Reporting for Duty, Sir

With the permission of his family, I report, with much sadness, that another young veteran whom I have had the honor to serve died this past week. The cause of his death remains unclear, but all agree that it was not self-inflicted, and it does appear that he died suddenly and without suffering.

Ethan (not his real name) first came to my office a couple years ago. He was not in good shape. He had suffered a significant traumatic brain injury (TBI) from an IED (improvised explosive device) explosion while having served in the Middle East, and he had subsequently become hooked on opiates (painkillers). When I first met him, he was gaunt of body and of gaze. He had the distractibility that I have often seen in veterans who are struggling with the consequences of TBI, but his had a desperate edge to it, an irritation that appeared to be heading nowhere, targeting no one in particular.

How good it was, then, that he found Suboxone (an opiate-substitution medication) to be so hope-restoring for him. He filled out in body and in soul, and a smile took up permanent residence on the lower half of his much-less-lined face, a puckish one, I guess I’d say. Great word, puckish. Great smile.

He grew up in a semi-rural area south of Indianapolis. He once told me how to get there, and I realized that I had often passed the requisite landmark on Indiana State Road 37 during my many trips through the years down to Indiana University in Bloomington, where I had taught an undergraduate class. In fact, he was still in high school when I first began making that trek. It was a well familiar one to me, in other words, by the time his mother, who lived not far from that landmark, had already begun praying every morning, every night for his safe return home.

He did return home. But he was not whole. He knew it. His family knew it. Everyone knew it.

Ethan was working with two of our finest therapists at the Indianapolis VA when he came to see me, so he never had a need to share with me any of the worst aspects of his combat experiences. He did hint at them, though. I needed no more than that. His experiences of the War—both of what he saw and of what he had to do—haunted him daily.

Yet as time progressed—and even more, as he worked with his therapists—those haunting experiences receded in prominence, leaving in their wake the far-less-easy-to-treat symptoms of his TBI. Day-to-day detail often confused him far more readily than it had before deployment. Often he forgot where he was to be and when he was to be there—appointments, for example. Family did their best to help him keep track of everything, a challenge for them all. How many times did Ethan come into my office, once more apologizing for having forgotten something, sometimes an important something, sometimes not.

Then he met Robin.

Robin had had her shares of struggles also, but together they went on to make a life that, while not without its challenges, was nonetheless even more with its hopes, saturated with a love that kept a certain puppy-dog air about it, even as they faced together, head-on, all the Shakespearean “slings and arrows” that Life can bring any of us. They got married. They made plans to buy a home. Those plans fell through. They kept looking, envisioning for themselves a family that would be as safe as they could make it, as secure as they could love it.

Still, Ethan suffered, suffered from War like so many other thoughtful, good-hearted men and women with whom he had flown on that plane to Kuwait, with whom he had ridden into extremely-hot, extremely-volatile territories in vehicles that were, in spite of their advanced technology and their construction, still all-too vulnerable.

He knew that he suffered. Robin knew that. His family knew that. His therapists knew that. I knew that. Everyone knew that.

He continued to find Walmarts nerve-wracking. He still had to have a seat in full view of the door, wherever, whenever. He still had nightmares. He still had became leery of unseen powers in government, in society that could, at a moment’s notice—perhaps, just perhaps—take away from him all whom he loved, all that he had worked for.

Yet in spite of all that, recently he had been coming into my office with all the fervor of a country boy ready to start yapping away on a Saturday morning with a bunch of men, old and young, spread out in the back corner of the local McDonalds, solving the world’s problems over large cups of rapidly-cooling java.

It was his smile, though, puckish. Got me every time. It reminded me of the smile, the “I’m so tickled” demeanor of a fellow Hoosier from long before his time, one who had reigned over Tuesday nights on CBS at my house all my growing-up years: Red Skelton. Like Skelton, Ethan always looked as if he was just so taken with the punch line of the joke he was about to tell, he could barely contain his guffaws long enough to spit out the first words without being stopped by a string of giggles that would bring the audience—and even more, him—long past the verge of tear-stained laughter.

He was a good man, a young man. He had the heart of a Boy Scout rushing to walk the old lady across the street. He had the sense of honor, of duty of a soldier who, while still trying to be good, would learn how to harm, how to kill, if necessary, to protect those whom he loved, whether miles away or right next to him.

We had our regular appointment this past Wednesday. Without any notice, he, quite willingly, came and spoke to a group of my colleagues about his experiences as a patient at our VA. He was articulate. He was honest about his past struggles, his current memory problems, his hopes for a better future. My colleagues applauded him at the end of the discussion. After we had shaken hands after the meeting, he walked away with a smile about twice the size of the some of the country fields he must have run through when he was a boy.

He died the next day.

I had a chance to speak with his mother on Saturday. In her grief and complete disbelief that he was, indeed, gone, she still spoke of how excited Ethan had been becoming about Life, even as he had continued to struggle with the combat-related anxieties of the day-to-day. They had been planning for a family gathering on the day that he had died. In the preceding weeks and months, she had begun hearing in his voice a certain quality, a certain youthfulness that she had feared would never, ever return.

“So you were getting your boy back?” I said.

Her tears answered me.

Then she told me something quite extraordinary.

“You know,” she said. “Ethan had been telling Robin a lot recently that his dreams had been changing. He kept on having these dreams, these feelings that he was to become a guardian angel.”

You can’t make these things up.

Ethan was not an imposing man, yet neither was he a reticent one. Even as he displayed that puckish smile over and again, he also displayed a certain resolve, a certain protector-warrior sense, even if only in glimpses, that reminded us all—that reminded him—that he was still ready for duty, ready to assume a role that he loved, ready to face again, if necessary, a violence that would perhaps destroy him, but that would not—would not—destroy those whom he loved.

War, with its horrors and realities, did try to destroy his tender heart. It did leave its wound in that heart, its permanent reminder of what had been lost, of who had been lost. Yet along with a tender heart, War found a determined heart. That, War could not take away, in spite of the nightmares it had implanted in him, in spite of the memory and the focus it had robbed him of.

I leave it to everyone else to decide as to whether there is indeed some Heaven somewhere that serves as a place of further, dutiful service for one who had so faithfully tried to fulfill such service in this life. All I can say is this: if anyone—anyone—had the heart of an angel and the resolve of a guardian, it was Ethan. If he has indeed reported for duty, God has indeed already sent him out on his first of many, many missions.

May he rest in peace.

