Conical Combat Linkages

Sometimes it takes some days for an encounter with a combat veteran to sink in. Sometimes it takes some days just to decide how much I dare let it sink in.

I’ve talked of this man before, in Buddy, Got the Time? He’s sharp, insightful, witty. He can be cutting (hilariously so, I might add). He’s a Desert Storm vet.

He’s been trying to make his life work for over twenty years.

He’s been doing much better at that since we’ve begun working together. His combat nightmares have dramatically reduced. His relationships, though still, shall we say, on the complex side, have calmed, at least some. He has been able to work more regularly, and he has come up with some very doable, very challenging long-range business plans.

We hadn’t spoken for a few weeks, primarily because of my being in and out of town. When we did, I heard it in his voice.

“Been a tough couple of weeks, Doc.”

“What’s been up?” I respond.

“The nightmares. But they’re totally different this time. It’s weird. They’re not about combat. They’re about guys I knew back in Desert Storm. None of them died, but somehow I keep meeting them in my dreams. And these aren’t good meetings, Doc. They’re confusing, upsetting. There’s one dream I’ve had a good five times, and every time I bolt up after it and can’t fall back asleep.”

“What happens?”

“There’s this senior officer I served under. He’s just standing there, not even in his combat gear, looking at me. He’s covered in blood, sand, dirt. He’s upset, and he keeps talking, keeps trying to tell me something, keeps reaching out to me. But I can’t understand a word he’s saying.”

“What was he like,” I ask, “the real man, as a person, to you?”

“He was like John Wayne,” he answered, his voice brightening slightly. “He even sort of walked like Wayne did. He was a man of few words, but he knew what to do, when to do it, and he knew how to lead. He could be calm when no one else was. He took charge. He was quite the guy, almost like a big brother to me. And that’s what’s so strange: in my dream, he looks so lost, desperate, trying to tell me something, I know it, but I can’t understand a thing. It’s not him, Doc. But it is.”

“How long have you been having the dream?”

“The last two weeks, I’d say.” He paused. “I’m trying to think if there was anything that went on then. I really hadn’t thought about that before right now.” He paused again.

“Anything?” I finally asked.

Still no words, but then, slowly, “You know, that’s right. That BBC show, about the guys in Afghanistan. Yeah, that’s it. It really upset me.”

“What happened in it?”

“It’s not so much what happened as what was happening. These guys had taken direct hits. They’d lost several men. But you know what they were doing over there? Helping Afghans learn to farm. Can you believe it? It was agriculture class. And guys were dying for it.”

His voice had become more distant. I could almost feel him in front of that television, open-mouthed, furious, but too shocked to do anything about it.

“I mean,” he continued, his tempo picking up, “that’s crazy! Crazy! There’s a f***ing war going on, we’re sending these guys to battle, and for gardening? Look, I understand: the best thing we ever did when I was over there, the one thing I’m still proud of, is that we completed a big public works project that saved the lives of I-don’t-know-how-many people. I get it: we’re trying to help the locals, show them we’re not horrible people. But what, Doc, what?”

I hadn’t heard him this animated in quite a while.


“What the f*** are we doing over there?,” he continued. “Where has all this death, this destruction gotten us? What is it about these politicians? None of them served. What do they know? My job was to watch out for young kids like those kids over there who are plowing fields or whatever they’re doing–and getting killed! I was a kid myself. I mean, if you want us to do good works, send us to do good works, fine, we’re the best, we can do that. But to send us over to fight, to kill, to die–and then to garden? Are you, like, for real, man? This is crazy, Doc, f***ing crazy.”

He was on a roll. I couldn’t have stopped him had I even wanted to.

“And you know what else? I just remembered this, too. It was around that time that I had this really serious talk with my daughter. She told me she wanted to talk to me as an adult, not as my little girl. So we did. And you know what she said to me?”

I couldn’t even utter a mere “what?”. Clearly he had too much to say, right then, now, now.

