2K, 1 by 1

The past few days have been challenging ones, with many men and women having passed through my door, most of whom I know well.  Fortunately many are doing well.   Unfortunately some are not.

It’s the nature of my business.

Sadly, there is an additional factor in the nature of my business.  It’s called reality.

Reality, this week, has not been kind.  For as many readers may already know, this past week our Nation achieved–if one only could, without bitter irony, call it that–a milestone.

Two thousand service members have died in the conflicts in Iraq and Afghanistan.

The New York Times published a powerful memorial for these men and women.  In the print version, the pictures of all two thousand were laid out over the pages of the paper.  On the website, however, was a memorial that simply left me, what, sighing, deeply, closing my eyes, rubbing the back of my neck, dropping my head back, opening my eyes toward a ceiling (a Heaven?), taking in a deep breath, letting it out, looking back down at a laptop screen, silent, staring.

I do the very same now.

Before me on that screen is a picture of man, pixilated.  Two thousand pixels form his picture.  As I move my cursor over an individual pixel, a box appears with a name and a date.  If I click on that pixel, the overall picture changes.  It is now that man, that woman whose name was in that box.  Different pixel, different box, another click, different picture.  Two thousand times over.  The wonders of modern technology.

The title of the page is “The Faces of the Dead.”

You can search for an individual by name, by home state, by hometown.  Click on the name, and you’ll see the picture, some with faces smiling, some serious, some clad in T-shirts, some in full dress uniform.  You’ll see along the right-hand side of the screen the man’s, the woman’s name, date of death, home, service branch, age at death, theater in which they died.  They are in their twenties, thirties, forties–their teens.

Of course I eventually found the young lad I had memorialized in Dona Ei Requiem.  Yet for many of those about whom my patients talk, they are just first names to me, their dates of service and death somewhat of a blur.

But for one, I knew his home state.  So I typed it into the appropriate search box and hit the button.  It turns out that his home state has suffered relatively few deaths, all in all.  I scrolled down the list.  There was the first name, the date of death.  Yes, that was when it happened, when my patient died–but didn’t.

I clicked on the name.

There he was.

Just another name, I suppose, another face.

If only.

I knew that I would end up having to write about this experience.  But before I could even get enough breathing room to consider doing that, within hours of my having viewed that screen, I was sitting before my patient.

He is not doing well.

He is not suicidal.  He is not giving up.  But he is tired.  He wants to move forward in his life.  He wants at least some of it, the pain, the memories, please, God, to stop.

I debate whether to say anything to him.  He is distressed already, after all.  Yet I also wanted him to know that I had not forgotten, neither him nor the name of his best friend.

“Have you seen the pictures in The Times?” I asked.

He hadn’t.

“Would you like to?”

He looked at me, an odd mixture of blankly and knowingly.  That was such a dangerous move for a therapist.  I’d taken the risk that he’d say “yes” for my sake, not his.  I might have misstepped.

“Yes,” he finally said.

I believed he meant it.  I was tempted to check that out.  I kept my mouth shut, though.  What’s done was done.  He didn’t owe me any more assurance than that.

He scooted his chair next to mine, and we both turned to my Government-issued monitor.  Type, click, type, click.  Page found.  Search box clicked, state typed, menu appears.  I began scrolling down.  I saw the first name, but was that the last name?  I continued to scroll down quickly.  There, another with the same first name, but, no, I was sure that was not it.  Scroll.

“You just passed it,” he said quietly.

My eyes focused.  Indeed I had.  There it was.  I clicked.  A picture appeared on screen.

I looked at my patient.

He was staring, nodding every so slightly.  He was not smiling, yet he was not frowning, either.  He swallowed.  He looked at me.

“Yes, that’s him,” he whispered.  No smile, no tears, no distress, just acknowledgment.

His friend had not been the only one who had died that day, in that place.  I knew that.

So I turned to the screen, shifted the cursor one pixel to the right, to a new box, new name, same date.  I clicked.

He looked at the picture with the same expression on his face.  He nodded.