Oprah and Monday-Morning Quarterbacking

“Doc, Monday was probably one of the worst days I’ve had in a long time. A long time.”

I’ve written about this combat veteran several times before, e.g., in Buddy, Got the Time? and Conical Combat Linkages. He’s older than many of the men and women I usually see, a veteran of an earlier conflict, smart, insightful. He’s been doing much better overall, so his statement took me by surprise.

“What happened?” I asked.

“I had some of the worst nightmares I’ve had in I-don’t-know-how-long,” he replied. “And it was as if I just couldn’t get the War out of my head all day, no matter what I tried to do to distract myself.”

“Any idea what brought all that on?”

A brief pause, then “I think some of it may have had to do with the Father’s homily on Sunday about good and evil; for some reason that got to me. But when I asked myself that question, believe it or not, the best answer I could come up with was that it was that Jeep commercial during the Super Bowl.”

Sidebar and true confession: I’m neither pro nor con American football. I was never that much of a fan growing up, and I know only enough about the game to keep myself from gross embarrassment when discussing the topic. Whenever the Indianapolis Colts are doing well, I do feel under a civic obligation to take reasonable notice, but otherwise football season is no different from pre-inventory shopping season at the local Walmart as far as my day-to-day life goes. (Although yes, I confess: as a former Bostonian, I do have to keep up with the New England Patriots every now and then, whether out of nostalgia for the old days or out of the national pastime of hating Tom Brady “just because,” I can’t quite tell.)

Ergo, given that I didn’t have much of a stake in either Baltimore or San Francisco, and given that I find Life moving forward fairly easily whether or not I take note of Beyonce in this world of ours, I was napping during THE Game.

I had seen something somewhere, however, about some commercial featuring Oprah having been THE Super Bowl commercial of 2013. I think it had even registered with me that it had had something to do with veterans.

The week’s news about combat veterans, however, whether mainstream, independent, or blogged, had been almost exclusively about the murder of OEF/OIF combat veteran and renowned sniper, Chris Kyle, by another combat veteran whom he had been trying to help. From the Right, the Left, the Pro, the Con, from all points in-between, it had been all-Texas-shooting, all-PTSD, all the time.

Not Oprah.

“I’m afraid I didn’t pay that much attention to the game,” I therefore confessed. “What was the commercial?”

“God, it was . . . I’m not really quite sure why it hit me like it did. It was a long commercial, heavy orchestration, the whole bit. It was all from the soldier’s perspective, coming home. But then–I don’t what it was, Doc–but at some point, one of those scenes, the music, everything: I wasn’t in my house. I literally was hearing my son’s footsteps, watching him running toward me, yelling, ‘Daddy, Daddy!’ Back then, when it originally happened, I was standing next to this guy, about my height. Our hair was short, his and mine, about the same color, and both of us were dressed in our fatigues. So for a moment, my son wasn’t quite sure which one of us was his Dad. But then he just grabbed me. Doc, I . . . they were his footsteps I was hearing. His.”

For a few seconds, both of us were silent.

“And then,” he continued, “this commercial started talking about how we’re all in this together, you know, for the veterans, yadda-yadda? And I almost got sick, literally. How many times have I heard that through the years, ‘we’re here for you,’ and then nothing, just talk. It was as if I were in two worlds at the same time, one back then, one now, feeling how important it all was, my son, the military, yet at the same time feeling how ridiculous all those empty promises can be, over and over, sending us off to War, expecting us to be fine afterwards, don’t complain, ‘thank you for your service,’ blah, blah.

“Then Sunday evening, in my own home, all of a sudden this women next to me brought me back to reality, asked me–I’m not kidding you–‘Where are you? You’re not here, are you?’ And I just turned to her, looked at her for a couple of seconds, and said, ‘No. I’m not.’ That was it. And then I was back. And then Monday came.”

He paused, and then he finally said, “I’m so glad that I’m feeling better, Doc. But this PTSD stuff is terrible. I don’t know how else to put it. Terrible.”

After we had finished speaking together, I Googled the commercial and watched it. He’d been right, of course, about the heavy orchestration, perfect for the setting: the violas and cellos leading the way, giving the whole couple minutes of film all the necessary lower-register depth, with the French horns making their entrances at the appropriate times, at least in three parts, sometimes four.

And Oprah was at her best as well, ever dramatic and ever genuinely so. I had no doubt that she spoke every word from her heart, trying to express for “all of us” how we want to be honest, yet hopeful; upbeat, even as we each know that we dare not be that too strongly, lest we dishonor, lest we, even worse, disavow.

I couldn’t help but think of another meeting with another combat veteran, only days earlier: with Porthos, about whom I’d written in my last entry, To Remember, Not Relive. As I always do, I had read with him the entry. About halfway through, he’d stopped me.

“Doc,” he’d said, quietly, yet, as always, intensely, “that’s OK. Really. I want you to publish it, but . . . but I think I’m going to need to read it by myself, later. I . . . I just can’t go back there now. I want you to put it out there, but . . . I need to come back to it later. Thank you. Is that OK?”

Of course it had been.

The next day, Porthos had then texted me: “It was a hard night. I hardly slept. It was your blog, Aramis, everything. Thank you so much for writing it, but it’s just so hard. Please don’t be upset. Thank you for understanding.”

A few days later, I learned from my “statistics guy” that I had, in the previous week, seen sixty-five patients within the course of five days. Thankfully, most of those men and women had been doing fairly well, moving on with their lives now that they are on Suboxone, the opiate substitution regimen.

Some had not been, though. Many had had to change scheduled appointments because their babysitter hadn’t shown up; or because their parent had had to work that day and couldn’t watch their child; or because their boss had changed his mind and had refused to let them off for their appointment, and they can’t afford to lose this job, understand, because it had been so hard to find; or because they had had to get to that job interview and hope that this one will work out, even if the pay is a pittance, because it’s at least something; or because the bus had broken down across town and now they’re going to be late for work if they have to wait for their sister or boyfriend to pick them up after the latter gets off work; or because . . .

But then there had been the guy who had claimed that his meds had been stolen. Now some programs have found it quite easy to manage such situations: if your meds are stolen, too bad, you signed an agreement when you started, and that’s the way it goes, so you’re just going to have to wait until your next scheduled time, so here are some side-effect medications, and be sure not to start using again because then we’ll have to re-look at your whole program, and don’t forget that we know those Suboxones are going for $20 a strip on the street, so how are we so sure that they were really stolen anyway, and . . .