“She said that she’s sick and tired of people telling her that she should have known me before I went over to Desert Storm, that she should have known the man I ‘used to be.’ She looked right at me, Doc, and she dropped the F-bomb. I’m not kidding: I’d never heard her say that in her entire life. She looked at me and said, ‘Don’t they f***ing get it? You’re my Dad. You’re the man I’ve always known. I don’t care what you were like before. I care about who you are now. I care about you trying to care of yourself, trying to take care of us. Why can’t people just let you be who you are?’”

Silence. On both our parts. It was one of those silences that I dread, a silence that dares me to say one, single word, a silence that shakes me at my core, demanding that I say something, anything, all the while laughing at me because it knows there is nothing to say, nothing to do except feel the silence shake me, shake, shake.

Then I thought it. I waited a few moments. I asked it.

“Is that what your officer is trying to ask you? Why did we do all this? Why did this happen to us, back then, now? We’re covered in blood, sand, dirt, we’re just . . . why?”

For at least fifteen, maybe even thirty seconds, he said nothing.

“Doc, ” he finally said, in a whisper that shouted, “I’m proud that I served my country. I’m proud that I made people’s lives better when I could. I’m proud of the men I served with. I honor the men I sent home to be buried. But, Doc, some days, I just don’t know, I don’t think I can take another g**d***ed minute. Do they know what they’re doing, do they have a clue, these politicians, these bureaucrats? Do they know what they’re creating? This is gonna take years, Doc, years to clean up the mess they started! And I’m just talking about the men and women who are coming back! And why? Why? For vegetables? Are you kidding me? Vegetables?”

I can’t fully describe to you how it is to sit with someone who feels that, says that, lives that so deeply. It was not the first time for me to be in such a position, but he was so passionate, truthful, precise. Like so many combat veterans whom I have served, he both despises war and acknowledges its inevitability, even, as is the opinion of many, its necessity. He’s no pacifist, but he’s no warmonger. He believes that what he values can sometimes be insane. He believes sometimes that he is insane to value what he values. Yet that is who he was. That is who he is. That is who he hopes he will always be.

“After war, Doc, nothing connects in a straight line. There’s no direct, uncomplicated connection between you and your spouse, your kids, your family, your coworkers, clients, nobody. It’s almost as if I’m back in engineering class. Life doesn’t develop linearly in any way whatsoever, but almost, what, geometrically. You know, a lot of the guys you see probably wouldn’t put it that way, but that’s really it. Everything multiplies, expands, spins, and the line, it becomes like a cone, a vortex, and you can’t even figure out which end is the tip.”

After a few seconds, he then chuckled.

“What is it?” I asked.

“Maybe you can blog about this one, eh, Doc? What could we call these things? How about ‘conical combat linkages’? We could do CCL for short. Yeah, that’s it. Conical combat linkages. Vortex after vortex after vortex.”

By this point, I’m simply stunned. I haven’t a clue what to say. The word vortex is living out its meaning inside my head, swirling, like the Charybdis that nearly swallowed Odysseus, like the tornadoes that periodically stroll down our Midwest alley.

“I’m so sorry,” I finally say. Stupid. A stupid thing to say. I’m ashamed of myself before the last syllable has the audacity to pass through my vocal chords. Stupid, stupid, stupid.

He’s a good man, though. He actually laughs. I haven’t heard this voice at any point in this conversation so far.

“Doc,” he drawls–and I mean, drawls. “It ain’t your fault, guy.”

I thank him.

And I wonder.

What do I believe about war, about peace, as a citizen of this country, as a Mennonite by choice, as a psychiatrist by trade, as one guy listening to the heart of another guy, that guy’s heart gritting its teeth, letting its jaw drop in incredulity, in exhaustion, left saying nothing? How many times have I said it in this blog–and yet how many times have I truly, truly asked myself: what venti, nonfat lattes did you give up, Rod? This War ain’t your fault, guy?


Maybe it wasn’t such a stupid thing to say after all.