“Yes,” he whispered again.

I moved right another pixel.

More than one group of men perished that day.  They served in different branches.  Yet whenever I clicked on a pixel and saw the particular branch of my patient come up in the side bar, I looked at him.

When I did, I saw the same nod, heard perhaps a name whispered, watched a man watching a screen.  I would then turn back toward that screen and move the cursor over another pixel, creating another box.  A couple times he whispered the name before I clicked, then nodded at the picture, almost imperceptibly, yet with an ever-so-slight satisfaction that, yes, he’d been right.

Finally, I hit a box with an earlier date.  I stopped.

I turned to look at him.  He was still staring at the screen, not exactly lost, but not exactly there, either.

“You all right?” I asked.

He nodded, still looking at the screen.  Then he looked at me.

“Yes,” he said.  He was right there with me.  Or at least I guess you could say that.

“How was that for you, seeing all them?”

He shook his head ever so slightly.  For an instant, he even had the glimmer of a smile, more one of pity than anything.  Pity for me.

“Doc,” he whispered.  “I see them every day.”

That, I was not prepared for.

It took at least a second or so for it to hit me.  And I mean hit.  Funny, though, not in a sock-‘em way.  More like the kind of hit that stops your breath in mid-stream.  The kind that demands a tear in recompense.

I didn’t even try to hide it.

“I’m sorry,” I whispered back.  It was all I could say.

He smiled, still slightly, but now with a warmth that melted pity into a shared humanity.

“It’s OK, Doc,” he replied.  “Thank you.”

It’s now hours later.

I look at these pictures, in the middle of a night in which I can’t sleep, pixel by pixel by pixel, and two questions keep coming to me.

The first is why?  I do not, however, dwell long on that one.  I can’t afford to.  I have to leave it to others to debate the why’s, to extol, to excoriate.  The very men and women whom I see every day often ask the same, of themselves, of each other, of us as a society.  My personal call, however, is not to the why.  The political will have to be decided elsewhere.

The second, though, is when?  Of course the political infiltrates that word as well, can’t help but to.  Yet there is a yearning in that word–that demand for Time to provide an answer, damn it–that allows me to pull away as an individual from the communal, political aspect of the question, to ask simply as a man, a father: when?

When will the pixels end?

The song almost awakened me tonight, if you want to know the truth:  the song of yearning, asking, please.  I remember hearing it sung in a Boston theater over twenty years ago.  Jean Valjean, praying for Marius at the barricades.  Cameron Mackintosh’s Les Misérables.

God on high
Hear my prayer
In my need
You have always been there

He is young
He’s afraid
Let him rest
Heaven blessed.
Bring him home
Bring him home
Bring him home.

He’s like the son I might have known
If God had granted me a son.
The summers die
One by one
How soon they fly
On and on
And I am old
And will be gone.

Bring him peace
Bring him joy
He is young
He is only a boy

You can take
You can give
Let him be
Let him live

If I die, let me die
Let him live
Bring him home
Bring him home
Bring him home.

How many Valjeans, Fantines pray that song tonight, every night.  I am a father.  I understand.

Yet also tonight, for me, that song implores on behalf of another, a young man who sees the faces of the dead every day.

Together he and I are working to find him a place where he can stay for a while, remember as he has to, cry and rage as he must, finally to inhale the pictures of those faces and then pass them through his alveoli, into his bloodstream, to be transported artery after artery, arteriole after arteriole, until finally they find their true, final resting place, in neurons of memory that are mere holding stations for the soul, to be called upon in times of need for strength, for purpose, for thankful love.

Like so many of his brothers and sisters, a part of his soul is still over there in the desert, outside that town where he finally lost consciousness, where, without knowing it, he said his final goodbyes.

Bring him home, God.  Embed those pictures, those men into his heart, pixel by pixel, life by life.  And bring him home.

The Onion Takes Manhattan, or A Tale of Two Essays

It is the best of times. It is the worst of times.