But then, of course, there was also the fact that the guy probably shouldn’t have tried to get back together with his wife, since she had been sleeping with another guy, after all, the one who may in fact have been the father of “their” last child, but since that guy always did have a tendency to smack her around a bit if she stayed around him too long, my guy just couldn’t refuse to take her back, but then he’d had it that night and had put his bag outside the door of the apartment just as he stepped back into the apartment to give his older child a hug, but then his wife started yelling at him again and said the one thing that always sets him off and so he said the one thing always sets her off, and then she screamed for him to get out, but by the time he had turned around the bag was gone, but then why did they live in that junkhouse of an apartment building anyway, you know, right next to the stairs, so couldn’t he have just run after the culprit, like anyone would have who had an ounce of sense, but then she had grabbed his arm as he’d yelled at her to stop and the kid was crying and he knew that she’d call the cops if he tried to pull her off because that was what she was saying that she was going to do if he walked away, but then . . .

But, of course, that all could have been some big lie, because you know how these addicts are, and Suboxone is $20 a strip on the street, and . . . well, everyone knows that I’m too nice, you see. There are no dearth of people who are willing to tell me so, in fact. Sometimes right to my face. Only because they care. About appropriate patient care, of course.

But then, as had been reported to me just the day before, a quote from a psychiatrist in another state about working with military personnel and combat veterans: “they’re all just ‘entitled’ anyway, these guys, as if someone owes them something. So what do you expect?”

Monday-morning quarterbacking: how easily it comes for some. How devastatingly for others.

Sometimes I am amazed at how, even with the best of intentions, whether via stirring commercials, well-meaning blog posts, or anything else, we can both thrill and injure those whom we admire, encourage, care deeply about. Nothing is straightforward about War, of course: before, during, after, no matter who the victor, no matter what the spoils. Even as we remember that, we try to forget, and even as we try to forget, we remember.

I can say this, though, from my Monday-morning armchair, clueless as I am about football, even more clueless as I am about the destruction of property and soul that War brings: all men and women who believe they are called to protect others, even at those moments when it is unclear whether anyone is being protected or even wanting to be protected; all those who are both ready to die for the ones next to them, yet also ready to wonder whether they should hold off just a few more seconds, to make sure that car’s driver is not a “bad guy,” to make sure that what that kid’s pulling out of his pocket is just his hand, not an explosive device; all those who press two fingers to their lips and then press those very fingers onto a computer screen that transmits the images of those fingers across land and sea to a partner, a parent, a child who is doing the same, only in a room that, thankfully, will not be at risk of a mortar attack any time soon–all such men and women are “entitled,” period, end of story: to our respect, whether borne via Jeep or not; to a living wage at an honorable job; to a second chance to get it right, maybe even to a fourth or fifth.

When one has earned what one is due, one is not “entitled,” after all. One is “entitled to.”

Big difference.

Any quarterback can tell you that.

I suspect Ms. Winfrey and I easily–and unashamedly–agree.

Dona Ei Requiem

Late last week I received a call from our Emergency Department, directly to my office phone.

This is not usual.

“Doctor Deaton,” a voice greeted me, the edge therein more than a little palpable.  “This is the charge nurse in the ER.  One of the doctors has a question for you about Suboxone.  Can you speak with her?”

This too is not usual.

It turned out that a young man had appeared in our emergency room who was in great abdominal pain.  He had been on Suboxone through a private doctor in town, and when he became no longer able to afford the medication, he had to stop it, precipitating withdrawal symptoms.  The situation was even more unusual, though, in that the man had only been on a relatively small dose of Suboxone, yet was having quite serious abdominal symptoms.  By the time the doctor got to me on the phone, matters had become so difficult that, shall we say, help was rapidly needed in the ER to keep matters under control. (I heard the call for it over the hospital loudspeaker.  Never a good sign.)

The young man was hurting, and apparently he was not a happy camper.

Eventually he was admitted to a medical floor of the hospital, from which another doctor called to ask me to consult in a few days about the Suboxone.  When I did call those few days later, I learned from the young doctor caring for the man that “he’s got a lot more problems than just Suboxone.  His wife says that he’s really got problems from the war, and I’ll tell you:  he really looks like he’s suffering over here, too, especially at night.  I think he may need some time on the Psychiatry service.”

Fortunately by the time this young man had arrived at my office, much had improved.  He was back on a good dose of Suboxone.  He was taking medication both for his nightmares and for his mood swings.  He was living in a much calmer world.

Sitting there before me, in his late twenties, he was the paragon of the “good old country boy”: on the slim side, but still with a military man’s body, along with a respectable blotch of hair on his chin and a respectful grin on his face that would have made Andy Griffith proud.  Obviously, he was feeling much better.

“I’m back on the Suboxone dose I was on before,” he told me.  “It’s a lot better.  And the new medicines are helping, too, already.  I’ve slept better these last couple of days.”

Matters had been worsening for a while, long before he stepped into our hospital for the first time that previous week.  He is several years out of his last deployment.  Fortunately he has been able to work effectively, but he’s been just as fortunate to have understanding superiors who have genuinely liked him and appreciated his hard work.  Apparently he has not always been a pleasure to work around.

Similarly, he is fortunate beyond belief that he has had the family he does.  He married his high school sweetheart quite young, and their first child quickly followed. His wife has stuck with them through thick and thin.  His parents have been extremely supportive of the couple, and they remain so to this very day.

Still, he had had opiate problems long before his enlistment.  He did become clean for his first few years of service, but after an injury in the field, he returned to the medications, first as prescribed, but later, especially when he returned home, as a way to deal with all the demons that were haunting him.  He finally got himself to a Suboxone provider in the community, and matters changed for him.


“What was your MOS?”  I asked him.   (MOS is, essentially, his job in the military).

“Infantry,” he told me, sheepishly, yet still pleasantly.  “But I spent most of my time on transport.  We were ‘outside the wire’ all the time.”

With that final sentence, his whole tone, his whole demeanor changed.  When a soldier or Marine is “outside the wire,” he or she is outside the (very, very relative) safety of the operating base and out in the world of curious kids begging for chocolate bars–oh, and IED’s (improvised explosive devices) ready to destroy everything in range, including you.

The change in him was dramatic.  I paused.  He suddenly looked about ten years younger, far more vulnerable, far less sanguine.  He was staring down at the carpet–or through a tunnel of time, I’m not sure.

“Bad?” I finally say.

He nodded, said nothing.

“How many did you lose?”  I asked, trying to keep my voice at a respectful quiet.

“Four,” he finally whispered.  “One . . . one was my best friend in the world.”