The linkages swirl, between me and this veteran, between him and his ex-wife, his children, his siblings, between me and the next man or woman I’ll interview the next time I step into my office–”next in line, please!”– between me and a nation, between me and a faith tradition, a family tradition, between me and a wife, three children, a world. Conically. Combat half a globe away geometrically expands all my linkages, all our linkages.

The vortices will demand our attention. They’ll get what’s due them. That’s the way of vortices. Even Odysseus found that out. Pay now. Pay later.

Whether or not you eat all your vegetables.

Not Yet, But Maybe . . .

I talked about this combat veteran in an earlier entry, One More Time Around, With Feeling.  I first met him a couple years ago.  In the interim he had struggled with difficult circumstances.  He had called me a couple months back to see if I would be willing to work with him again.  He’d been surprised that I so easily said yes.

We’ve been in touch since then, though infrequently.  He had found clonidine to be helpful (a blood pressure medication that can reduce some symptoms of opiate withdrawal).  He had been reluctant to consider Suboxone again, although I could never quite figure out why.  Then yesterday he called me.

“Can you see me today?  Everything’s falling apart.  Everything.”

This is not a man who would stoop to sounding desperate even if he were so.  Yet his vocal chords did not allow him the luxury of anything even close to coolness in his words.  I heard the message.

“Of course,” I replied.

He came in about an hour later, accompanied by his girlfriend–well, at least she had been his girlfriend, but he wasn’t sure if she still was, and he wasn’t even sure he cared whether he was sure if she still was, and she, for her part, didn’t . . .

Enough said.

Initially he brought her with him into the office, but within microseconds all three of us realized that little was to be gained by this exercise except for another entry for their scrapbook of crummy times.  I suggested that he and I speak alone.  She wasn’t pleased, but honestly I couldn’t tell whether she was displeased with me, with him, with herself, with all the above, with whatever.  She left.  Thankfully, drama was minimal.

“She lied to me,” he said, his voice as steely as a hanging judge’s.  “I can’t stand that.  I’ve always told you that I’ll never lie to you, and I won’t.  She’ll try to manipulate and say she didn’t, but I don’t care what she says: she lied.”

This line of discussion wasn’t going to get either of us anywhere, and I believe he knew that as well as I did.  I will vouch for one statement, though: I believe it when he says that he wouldn’t lie to me.

He might have lost his job a few days before.  He wasn’t sure.  He had been too upset to check.  He had been living with his parents, and it was likely that his mother was going to demand that he leave the house, for reasons complicated and anything but new.

His struggles hadn’t just accumulated overnight either.  Whatever few chunky-ish pounds he’d previously sported, they were no longer there.  Food had not apparently been a priority.  From a physical standpoint, he looked quite good, even, as strange as this might sound, dashing.  From an emotional standpoint, though–well, he was right:  everything was indeed crashing around him.

But he hadn’t used.  He was proud of that.  “Check my urine,” he said.  “You’ll see.”

He was right.

But he had hoped that he would get to see me, prayed that I would pick up the phone earlier that day, because he had been afraid that if something were not to happen fast, he was going to use.  He wanted back on the Suboxone.  He wanted back on anything that would do something to make all the emotional pain abate, even if slightly, even if momentarily.

I had to say it.

“I know that you’re struggling with the opiate dependence, but clearly: your depression’s back.”

In a previous encounter he might have stiffened at that comment, just enough to let me know that he wasn’t going to let some hot-shot doctor label him that easily, thank you.  None of that today, though.  Not a facial muscle moved, in irritation, in relief.

“I don’t have a clue what I feel,” was all he could answer.

The Suboxone part was easy; we discussed the dosage at which he’d previously been able to maintain his sobriety.  We decided to do one task at a time: get the Suboxone started first, then think about whether an antidepressant might be helpful.  I told him I suspected it would.  He didn’t even make a move to disagree with me.

We talked about housing options.  He was unsure whether he’d have to leave his parents’ house or not.  He has always been quite close to his father; it had always been his mother who had been his periodic nemesis.  He was going to speak to his father later that evening.  He promised to let me know if he needed something from me.  He assured me that he knew that the emergency room was always available to him.

Then we just looked at each other.