While I apologize to Mr. Dickens, I have to say, as a psychiatrist who works for the VA, that no truer words have e’er been spoken.

I have lived to see battlefield medicine reach a level from which many a man, many a woman, who otherwise might have become a name etched on a monument, has instead been able to return home to loved ones, to life.

And I have lived to see such men, such women struggle, claw their way, beg-borrow-steal to find a life worth returning to.

I have lived to see my profession, mental health, finally take seriously the long-term consequences of combat.

And I have lived to see some in my profession define “taking seriously” as prescribing pills as if there were no tomorrow; as manualizing protocols to get the job done in as few steps as possible, as if emotional healing were an advanced form of “Name That Tune” in three notes; as being oh-so-proud of itself for its evidence–its chi squares, p values, meta-analyses and all–while farming out the long-term emotional, the existential, the spiritual to the chaplains for them to clean up once the real work of psychological treatment is over.

The best, the worst.

If Dickens told us a tale of the London and Paris of old, then this week I had the opportunity (or the misfortune, rather) of reading tales from two publications that purport to represent (and proudly, I might add) less the best and the worst of today, but perhaps more the sublime and the ridiculous: The New York Times and The Onion.

Last Sunday, in the Sunday Review section, Nicholas Kristof wrote the essay, “War Wounds,” a devastating piece on the consequences of combat in the life of one man, Major Ben Richards, a 2000 honors graduate of West Point, who is, in Kristof’s words, “a brilliant man tracking his [own] cognitive deterioration.” Since having survived the explosion of two roadside bombs, Richards, fluent in Mandarin, who at one point pioneered cooperative work with Sunni Muslims in Iraq, has struggled to maintain enough adequate attentional focus to monitor the whereabouts of his toddler at his own home, let alone to write the papers in a Georgetown University graduate school class that he once would have breezed through without a second thought.

Kristof, who wrote earlier this year another excellent piece about which I commented in the blog, (In Memory of Ryan), pulls no punches as he sits down with this man and his wife, both only in their mid-thirties, in an Iowa home that became their refuge after Major Richards could no longer manage a teaching position at West Point:

[M]y take [says Kristof] is that whatever political leaders say in Washington, and whatever directives emerge from the Pentagon, not nearly enough is changing on the ground. Mental health still isn’t the priority it should be. Just about every soldier or veteran I’ve talked to finds that in practice the mental health system is clogged with demands, and soldiers and veterans are falling through the cracks. Returning soldiers aren’t adequately screened, diagnosis and treatment of traumatic brain injury are still haphazard, and there hasn’t been nearly enough effort to change the warrior culture so that getting help is smart rather than sissy.

The essay makes clear that both Richards and his wife have struggled with a dual obstacle course far more daunting than any that the good Major might have faced in his Army training maneuvers: the Department of Defense and the VA. Mrs. Richards struggled to find a kind word about anybody connected with either system, while, to his credit, Major Richards–Army loyal to the bitter end–tried to relate the best spin on his own tale that he could.

If Mrs. Richards somewhat held her tongue, however, other with whom Kristof spoke felt no compunction to follow suit.

“The V.A. certainly doesn’t care,” said Jim Strickland, who runs the V.A. Watchdog Web site. As he observes on the site’s home page, “This country is capable of drafting you, putting you in boot camp, teaching you to kill someone, and then putting you in a war zone within six months. So why can’t they process a claim that fast?”

What do I say after that?

Well, I did say something, the first time that I have ever commented on a Times article. I believe what moved me to do so was Kristof’s poignant one-,two-word descriptions of the Major’s struggle to maintain his composure as he related his disappointment over his injuries and his shortened military career. I wrote:

Sad to say, I can’t thank Mr. Kristof enough for his continued focus on the needs of our combat veterans. I’m sad to say precisely because I walk into a VA every day, trying not to lose hope, focusing day in and day out just on the man, the woman in front of me. Yes, we deserve a great deal of the calumny we get. Yet I’m still proud to work for Secretary Shinseki, for my Medical Center Director, for my Chiefs of Psychiatry and Mental Health Services. As a psychiatrist who sits with the tears, the rage, but also the hopes and the courage of these men and women, I’m honored to be allowed into their lives. And they keep coming,

We need your voice, Mr. Kristof, and the voice of brave men like Major Richards over and over. If not, the country will forget before it even has the decency to remember in the first place.