“Who was he?”

He told me his name.

“Where’d you guys meet?”

He looked back at me, a slight smile returning.

“We were in AIT together (Advanced Individual Training, where one goes after Basic Training to learn one’s job).  We just hit it off.  He was a farm boy like me, you know, just simple, no big deal.  He was so funny.  We’d laugh our heads off.  He . . .”

He looked back down, his smile suddenly retracted into his face with the breath he’d drawn in, held.  It appeared that his body was betting that if he just didn’t move, that tear at the end of his left eye wouldn’t dare move either.

I said nothing.

As he began breathing again, he looked back at me.  The tear had already headed points south.

“He was just twenty, Doc,” he barely whispered.  “He was a lot younger than me.  He was just twenty when he died.  He . . .”

Our eyes remained padlocked on each other’s.  Ever so slightly, he began to shake his head.  As he did, he bit his lower lip–but the tear in the other eye paid no heed.

“He never even lived, Doc.  He never even got a chance to live his life.”

This was not, of course, the first time I’d heard that sentiment.  Yet somehow, coming from him at that moment, so honestly, so sincerely, so achingly, almost as if Jim Nabors had transported his Gomer Pyle across time to sit right there in front of me, but this time with no “Howdy, Sergeant!”, no “Gollllllllllly!”, just a farm boy’s face, trying, begging to understand.

“What happened?” I finally asked.

“He was in the Humvee right ahead of me, inside.  Then all of a sudden, everything exploded.  The gunner on top just blew right off, the gun and everything, gun landed right on top of the guy in the hole that had just opened up.  I ran up, and . . . and my buddy still had a pulse in his leg, I could feel it, but they . . .  they Med-Evac’ed him but  . . . he never made it.”

We were staring at each other, but the padlock on our gaze had fallen off.  The chain connecting our eyes just hung there, limply.

“The NCO,” he continued, “we got a tourniquet on his leg in time.  He lost it later, but he made it.”

Neither of us said a word.

“Does anybody,” I finally whisper, “understand what’s going on inside you?”

Our interocular chain dropped, he briefly looked down, smiled, and then looked back.  “Yes,” he nodded.  “My wife.  She knew him, too.  He and I were stationed together.  He lived over in the barracks, and we had our own apartment, and he’d come over every weekend and stay with us, and . . .”

He stopped, pursed his lips, seemingly sending another telegram to the eyes to lay off.

Obviously they didn’t receive it.

A few seconds, nothing, then,

“She really loved him, too.  I was his big brother.  He was my little brother.  She . . . she knew he was dead before I did, heard it on the news.  She was freaking out.  She knew we were joined at the hip.  She . . .”

A tear was nestled in the bush of hair on his chin.  He was so sincere, so genuine.  Gomer himself never looked that genuine.

“He was only twenty, Doc.  Twenty.”


“I don’t want to live like this any more, Doc.  I’m tired.  I can’t do it.”

Now it was my turn to smile, ever so slightly.

“You want to make it right for your family.  For his sake.  Your kids would have played with his kids.  Now you’ll just raise your kids right and remember him, in his honor.  True?”

Slowly the smile arose on his face.  It was still slight, but the eyes–they had brightened ever so slightly.

“Thank you,” he whispered.  “I’d never thought of it that way.  That helps.  Thank you.”

After he left, I decided to do it.  After all, I cannot remember the last time I had a full name.  I went to Google.  I found him, he who, unlike Harry Potter, was the boy who never lived.

I looked at his picture, smiling brightly, his beret just at the right angle to add a year or two to that face, that . . . young, so full-of-life face.

As I looked at that young man’s face, I saw the face of my daughter’s boyfriend, of her buddy beaming from the stage of his Rent production, of her boyfriend’s roommate who could win at least a silver medal in whatever “sardonic smiles” competition he might enter, of the young man across the street whom I’ve watched grow up since he was in kindergarten.

I couldn’t stop looking at it.  I couldn’t help but imagine the three of them, this young man in the beret, my patient, his wife, all laughing their heads off.

On the way home, it hit me, a memory of my own.

Twenty-five years ago, the minister and his wife of the church I was attending, the church at which I met my wife in the choir, lost their six-year-old daughter to cancer.  The congregation was devastated.  The funeral was huge, unforgettable.

From that time, what I can least forget is one song, the choir accompanying a duet of two sopranos, one the wife of one of my law school classmates, the other–my wife, a voice major from Michigan.   It was Andrew Lloyd Webber’s Pie Jesu, which at that time had just recently debuted.

Back in the present, when I got home, I grabbed my phone and headed straight to Spotify.  There I found it, the original recording of the song with Webber’s then-wife Sarah Brightman and the boy soprano, Paul Miles-Kingston.  I played it.

It was as I remembered it.

Pie Jesu means “kind Jesus,” and it forms part of the old Latin funeral, or Requiem, Mass.  Webber takes those words and combines them with another phrase of the Mass, the Agnus Dei, the “Lamb of God,” to create a seamless hymn of memorial:

Pie Jesu, pie Jesu
Kind Jesus, kind Jesus,

Qui tollis peccata mundi
Who takes away the sins of the world.

Dona eis requiem
Grant them rest.

Agnus Dei, agnus Dei
Lamb of God, Lamb of God

Qui tollis peccata mundi
Who takes away the sins of the world.

Dona eis requiem sempaeternum.
Grant them eternal rest.

To this day, it remains the song I recall immediately when contemplating the death of one who has died too soon, one who never even had the chance to live.  It is the song I recalled as I looked at that smiling face under that dapper beret.

We live in an odd world.  Here they are, two farm boys, both laughing their heads off as they make their dads proud when they go into the military, honorably, bravely.  The last thing on their minds would have ever been some high-falutin’ song sung in Latin, of all things, Latin.

Yet for centuries we have all mourned the loss of those who never had the chance to live, the Roman church through its Mass, the country Baptist church of this young man’s childhood through its hymnody, a group of Iraqi women who cry over their sons, their daughters who never wanted to harm anyone, who got caught in the crossfire, wrong place, wrong time, through the soft sounds, the wails of their songs.

All of us are united.

And today, the song weaves its way around two country boys.  To say goodbye to one of them.

Creator God, dona ei requiem.  Grant him rest.  Amen.

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.

