

“It’s going to have to hurt,” I eventually said to him. “I can’t take that away. But you and I both know that it’s already hurting. It just needs to hurt in a different way, a way that can get you somewhere, that can help you put into words what you can’t say now, that can make it real for both of us, make it a pain for us to share, not just one to torment you alone.”

“But you’ve got to understand,” I continued. “You’ve developed a talent that once served you well, that will one day serve you well again, but that right now is doing you no good whatsoever. You have the ability to store your deepest pain on a shelf in your brain and then tell yourself it’s gone. You can even convince yourself that’s the case at least half the time. But not only is it not gone, the rest of us can feel that it is not gone. You stand there looking at us as if the world’s just fine and dandy, yet your whole body is practically screaming to us out here that nothing is right. Most folks haven’t a clue what to do with that mixed message, so they either just leave you alone or come to the conclusion that you’re shallow and self-centered and then leave you alone. Either way, you end up alone. I know you think you deserve to be alone, but that’s a consequence you’re creating, not enduring.”

It was odd. He shed no more tears. Yet I could feel his soul weeping.

Yet also, had I not just spent the previous minutes with him, absorbing his words, not just hearing them, I could have looked at him and thought: grief that can’t be spoken? Seriously?

I know that looks can deceive. But can they deceive so thoroughly that even when I know–I know–a man no more than three feet away from me is, even as we are speaking, doing everything in his power not to be running down an Iraqi street, screaming, dodging bullets, without a single Parisian barricade between him and those who have no care whatsoever how few body bags he’ll require for the trip home, can even then I find myself wondering: does he get it?

“I shouldn’t be here, Doc,” he says, answering the question that must have been obvious from my own looks. “My buddies are gone. I still hear that girl crying some nights. I shouldn’t be here. And now my relative is the only one who’ll speak to me. Except for her, I’m alone. I don’t want to die, but I can’t live like this. But I don’t know what to do, Doc. I don’t know what to do.”

Just because a grief can’t be seen doesn’t mean that it can’t be spoken. You just have to be open to hearing it. It’s in the notes, whether sung or not.

“What you do now,” I say to him, “is go stay with your relative, keep out of trouble, and don’t file this away one more time and forget about it until the next disaster. It’s OK to forget sometimes, but not all the time. It’s OK to watch mindless TV. But you also need to hurt some this weekend. Don’t worry: you’ll have your relative there, and remember that you’re only going to have to hurt for a while, for a reason. Hurting now does not mean hurting forever. Yet if you don’t hurt now, you might hurt forever. We’ll pick up right there next week, OK?”

“OK,” he replied, his voice once again affirming what his facial musculature, once again, had not yet found itself ready to affirm.

Eddie Redmayne proved that a grief that cannot be spoken can nonetheless be seen, be sung. My patient proved that a grief that cannot be seen can nonetheless be spoken, even when there is no song to sing.

It’s in the notes, the silence and the notes.

We go forward from there. Marius did. The poet of A Soul’s Walk will. My patient will.

As the Les Mis cast sings at the end of Act One: One Day More.

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