There was no defiance, no begging, just heaviness, a face that could have been on the verge of a sob had he been anybody but himself.  It didn’t feel as if he were trying to keep that sob at bay.  He was just too tired to deal with it.

He looked so sad.  He broke my heart, seeing his sadness encase him like a second skin, so familiar, so alone.

So once again, I had to say it.

“This isn’t working, you know, the posttraumatic stress injury, the holding it in, the nightmares, everything.  It’s going to take you down.  You have no more strikes left.  You’ll become a statistic, another one of those combat veterans, defeated, imprisoned, alone.  The opiates are too ready and willing to do just that.  You know that as well as I do.”

He just stared at me, blinked, stared.  He swallowed.  His eyes then did the nodding in agreement for him.

“Please,” I finally whispered.  “You’re a good man.  You are trying.  Please.  Please.”

He swallowed again, looked down.

“I’ll come back tomorrow if I can, Wednesday at the latest.  I will.  I promise.  She’s got an appointment she’s got to get to now.  She’ll be freaking out if I don’t get going here.”

“You two going to be OK in the car together?”

He looked up, sporting the closest thing to a smile I’d seen in I-don’t-know-how-long.

“It’ll be fine.  I don’t care what happens, if you want to know the truth.  If she makes me get out of the car in the middle of the street, I’ll be fine, whatever.  I’ll get home.  I’ve always had to take care of myself.  I’ll do it again.  I won’t use any drugs.  I’ll make it.  I’ll be back here.”

“Talk to your Dad,” I finally said.  “Let him know at least some of what’s going on with you.”

He nodded and then simply said, “I will.”

He got up and stood before me.  In another life he could have been a model, not the pretty-boy type, mind you, but the J. Crew type, maybe in the winter jacket section, woods behind him, self-confident enough to have the camera snap his picture, but no posing, pal, none, leaving you, oh, casual peruser of the catalogue that you are, with no doubt whatsoever that he could whip up a more-than-decent-enough campfire and take care of himself just fine, thank you, long before you’d ever know that you really are as untalented as you look.  You’d be welcome to join him, of course, if you were to so choose, but don’t expect a second invite, understood?  Then as he sits down on the log just behind him and takes a swig of whatever ecologically-sound water he had stuck in that backpack of his, he’ll half-smile enough at you to remind you one more time–because, you know, he’s really not totally as über-cool as he looks : yes, you really are more than welcome to join him.

If only he weren’t so sad.

He offered me his hand.  I took it.  Unlike the last time, I did not linger with it.  He turned toward the door, sighed, uncertain, apparently, of how much drama awaited him on the other side, opened the door, and with a “See you,” he was gone.

He doesn’t lie to me.  He’ll be back.

The Dad in me sometimes just wants to take these guys by the shoulders, look them straight in the eyes, and then . . . and then, what?

Just look at them, I guess.  Make no promises except the promise to remain as faithful as I can for as long as I can.  Not waste his time or her time or my time with anything ridiculous like “I’m so sorry” or some other such nonsense.  Let, instead, my eyes speak as honestly as they can for me.  Hope to God that he or she’ll get the message that needs to be gotten–the message that I mean what I say

And then let go, I guess.  Not leave.  But let go.

“See you,” would be all I’d be able to say at that point.

And all I can hope is that he or she would say “See you” in return.

We keep going.  No Plan B.

Quite the Handful

I’d first heard about him several months ago.  His has been a complex story, and truth be told, he shouldn’t be alive.  He has had several near-misses, although there has apparently been much-heated disagreement among him and some of his treaters as to where “accidental” ended and “purposeful” began.  Still, he’s pretty much the straight-shooter: he readily admits that sometimes the latter is the only adjective worthy of at least a few of his tête-à-têtes, shall we call them, with the Great Specter from Beyond.