One More Time Around, With Feeling

Often Thursdays are quieter days for me.  I only began working them in January, when I began working full-time at the VA; consequently not a lot of appointments have found me, so to speak.  The Joint Commission, the major hospital accreditation organization, was at our facility this week, but my section had finished its part of the evaluations, so in a sense, mid-morning that day was a perfect time to catch up on notes–or, in the alternative,  to stare mindlessly at a computer screen, wondering whether I have ever really slept adequately in my entire life, come to think of it.

“Hey, doc!”

It took a few seconds to shift my computer monitor reveries toward my doorway.  There stood a man I hadn’t spoken to in at least eighteen months, maybe more.

“Well, look at you!” I retorted.  It was indeed good to see him.  There’d always been this sotto voce warmth between us, as he would never, thank you very much, ever let himself actually show me too much excitement in this world.  His exterior had never been nonchalant, nor indifferent, nor certainly aloof.  It had merely been enigmatic, with a protective skin surrounding his psyche that certainly was thicker than paper, but not even close to being thicker than stone.  In the past I had seen his inner fire, true, but only in his eyes–and occasionally in his “you-know-I-could-blow-this-popsicle-stand-any-time-I-wanted-to” half-smile.

“Are you busy?”  he asked, no half-smile to be found.

“Not at all.  Come on in.”

“You sure?”

This was not some “after you, no, after you” comedy routine, believe me.  He was being quite deferential–yet seemingly quite uncertain as to whether I’d follow through with what I’d just said.

“Of course.”

He eased himself into my office, carefully closing the door behind him, and lowered himself into the chair next to my desk, adagio, poco a poco.

He’d gained some weight since the last time I’d seen him–not a lot, but he was admittedly heading into the stocky range, though quite admirably so, if I do say.  He had the same wire-rimmed glasses.  His hair was not much longer than it had been before, not military-issue, but not long by any stretch, more like “length of hair that would grant ready access into any middle-class home to check out a broken toilet.”  Come to think of it, that would have been a great title for a picture of him sitting here: Plumber in Blue.

How different he appeared from the man I’d first met in Spring 2010.  I first noticed him as he was walking down the hall with another physician for an intake, far thinner than he should have been, his countenance this odd mixture of the enigmatic and the panicked.  Within hours he was standing at another doorway of mine, this time solely panicked, pleading with me to speak with him.  It had been the heroin.  He couldn’t take it any more, he told me.  He’d already ruined his life (so he thought), for the authorities had him nailed.  His daughter’s mother wouldn’t let him see her.  He was just wanting all the dope-sickness to stop, all the pain.

But no talk of The War, understand?  He made that quite clear, thank you very much:  off the table, nichts.  Maybe one day, but . . . no.

“It’s been a while,” I say to him this week, hoping that he would pick up that I genuinely was glad to see him.

“Two years this fall.”

“When did you get out?”

“A while ago.  I haven’t used, though.”

This was anything but an innocent statement.  He was wanting me to notice, to be proud.

“Of course you haven’t.  You’ve been wanting to make this work, from the beginning.  We both know that.”

His smile flashed by so quickly, I’m still not sure I saw it.  He looked down and then made an attempt at a deep breath.

“I need your help.”

For the life of me, I couldn’t figure out why he’d be as reluctant to ask for it as he was seeming to be.

“What’s the matter?”

He filled me in on what had happened since I’d seen him last.  He had had to pay a price for some mistakes he’d made before we first met, a high one.  We’d talked about that a lot before he’d had to summarily disappear that fall, so I was familiar with the basics.  Suboxone had made the difference for him that summer, though.  But even then he’d known that he’d never get any after turning himself in.  He was right, of course.

But he hadn’t used.  That said it all, right there.  Not that there had been any dearth of opportunities where he had gone to do just that.  Don’t ever fool yourself on that account.

“I need to get back on the clonidine.  I ran out, and they won’t help me get any.  I’m going crazy without it.  You don’t understand.  Everybody around me’s using drugs.  I could have whatever I wanted.  I don’t want to do that, you’ve got to believe me.  But my nerves are shot, doc.  Shot.”

I’d never heard his voice that halting.  I’d never seen him that close to tears.

Clonidine is an old blood pressure medication that works by decreasing the body’s adrenaline responses.  The theory has it that taking medications like it will decrease the adrenaline surges associated with combat dreams, reducing the intensity and ferocity of the nightmares.  Sounds a bit hocus-pocus, I know, but it and a cousin medication, prazosin, have proved quite successful for these very tasks.

“Of course.  Be glad to.”  I hesitated, but I knew that eventually we were going to have to open the topic.  “The nightmares back?”

His jaw tightened, more as self-precaution than as warning.  Shifting his gaze to the floor, he nodded.  “As bad as they’ve ever been,” he whispered.

Might as well go for two, I thought.

“Have you seen your daughter?”

He was glad that I’d asked, I could tell, glad that I’d remembered her, remembered how her absence chipped away–no, sliced away–at his heart daily.  But it took a few swallows before anything could come out.

“I can’t even get her mother to answer my calls or texts.”  A couple more swallows ensued, eyes still downward.  “I deserve everything I’m getting, you know.  I messed up her life, my life, everybody’s life.  I just wish . . . she’d give me a chance to show her I’m trying.”

For some reason I felt compelled to scoot my chair closer to him, still a respectful distance, but one that felt more, what, real.

“You don’t have to go living like this, you know,” I said, consciously trying to be as gentle as I could.  “We can’t just make The War go away, but it can be better than this.”

For a few seconds, nothing, then “I can’t.  I just can’t do it now.”  Gone was the certainty of the past, though.  In its place, a familiar sound: words saying no, a voice saying please don’t take that answer.

“Should we think about getting you back on Suboxone?”

His head jerked up, and his eyes grabbed mine, seemingly clutching for dear life.

“I can?”

Had I not been so dense at the moment, I’d have picked up the cues by now.  But dense I was, so I was still at a loss to explain his reticence.  After all, he’d always been reliable as a patient.  I’d never worried about diversion.  Suboxone stopped his cravings and stabilized his moods.  We stopped it only because he had to leave the area.  So why would he ask that question?

“Of course” was all I could manage to say.

In the end, we both determined that it was unlikely that he’d be able to take Suboxone while living in his current housing.  Within a month, however, he would be returning home, and we could start the medication back then.  He felt that the clonidine would hold him until then.  When I wanted to discuss any psychotherapeutic/counseling services, though, he bristled.

“I’m not going back and having people tell me ‘drugs and alcohol, drugs and alcohol.’  I know I have a problem with drugs and alcohol, but that’s not the real problem, and I can’t seem to get anybody to get that.”