I agree with Mr. Kristof that the Major is anything but a failure. He’s still watching over his troops by refusing to live as if he were a failure. So many men and women have wept in my office because they had to give up a career that had finally given them meaning, all because of wounds that many would prefer to chalk up to some crazy notion of golddigging on the Government’s dime, as if men and women who volunteer in a time of war to do what they believe is right are the type who were really looking eventually for taxpayers to subsidize their cigarettes and bon-bons.

Keep calling all of us to task. Please.

So, all in all, one scrapbook-of-crummy-times essay should have sufficed for the week. But then came The Onion.

For any who might not know, The Onion is (allegedly) as far from The Times as mere mortals can travel. It’s an often-hilarious, always-irreverent newspaper spoof that has been skewering both the Right and the Left (although, admittedly, a bit more the Right) since 1988. Let’s just take a gander at a few of the “paper’s” lead stories this week to get a flavor of our publication here:

Putin Learns Putin is Behind the Plot to Assassinate Putin

Ugandan Powerball Jackpot Hits 31 Grains of Rice

Jennifer Aniston Engaged to a Guy Who Frankly Will Never Replace Brad

Need I say more?

However . . .

Another story also appeared in this week’s edition:

It Would Be an Honor to Serve My Country, Return With PTSD, Sit On a Mental Health Care Waiting List, Then Kill Myself

We ain’t in Kansas no more, Toto.

Purporting to be a “commentary” by an Army private who is about to be deployed to Afghanistan, it takes “black humor” to realms unknown. Some (e.g., Time magazine) found it tasteless and even vile. Far many more, however (e.g., persons posting comments on The Onion’s Facebook page), found it disturbing, satire at its most truth-filled, its most gut-wrenching, its most awful. Here are excerpts:

It’s a matter of principle, really [why I joined the Army]. From a young age I was taught that throughout our history, Americans have had to stand up and fight for the freedoms we enjoy. I always knew that when the time came, I would serve with honor and nobly suffer from post-traumatic stress disorder until my only recourse was to end my own life. So it’s with eager anticipation that I head off to the battlefield to defend, be ignored by, and then—left all alone, with my personal demons closing in—kill myself for the land I love so dearly.

I know no greater honor than relying on an agency [the Veterans Benefit Administration] with a backlog of more than half a million claims that can’t get its sh** together enough to transfer its paper files to a central computer.

And to see the look on my child’s face as he watches his own father, fresh off the battlefield, crying in a fetal position in the corner of his living room because he can’t get the help he needs, even though he’s been calling doctors for three straight months—tell me, is there any feeling greater than that? I don’t think there is.

So when I finally can’t take it any longer and decide to check into a hotel to end my own life, please know that I have but one simple request: My agonizing struggle and tragically preventable death should be the last thing on anyone’s mind. Because the only thing that’s important for someone like me, who will be dedicating his life to serving his country, is that my government lets me waste away until I become a shell of my former self.

That’s what being an American soldier is all about.

God, I wish I could laugh at this. I always gladly take laughter over nausea. Not my lucky day, though–or maybe more accurately, my lucky life.

I read this as I ended a week in which, happily, good has occurred: Will Do, Sir is sincerely trying to communicate more openly with his girlfriend. Buddy, Got the Time? is doing his best not to get into the same old Abbott and Costello routines from Hell with his young-adult son. Inside, Outside, Anywhere is trying to find ways to get his energy back into the world and into the lives of others. Maybe a Letter was proud to help out a good friend with some remodeling work. New Year, Old Challenges is also going to help a buddy remodel–at least two states away, much to my patient’s relief. The new guy from 525,600 Minutes has decided that perhaps he doesn’t have to be ashamed to admit that he’s depressed after all and therefore that he doesn’t have to freak out about trying an antidepressant.