He came to me for Suboxone, the new opiate substitution regimen that has proven so helpful for many combat veterans who have struggled with addictions to painkillers and heroin since their return from The War.  Like many of his fellow veterans, he has endured chronic pain both of a physical variety and of an emotional one.  He has also long complained of very marked, almost continuous anxiety, an anxiety that, true, sometimes has had the quality of the hypervigilance so characteristic of the combat veteran who just can’t seem to get off guard duty, but at most times has simply seemed to be (to me, at least) a dramatic, post-combat upsizing of the chronic tension and energy that has been his hallmark since toddlerhood.

He has not been, what, particularly enamored with us at our VA.  He’s willing to admit, though, that he’s not always been, what, particularly enamoring himself.  When so much pain is ricocheting through a room as a combat veteran struggles with the acute emotional challenges of posttraumatic stress injury, both veteran and treaters can sometimes get caught up in the tornado-esque swirls of suffering.  We treaters do our best not to get so caught up, but indeed, we’re human, and humans catch emotions from each other, especially powerful ones, and since most of us went into the field precisely because we are good at experiencing the emotions of others, even the most calm and patient of clinicians can, at times, feel a bit unhinged in the midst of tense situations.

We had no such experiences together when we met, though.  He was pleasant, though (appropriately) wary.  I had no doubts whatsoever as to the sincerity of his desire to find a more satisfying solution to all his pains, for his relationships have suffered tremendously because of them.  I also had no doubts whatsoever that he can get quite ugly quite quickly, and both he and his wife had no problems whatsoever acknowledging that very fact.  He knew he needed help.  His wife knew it.  I knew it.  We came to a “meeting of the minds” quickly as to the medication.

But I will remember my encounter today with him not because of Suboxone.

Several months ago I wrote a post entitled Cluster B Traits.  Only one other post, The Killing Floor, has received more hits.  As of today, that post has been visited a total of 557 times.  In fact my new claim to fame is that if you Google “cluster B traits,” my post comes up fourth (some days, third) on the list after Wikipedia, Answers.Yahoo.Com, and another blog post!

I’m kind of impressed with myself, if do so say.

All these months later, I still have my reservations using that label (“cluster B traits”) with combat veterans.  My patient today, for example, has been the recipient of that label more than once.  He has, in fact, read page after page of his medical record, and he has more than noticed how frequently he has been given the honor of that quasi-diagnosis.

He has not been impressed.

Quite the contrary: he told me that he now finally understands why so many treaters at our VA have been, in his words, “less than supportive,” especially of his medical concerns.  “If you have a ‘personality problem,’” he said, “people just assume you’re trying to get something over on them.  I mean, that’s what I would think if I read that, you know what I mean?”

And . . . well . . . while I might say that he may be being a bit harsh and overgeneralizing with that claim . . . well . . .

I wouldn’t say that too vociferously.

Instead, I had him consider an alternative interpretation.

“But isn’t it a fact that you’ve felt this inner tension ever since you were a boy?” I asked.

“Yeah.  So?”

“So wouldn’t it make much more sense to call it for what it feels like, that is, lik too much adrenaline flowing through you all the time?”

That stopped him cold.  Apparently he’d not been expecting that from me.

“I’ve seen it with a lot of you guys in the military,” I continued.  “Ever since you were kids, you’ve had a motor running.  People usually called you ‘hyperactive,’ but that wasn’t quite right, was it?  It wasn’t so much that you couldn’t focus as it was that you couldn’t focus on the routine or the trivial.  If you found something that really interested you and allowed you to work out your energy, live it, love it, you could actually be quite focused.  True?”

He just stared at me.

Then I saw it.  His eyes began to well up.

He turned away from me slightly, looked down.  He brushed the edge of his right hand against the edge of the corresponding eye, swallowed.  Still he still looked down.

“Isn’t that true, though?”  I asked again, though a bit more genly this time.  “That it’s always just been so much to handle on the inside of you, that the military took care of that, gave you something meaningful to do with all that, rewarded it?”

He looked up.  Whether he was fighting the tears or just not caring what happened anywhere north of his lips, I couldn’t quite tell.

“I wish other people understood that,” he whispered.

“Not even your wife does?” I asked.

He was still looking right at me, every microfiber of muscle still.