Only then did it dawn on him what he’d just done: he’d admitted his problem with PTSD, its primacy in his life, and, to his chagrin and yet relief, his need for treatment.  To someone who gets that.

We stared at each other for some fifteen, twenty seconds, must have been.  His eyes began to moisten, but I could see the fire reigniting within them, even if gently.  There, they seemed to be saying, you’ve gotten your satisfaction, your admission.  Fine.  So don’t push your luck and ask for tears as well.

Understood, soldier.  Understood.

We briefly considered various options, finally agreeing that an intensive, dual-diagnosis program might be his best option.  I warned him that our local program was anything but for lightweights, but assured him that the leader was always willing to slow matters down when necessary.  He seemed genuinely relieved.  His eyes were still moist.

Soon we made our arrangements to get together after my time off next week.  He was in better self-control, so he quite rapidly bid me goodbye, promised to see me in a few, stood up, turned toward the door, move on out, baby, move on out.  As he did so, I offered him my hand–more like required it–and he ever-so-briefly paused to shake it dutifully, his gaze basically still fixed toward the door and his imminent liberation.

Then I made a conscious choice.  I didn’t let go of his hand.

He turned back to look at me, puzzled far more than irritated.  One more time our eyes met.

“It’s good to see again,” I said.

He breathed in deeply, I suspect still plotting out the mad dash for his escape.  But then suddenly he calmed, regained the lacrimal glimmer in his eyes, and his been-there-done-that half-smile returned.

“Thanks,” he whispered.  A brief pause, and then “It’s good to see you, too.  I don’t understand hospitals, so I had no idea how I could get back to you.  I’m . . . I’ll see you in a couple weeks.”  Within seconds, he was gone.

Two things, one my cluelessness, one his.

As to me: at the time I had no idea why I scooted forward or why I held on to his hand.  This is a bit dangerous for a therapist.  In a way I confess this precisely to keep myself on the straight and narrow.  I can’t save this man.  I can’t even give him a nanosecond’s thought that I think I can.

Yet at the same time, if a part of me doesn’t in some way reach out and say, “it’s good to see you,” he’ll never know that it is.

And he needs to know that.  More than anything.

For ultimately it is his cluelessness that is the problem.  In my cluelessness, my constant wondering “why is he so hesitant?”, I forgot his cluelessness, his day-in, day-out self-lie: nobody would ever in his or her right mind reach out to me.   I’m a crazy combat vet.  I thrash around at night, moaning on the good ones, screaming on the average ones.  I’m a junkie.  I’m a worthless procreator.  I’m a worthless son, a worthless brother.  Better men than I are dead.

It wasn’t just hospitals that this man didn’t get.  It was me.

Plumber in Blue.  I was so glad to see him.  You cannot even begin to know how hard he is trying.  He is indeed surrounded by drugs 24/7.  Opiate addiction changes most people’s bodies, makes them a hunger-machine for a fix, causes every single neuron south of the neocortex to demand–now, baby!–one more swallow, one more snort, one more injection.  Yes, clonidine will help him, but believe you me: what’s getting this man through this–what is going to get this man through this–is the inner soldier who did not die over there, who still wants to live out of respect for those who no longer do, who wants to be so much more than a sperm bank, who wants a family, a life, honor, hope.

It was good to see him.  Round Two has begun.

Inside, Outside, Anywhere

Last Sunday, the New York Times Sunday Magazine ran an article entitled “Post-Traumatic Stress’s Surprisingly Positive Flip-Side.”   It was an interesting piece describing what’s called “post-traumatic growth,” a concept exploring how one can grow more resilient out of an experience of life-changing trauma.   The piece described a program that the Army is implementing that encourages troops to approach difficult situations with an eye toward viewing the situations as neither good nor bad, but rather as opportunities for change and positive outcome.

In addition, this past week I met a veteran who had survived significant combat trauma and who, as a result of physical injuries he had sustained, developed an addiction to painkillers.  It does appear that with the use of Suboxone, a modern opioid substitution agent, he will gain a new chance at living life without resorting to the illicit use of substances.

The veteran had already undergone standard treatments for PTSD, including the “prolonged exposure” therapy that many practitioners are now using to help combat veterans process the emotions they are experiencing as a result of their combat experiences and, at least to some extent, to help them integrate those emotions and their associated memories back into a coherent-enough narrative of the veterans’ lives.  He had found the treatment to be helpful, and he told me that he felt that he was “doing fine” vis-a-vis his war experiences.

He was a burly, friendly chap, although understandably embarrassed by the extent to which the opiates had become the center of his life.  He had gone into sales and had been successful, although he had found the whole rigamarole boring, truth be told.  He certainly had a saleman’s air about him:  focused on the pragmatic, with a certain bottom-line no-nonsense.  He has his demons, to be sure:  his addiction did not arise from nowhere.  Yet I had a sense that his usage stemmed more from boredom–as well as from the desire to avoid withdrawal symptoms–than it did from terror.  We’ll see what the future brings.

It is an intriguing question, though, one that is even now confounding, yet captivating researchers:  why do some veterans leave combat with extensive, long-standing psychological sequelae, even after the “best” of “best-practice treatments” (essentially everyone has challenges in the short-run), while others do not?  Is “resilience” and ease of “post-traumatic growth” a state to be learned or a trait to be appreciated?  Do “some got it and some don’t?”

Certainly I don’t have the answer, and I cannot be too bold generalizing from my experiences, given that mine are clinical experiences, i.e., the people whom I meet are already suffering.  I do find myself wondering, though, what might be the relevance of an old Jungian concept that became popularized through the Meyers-Briggs, a common measure of personality typing: extroversion versus introversion.

Colloquially, these terms are about sociality, the life-of-the-party versus the wall-flower.  In this sense I’m describing, though, the words deal more with the cognitive than the interpersonal.  Extroverts “think,” if you will, from the outside-in, while introverts do so from the inside-out.  Extroverts make sense of the world initially (and preferentially) via looking outward, making things happen, seeing how matters fit or do not fit together.  Introverts, in contrast, make sense of the world intially (and preferentially) via looking inward, contemplating, rehearsing.  Extroverts are capable of inner contemplation, and introverts are capable of external focus.  Yet each has his or her major and minor.

When trauma hits extroverts, it hits them in their minor.  The memories, the emotions:  they haunt and they demand.  Yet they reside in “foreign territory,” if you will.  The extrovert keeps being drawn back inward to a place that never did feel that comfortable.  When they work in therapy, they seek to be freed from all the inner focus of trauma so that they can return more reliably to the familiar world of their major:  the world out-there.   Extroverts find hope in escaping the War’s clutches and going back “home.”