But I read this as I ended a week in which, sadly, No Trouble At All revealed to me some truths–not about himself–that have been haunting him for weeks, more than explaining why his combat trauma symptoms have been skyrocketing. Quite the Handful struggled with several of us treaters over proper medications–and not at all pleasantly, I might add.

And I read this as I ended a week in which, even more sadly, three men entered my life within a matter of about six hours: a mortician whose traumas span a lifetime, culminating in body of a peer after body of a peer after body of a peer; a scout who lost, at one point, nearly a buddy a day, “hanging in there” until a natural disaster destroyed every thing in his life, finally forcing him to remember every one who had been swept away from him; and a chemical weapons man, so tolerant of alcohol that he hadn’t even felt that drunk when his blood alcohol content was over 300, desperate to hold his marriage together, hoping that some Librium would be all it would take to smooth everything over, so not wanting to admit to himself that he had not been drinking himself into oblivion solely for kicks, so not wanting to whisper to me, in answer to my “One day you’re going to face this,” a tear-embroidered “You’re probably right.”

The Muppets Take Manhattan is a fun, no-brainer little romp from the Eighties that used to keep my kids in stitches long enough for me to catch a good half-hour of shut-eye back in the day. Kermit, Miss Piggy, and the whole crew vow to take their college senior variety show to Broadway, with thrills and chills ensuing along the way, culminating in Miss Piggy’s clobbering Kermit into kingdom-come to restore his memories and, with a cast of hundreds of chickens, dogs, rats, etc., etc., to keep the show going on. Moral of the story? Dreams can come true–even, for Miss Piggy, ones of marriage to a certain, dashing young frog.

I’m not quite sure whether The Onion took Manhattan or vice versa, whether “all the news that’s fit to print” ended up in an op-ed piece or in a devastating–what, parody? Truth that no one dares speak in polite, conventional company?

I ended up, though, with a moral very different from Kermit’s and Piggy’s, one that I have to sit with every day of my working life, one that I have to feel, even occasionally embroider with my very own tears:

Dreams can be killed, by an IED, by an indifferent public who dares to harrumph and tut-tut a biting farce, all the while living out every word of that farce every day.

I am thankful that dreams can nevertheless be re-formed. I am glad that I have the honor every day of being part of that reformation process for the children of my peers. As a society, as Londoners, Parisians, New Yorkers, Hoosiers: we all should be doing nothing less than the same.

Mr. Kristof, editors of The Onion: never let us forget that–especially before many of us even have the decency to remember that in the first place.

Please.

Saint Crispin’s Kindergarteners

In yesterday’s New York Times, columnist David Brooks wrote a fascinating piece entitled Honor Code, and even at the writing of this post, almost twenty-four hours later, it remains the most e-mailed article of the day for the paper.

Using an ingenious example, King Henry V of England, or rather his literary embodiment, Henry V, as immortalized by Shakespeare–ingenious on Brooks’ part, in that Shakespeare had already given his audiences a glimpse of a much younger Henry in two earlier plays, Henry IV, Parts I and Part 2, as the, shall we say, wild “Prince Harry,” or (as he’s more affectionately known by his portly, somewhat wayward, older friend, Falstaff) “Hal”–Brooks makes a passionate argument that modern education (and perhaps even modern social mores) takes passionate boys and turns many of them into angry, confused, and self-loathing “problems” (or as we in the mental health field might say, “clients”).

The guy pulls no punches.  We in the medical and mental health fields take our customary hits, given our semi-acquiescence in the apparent outbreak of attention deficit disorder (ADD) among our young, especially the boys.  In truth, he provides a succinct, quite plausible narrative that had Henry indeed been raised in the finest schools of modern America, he might easily have become a male poster child for my well-Googled bugaboo, Cluster B Traits.