“I don’t know,” he finally said.  “I think she tries, but I don’t know.  Nobody else does.  You don’t know how I fought to stay in the military.  They tried so hard to med board me out, and I fought it and I fought it and fought it, until finally I had to go.  You don’t know what I’d give to get back over there.”

“Because it all fit over there, didn’t it?”

“God, yes.  I loved what I did.  I was good at it.  I didn’t want to kill people, hurt people, destroy things.  I didn’t try to do it.  But I protected myself, protected my men.  We did what we had to do.  We saved a lot of lives over there.  Now I’m just here.”

“And inside you, the motor keeps running, on and on and on,” I said, myself whispering now.  “And it’s eating you alive.”

He just nodded.  What else could the guy have done.

He’s quite the handful.  Always has been.  Yet character-disordered?  Cluster B traits?  Oh, sure, I could make the argument as well as colleagues could: the veteran’s longstanding difficulties, his interpersonal challenges, his “persistent unwillingness” to look inward and “fix” it, whatever that it might be, “tame” it, “reflect” on it, “soothe” it.

Unwilling?  Or unable?

Yes, he loves his energy, his adrenaline, his push, push, push into the world, now, again, again, harder.  He feels alive with it.  He feels real.

But he’s no fool.

He knows that we don’t cotton too much to such energy back here in the civilian world, even if we say that we like our boys or girls to be “Army tough”, Semper Fi.  You leave that out on the playground, child, you hear?  Run that out of you and then get back in here and get to work.

You go do your military thing, man, woman.  Run that out of you.  “Thank you for your service,” we’ll say.  Shoot, we’ll even give you a parade or two (the Fourth’s coming up, you know).

Then get back in here and get to work.

And we wonder why he turns to pain pills to ease the pain.  All that energy, we say, if he would just use it right, ‘tis a pity .

Use it?  Really?  Where?

You gonna put up with his constant edginess, Mr./Ms. Civilian?  You gonna give him that opportunity to punch that bag, run that ten miles, pump that iron–even if maybe you might lose an hour of work out of him to let him do so?

You gonna tell him he’s a good man, that even when he’s a handful, yes, even when you’ll exhale quite the sigh of relief whenever he’s bounces out to do whatever it is he needs to do “get that out of you, boy, go on, go, go, go!, you’ll tell him that  you’re so glad that he’s here, that you wouldn’t want him any other way?  (Well, all right, most times . . .)

They just want to be understood, you know, these men and women with that Army-tough, Semper-Fi drive, energy, passion.  They know they’re a handful.  They know they’ve got too many hormones and neurotransmitters hurtling through their arteries and veins, banging on the doors of their neurons as if there were no tomorrow, ordering every cell within the vicinity to “move this sucker, baby, and I mean now!”

They know they’re not “normal,” i.e., not like most of us on the remainder of the bell curve.  You think you’re gracing them with some eye-popping epiphany when you label them “hyper” or “emotionally dysregulated”?

Actually, I’ve found them to be quite a forgiving bunch, if you want to know the truth.  You can label them whatever, from my experience–just as long as you can smile and like them, give them the space they need, the passionate direction they need to allow them to burn up a few of them inner chemicals so that, maybe, tonight?  We could just chill a bit, you know?  Be friends?  Talk?

“Now, true,” he or she might then say, “I’ll do most of the talking, but . . .”

Please don’t blame them for their bodies’ chemical composition.  Please don’t abandon them to some poor spouse or some few kids who cannot deal with this all on their own, who are are just going to need a break every once in a while–and not just talking every few weeks here.

It takes a village, a village that’s willing to adjust its work schedules, willing to say up front “We understand.  We’ll work with you.”   Willing then to do just that.  I can’t help but wonder what would happen to those veterans’ “Cluster B Traits” if that were to happen.

Well, actually, I don’t wonder, but then . . . I’m one of those types, you know, unwilling to call pathology when I see it, unwilling to set limits that must be set in order for an individual to learn to function in society, after all.

Yes, indeed.  I am.

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