For introverts, however, trauma bores right into their major, colonizes an inner world that had always been their home, making what had once felt so comfortable (or at least familiar) so very, very uncomfortable and unfamiliar.  Focus on action, even on internal action (e.g., “stepping back” and re-examining emotional and cognitive responses), is fine as far as that goes, but it always seems somehow beside the point.   Introverts find that the War has taken up residence in their “home” and that therapeutic “escape” takes them away from where they had once felt most real.

Extroverts have a point:  the world “out there” has far more options for freedom from War’s memories and pains.  Yet for us introverts, “out there” just isn’t home.  We can live there–and even live there rather successfully.  But we are always expatriates.

In my role as a Suboxone provider, I see many combat veterans who have completed “standard” PTSD therapy and who have benefitted greatly from it, usually with far less emotional upheaval and far more insight into their pain.  Yet in a real way, the thoughtful, internal ones, the ones who always prided themselves in their capacity for looking inward, not as navel-gazing (these are military folks, after all), but rather as preparation for action:  they still struggle.  “Home” has been invaded by an interloper who has taken these veterans’ most prized possessions–their memories, their emotions, their linkages between the two–and forever altered them, not only distorting them, but also robbing them of the healing, restorative power they had once had.   Looking outward may help, may even help greatly.  But sorry, extroverts:  ultimately your restorative, out-there “home” feels more to us introverts like a consolation prize than like a gift.

Perhaps because my style is the introverted one, I find myself so much more “captured” by the combat veterans who struggle with their inner demons within their beloved, internal home.  In a very profound way, I feel the adage:  there, but for the grace of God, go I.

It may not  be the most resilient of options, but it’s what I have.  May both introverted combat veteran and I “grow” all the same.

Will the Real Me Please Stand Up?

He came in without an appointment, first to our Access Center, then directly to me.  It was time:  he had to get off the dope.  He couldn’t live like this any more.

When persons first come to me in my role as the doctor who provides Suboxone, the remarkable medication that helps many opiate addicts find a second chance at life, they are never in good shape.  To start on Suboxone, one needs to be in the early stages of opiate withdrawal, which is anything but a fun state:  gastrointestinal disturbances (nausea, diarrhea), temperature dysregulation (hot and cold flashes), severe muscle cramping–in short, a generalized state of ick.  None of my patients first encounter me with a bounce in their step–with the ill-temper of a bouncer, maybe, but never with a bounce.

He presented as quiet, even a bit timid.  I could still feel the Marine in him, though:  the occasional flash of the “can we get the point, please?”  The disgust of a drill sergeant with a new recruit (i.e., himself) who just can’t seem to get it.  But all things considered, he was respectful and cooperative.  He merely wanted all this crap over with.

Good news:  since then, a lot of the crap is over with.  He is feeling better.  Physically.

Also since then, I’ve heard from others that he has not always presented himself thus.  He has in the past had a far more confident air about him.  He has made an impact on people that has been quite lasting.

Eventually I asked him about this.

“You know,” he told me, “I’ve thought a lot about what you said in the beginning, about how a lot of guys feel as if a part of them died over there.  That’s what happened to me too.  Ever since I’ve been back, it’s as if I’ve been trying to create this new person for the world, somebody who people would like, somebody who doesn’t get all angry, who’s put together, confident, ready to take on the future. Lots of people think that’s who I am.  So I keep trying to make that guy–but it isn’t working.  The foundation just isn’t there.  I keep asking myself what I’m doing wrong, and I can’t come up with any answers.  I don’t know what to do.  I’m lost.”

“How has love been for you?”  I eventually ask.

He drops his head. “You wouldn’t believe the number of women I’ve dated since I’ve been back.  And I’ve just been awful.  I reach a point, and I  get bored, and I disappear–well, all except my current girlfriend, though.  She’s stuck with me through all this drug stuff, encouraged me.  She really loves me.  I say I love her, but I’m afraid I don’t.  I’m afraid I’m going to hurt her, really badly.  I don’t know if I’ll ever be normal.  All I want is a family, a house, a career–to help people.  That’s it.  But I’m so self-destructive.”

Fortunately he has not recently had any thoughts of suicide.  But he has indeed more than once contemplated swallowing a gun.  It’s serious.

His story is an all-too-familiar one.  His best friend in the world was blown up right next to him.  He shouldn’t be alive–literally.  In any previous war, he’d have become another name etched on a memorial.  His picture is right next to the dictionary entry for “survivor guilt.”

Yet that’s not all he is.  He is a guy, for example.  We guys are not that hot at closeness.  We know we want it, but we’d all prefer that we wouldn’t have to get all caught up in that mess, you know what I mean?  Come on, women in our lives:  you know the drill, don’t you?  I mean, we’re still here, right?  If we didn’t want to be, we wouldn’t be.  Right?

He’s also a guy on the verge of life.  A talented guy on the verge of life.  You know, I’ve been able to feed and clothe my family off the notion that somehow–don’t ask me how–intense, thoughtful men should be able to figure out where they can put their ambition, do so while also being confident but not obnoxious, while being a regular “guy” your buddies would want to hang out with, while also being a decent partner and dad who can be comfortable and supportive at home, at all times, all the while rising to become the top of their game–and doing all that easily and happily.

True confession:  I bought into that once myself.  I think my therapist was able to remodel a whole wing of his house as a result.

My therapist enjoys that wing, I’m sure.  Lucklily, in the process, he also–finally–got me to see that maybe I too could start getting real and yet enjoy life as well.

The point of today’s post is the same as the one over the past several posts:  never, never, never fall into the trap of believing a combat veteran when he or she tells you–no, believes with all his or her heart and mind and repeatedly, repeatedly tells you, if you’d only listen, numbskull–that he or she is all-PTSD, all-the-time.  Never.

For the guys, certainly:  never, never, never let them think that if only they’d not gone to war, they’d have breezed into love and work like all the other “normal” men around them.  (If ever LOL was to find its utter fulfillment, it would that last statement, believe you me.)  Never.

“Listen,” I eventually said.  “Did losing your best friend in the world and not even knowing it until long after he’d been in the ground, all because it took you that long to recover enough to open your eyes–did that change you forever?  Yes, it did.  Will love be hard because you never want to hurt like that again, never want to feel the pain of someone for whom you’d die in a heartbeat having the gall to die before you had a chance to prove that?  Yes, it will.  Are you lost because a big part of you believes down to your core that a loser like you, daring to breathe while others far better than you are mere memory, should never be allowed to find a way anywhere, ever?  Yes, you are.”