One can easily argue that Brooks overgeneralizes, and I suspect even he would admit that on occasion he leads his argument down a more showman’s path.  ADD, for example, does exist, and I can provide you the references on request.  Yet the article ain’t Number One for nothing–and I tell you, if you work daily with combat veterans, you know exactly why it is.

I’ve discussed this topic already in a several earlier posts, most recently Buddy, Got the Time? and Quite the Handful.   Brooks, however, through Henry, adds an interesting embellishment, quite appropriately using the word people, and thus describing passionate boys and passionate girls.  He writes:

Schools have to engage people as they are. That requires leaders who insist on more cultural diversity in school: not just teachers who celebrate cooperation, but other teachers who celebrate competition; not just teachers who honor environmental virtues, but teachers who honor military virtues; not just curriculums that teach how to share, but curriculums that teach how to win and how to lose; not just programs that work like friendship circles, but programs that work like boot camp.

For those of you who might be a bit rusty on either your British history or your Shakespeare, wild young Prince Hal grew up to be thoughtful, charismatic, and brave King Henry, leading a relatively small “band of brothers” (hmm, combat vets, sound familiar?) to an amazing victory over the French at Agincourt on St. Crispin’s Day.  In the play, he agonizes over the role of the king, of the one who himself is only a man, yet who must make decisions that will affect the lives of many men.  Finally he stands before those men, all vastly outnumbered by the French forces, and Shakespeare has him speak the words that so many actors have endeavored to inhabit with passion for hundreds of years:

And Crispin Crispian shall ne’er go by
From this day to the ending of the world,
But we in it shall be remembered,
We few, we happy few, we band of brothers.
For he today that sheds his blood with me
Shall be my brother; be he ne’er so vile,
This day shall gentle his condition.
And gentlemen in England now abed
Shall think themselves accursed they were not here,
And hold their manhoods cheap whiles any speaks
That fought with us upon Saint Crispin’s Day.

Some today indeed see those words as glorifying the bellicose, the worst of the human spirit.  Perhaps they are right.  Some see today’s emphasis on the mutual, the ordered as finally attaining the humane, the best of the human spirit.  Again, perhaps they are right.

Yet every day I sit with men–and women–who desire peace in the world, in their lives, but who are anything but “peaceful” by nature.  They have a warrior’s energy.  They had a warrior’s energy in kindergarten.  They didn’t do circle time well.  They were often the outsiders, the problems.

Indeed many of them do feel that they are still “outsiders” in a world, a nation that tells them to live mutual, ordered lives after training them impeccably well in the bellicose, taking complete advantage of their passion and fire when necessary, demanding complete extinguishing of both when later deemed “necessary.”  They are more than aware that they’ve had to turn in the title “soldier” upon arrival onto US soil and then head off to the next debriefing station to pick up their new title:  “client.”

Brooks has an excellent point, one made not only by him, but by others: in a globally-interrelated, technological world, the mutual and the ordered may indeed flourish.

Yet, friends and neighbors: we have warriors in our midst.  Many of them were made to feel “problematic” as children.  Many finally found that life could have coherence and even meaning when their warrior nature flourished in the military.  They did not want to kill, but they did so if they had to, not for sport, but for the protection of those they loved.  They grieve those who died unnecessarily.  Warrior certainly does not equal monster.  It shouldn’t even necessarily have to equal client.  End of story.

So I get passionate when I think that we are taking one percent of the population, a percent that we allowed to volunteer and fight, exposing them to horrors on our behalf (and don’t you dare give me that “not my behalf” bit: did you give up lattes and/or Bud Light to stand against George or Barack?), with our then now doing nothing to find a way for them to fit into our society.  Talk about the ultimate bait and switch: You’re a problem!  No, wait, you’re a hero!  No, sorry, you’re a problem again.

Brooks is right.  We do have to rethink “problematic” boys–and girls.  We do have to rethink problematic combat veterans.

For many of us, then, we have to keep writing, keep pounding on doors, keep shouting.

His Majesty, Henry the Fifth of England, would have done no less.

And, boy, when he was a kid?  Let me tell you. . .

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