“But you’re more than that.  You don’t feel it, but your not feeling it doesn’t make it false.  Even if you’d never boarded that plane heading over the Atlantic, you’d still be terrified of closeness with a partner, uncertain whether you could ever make something of yourself, fret over which way to turn now, whom to trust, what to do next.  You think you’ve been creating this “actor” as if he were some figment of your imagination, smoke-and-mirrors out of whole cloth, the phony of phonies, hoping against hope that no one will catch you in the act?


“You’re a guy.  You’re a guy who’s seen some really bad things.  You’re a guy who’s lived some really bad things.  You’re all that–and you’re not.  Our task ahead of us is not going to be an easy one, but we can’t shirk the mission:  you’ve got to become more able to tease apart what’s PTSD and what’s normal-guy-ridiculousness.  Every young buck has to be tamed, at least to a certain extent.  And you, my friend?  Let’s face it:  you’re quite the young buck.”

He did look away–very briefly–on that one.  Yet I caught that hint of a smile.  Good for him.  We’ve got something to work with.

The combat veterans we work with desperately need a narrative to add to the “I’m just War” story they tell themselves day in, day out.  Good news, folks:  there is one.  It’s called “human trying to make it in this world.”  Their PTSD will complicate that narrative–but it will not obliterate it.  Never, never, never let them go on thinking that.  Never.

Your reward?  The combat veteran’s “real me.”

It’s worth the effort.  For both of you.

I can hardly wait to see it in him.

It’s the smile.  Gets me every time.


In so many ways, it was just another day.  I had not expected to see him.  He had, however, spoken with a colleague about his concerns about his painkiller usage, so the call had come:  could you see him?  He’s in bad shape.  He really seems sincere.

I said I’d be glad to.

When I walked into the waiting area, I saw a soldier’s soldier.  He looked like a high school wrestler who had aged rather well, thank you, hairline ever so slightly receding, strong facial bone structure.  He was looking at something in front of him that, I would estimate, must have been about twelve miles from where we were.  His whole demeanor was resolute–sort of, not really, but yes, really, it’ll be OK, but . . .   It’ll be OK.  Yes.

When I introduced myself, he looked me right in the eye as he popped up, ever the straight, good soldier he was, not rigid, but solid, putting out his hand confidently, sort of, not really, but yes, but . . .

“Thank you for seeing me.”  He spoke with definitiveness, yet vulnerability, as if both to assure me that all was going to be fine as well as to assure me that he was desperately needing my help, this was not a drill.

“Good to meet you,”  I replied.  We shook hands, again his grip both soldierly solid and humanly tentative.

His story was a familiar one.  He had injured himself in the Middle East.  He had begun opiates to ease the pain.  He came home, and the PTSD symptoms started.  He had seen a lot of war up close and personal.  The images continue to haunt day and night.  The painkillers did make them go away.  Somewhat.  Not really.

He’d reached a huge daily dosage.  He was desperately seeking it from whatever source he could.  A few days before he looked at his child and realized that he could barely focus on the kid, not because his eyes were weak, not because he was high–but because he could only think pills, pills, pills, God, where will I get the next pills.

As he told me this, I could see the tears gather, but he was a good soldier.  He didn’t let them go.  He sat rigidly and narrated his tale.  He sat limply.  He appeared in control.  He appeared desperate.

He loved his child.

We talked about Suboxone, the opiate substitution product that has helped so many of these veterans.  He was anxious to start.  Our converstion, though, had taken its toll on him.  He stood up to go out of the room.  He was not crying.  Sort of.  Not really.

But if he were to take one more step toward the door, he was going to start sobbing.  I knew it.  He knew it.

“It’s no problem, your staying here and pulling together a bit if you’d like,” I said.

At first he looked at me blankly, but within seconds came the smile of relief.  “Thanks,” he whispered.  He sat down.

Deep breaths, he took.  Sort of reminded me of the breaths you take before you’re about to try to shimmy up the rope on the obstacle course, I can do this, I can do this, I can do this.  Deep breath.  I can do this.

He looked at me, eyes resolute, eyes ready to release their torrents.

“I hate this,” he said.

I don’t know why I said it to him.  It’s not my usual opening statement when starting the guys on Suboxone.  I just felt:  I need to tell him.

“You know, the problem is that you guys came back with someone else in your soul.  The war.  The war’s there.  It’s not going away.  You know that.  I know that.”

He nodded his head ever so slightly.  “I know,” more of a swallow than a response.

“But the real problem,” I continued, “is that you guys feel that only the war came back, that the war is all you are, that you disappeared over there and only the war came home, full of rage and pain, the war-is-hell war, the war that makes you too horrible for anyone to love, to care anything whatsoever about.  Am I right?”

He nodded.  This was one determined man.  Breathe.  You can do it.  Breathe.

“You’ve got to trust me on this,” I said to him.  “You’re still there, inside you.  While I in one way don’t know you from Adam, I do know war when I feel it.  I feel the war in you.  But I feel someone else as well.  I know you don’t.  But you’re going to have to trust me.  You and the war are too entangled.  We’ve got to disentangle you.  It won’t happen just like that.  But it’s possible.  You’re not gone, the you that went on deployment.  He’ll never be alone again.  But he’s not gone.  Believe me.”

That was when the first tear began to respond to gravity.  He was still breathing, ready for the rope, trying to stop gravity’s pull on that tear simply out of sheer will.

“I can’t take the war out of you,” I continued.  “You wouldn’t believe me if I told you I could.  You will always have to live with it.  But you are not it, and once you can begin to feel that more consistently, you will be able to begin to find a way to live with it.  There’ll always be some pain, but it doesn’t have to hurt like this forever.  Once you get disentangled, it’ll work better.  Trust me.”

He swallowed.

“Really?” he whispered.


He closed his eyes and looked down.  A few pre-shimmying breaths again.  Then he looked up, first at nothing in particular, then at me.

“Thank you,” he said.

“Sure thing.  See you tomorrow, to adjust the dose?”

He nodded.  “Yes.”

I nodded.  “OK.”

He stood up, soldier straight.  One more breath.  A very resolute, very warm smile.  He gave me his hand.  I shook it.

He came the next day.  We adjusted the dose.  That’s how it goes with disentangling.  Steady.  Keep going.  Breathe.


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