“Psychoanalysis by Surprise”: Apartheid, War, and the New York Subway

Given that many of the blog’s readers are not mental health professionals, I must explain what many modern mental health professionals imagine when I say that I just spent a week at the national meeting for the American Psychoanalytic Association.

I would say that, roughly, you might consider that the idea conjured in their minds would be something akin to my having spent a week in a joint conference of the Whig Party and The Flintstones’ Loyal Order of Water Buffaloes (Grand Poobah and all).

I will not bore you, dear Reader, with the history of this phenomenon. Suffice it to say, blame is justifiably placeable upon all parties involved.

On the one hand, for example, we have the “Freud is Dead” folks, riding their moral high horses up and down Park Avenue, dancing with timbrels that the cocaine-crazed, misogynistic, pseudoscientific-witchcraft reactionary has finally been cast into the sea (or at least the East River), as generation after generation of “modern” therapists quote with disgust all that they know about the evils of psychoanalysis, basing that knowledge, of course, on the three pages on the topic they read about in their personality theory text in grad school, the source of such text having been the textbook author’s brief perusal of Peter Gay’s The Freud Reader. But if you’re modern, brilliant, scientific and/or progressive, what more would you need to read, after all, correct? Life’s short enough as it is.

On the other hand, nothing–and I mean nothing–is more ludicrous and irritating than sitting in a crammed hotel room, with nothing but a measly plastic cup of water to soothe the nerves, listening to and watching a bunch of psychoanalysts cat-fight with each other (in public, no less) about whether some particular turn of phrase is real psychoanalysis or not. Think of it as Woody Allen with attitude, over and over and over . . .

Yet I’m happy to report–very happy to report, in fact–that modern psychoanalysis ain’t your granddaddy’s psychoanalysis. We may have decided in our get-it-done, metric-obsessed, treatment-planned, cost-contained culture that psychoanalysis and psychoanalytically-informed psychotherapy are dead, unproven, elitist, worthless, yadda-yadda, but believe you me: just because those who manage the purse strings, the graduate programs, and the DSM-V say something is so, that don’t necessarily make it so.

This past Saturday, for example, I was, for lack of a more snazzy term, blown-away by a presentation by Dr. Mark Solms, a psychoanalyst and neuropsychologist (try that one on for size) from Capetown in South Africa. His presentation, “Psychoanalysis by Surprise,” a joint discussion with Dr. Kimberlyn Leary, Program Chair for the meeting, concerned Dr. Solms’ quite honest, quite ruggedly nuanced, current understanding of his return to his South African home. It was stunning: two leading psychologists (psychologists were once banned from the American Psychoanalytic), a Caucasian male and an African-American female, talking at the Association’s quintessential get-together about race, privilege, shame, and living by the seat of one’s pants.

Solms is the sixth generation of a wealthy, European, land-owning family in South Africa who himself had left the country in the 1980’s to avoid conscription into the Afrikaner military, who then returned to his family’s vineyard/farm after the dismantling of apartheid. There he found several multi-generational Black families who had “come with the land,” i.e., essentially having lived there as serfs. He described the painful, yet mutual process that they all underwent as together they worked to make the farm a cooperatively-owned venture as a successful wine producer.

Leary was a supportive, yet deeply-incisive interviewer who probed into all the psychological and political complexities of the situation, and Solms met every question with an honesty that was exemplary. He made no claims to “heroism,” no claims to “getting it right” or assuming that “it will all work out.” He only made claims to wanting to do the right thing, using the most full understanding possible at any particular point, stating simply that as an analyst he had to “face all the truth I could, especially about myself” and then live and act in accordance with that truth, whether in the past, today, or tomorrow.

As the day went on, I thought about how Solms had described his doing his best to be himself in the face of political and personal realities that simply “were.” Being in the city where the Twin Towers had once stood, I could not help but think about similar realities that continue to “be” for me, including an ongoing war, the consequences of which will surround me for the remainder of my professional and personal life. I woke up Sunday to a fresh, New York morning, so I decided to walk down to the 9/11 Memorial from the Waldorf-Astoria, where I had been staying.

I knew it would be a hike.

Boy, was it. I’m getting old.

It was great, though, walking down Park Avenue, past Union Square, down Broadway to the Financial District. I don’t know what I was expecting, truthfully, Manhattan at 7AM on a Sunday, but I have to be honest: a lot of times I felt like Will Smith in that crazy zombie movie, just without the dog. I mean, there weren’t no one nowhere.

Sure, there was the de rigeur Starbucks every fifteen feet, and I grabbed a poppyseed muffin at a bakery run by a Japanese family, along with a croissant further down the road at a coffee shop named Gregory’s, replete with two twenty-something baristas arguing over how to open the cash register, dressed in the all-black, slim-cut, open-collared shirt/flat-fronted trousers that appear to be pro forma among all males in Midtown even remotely close to that age demographic. But other than that, basically nada (or should I say, nadie), just Yellow Cab after Yellow Cab after Yellow Cab, looking for whom to pick up, I haven’t a clue.

Now I will say that the man with the two neatly-manicured, black Scottie dogs on long leashes did make his entrance on cue as I walked past his Park Avenue apartment building just north of Union Square, and even though this Midwestern boy was shocked to see a huge–and I mean, huge–Babies ‘R Us across the street, with a PetSmart, no less, down Broadway, I guess that nannies and dog sitters have to have a place to drop by in a pinch as well, don’t they.

So, anyway, I finally made it down to the 9/11 Memorial, no small thanks due to Steven Jobs and my iPhone 4S. Problem: there’s so much construction around the area, they’ve cordoned off the memorial “for safety.” Bigger problem: the cordoned off area was closed. And wouldn’t open for another two hours. And I had a meeting I was already late for.

OK.

Well, all right, we’ll make it work. I’ve lived in Boston and spent quite a bit of time in DC and Chicago, after all, so the NYC subway was going to be no big deal, I had to assume, plus it also seemed relatively straightforward from all the maps I’d seen, plus there was still hardly anyone walking around that part of Downtown except for cops huddled everywhere, in search of doughnuts, perhaps, I don’t know, and the occasional Japanese tourist. So, easy Plan B: just zip down the nearest station, buy the pass, and then get on back to the hotel. I checked out the map at the bottom of the station stairs: it seemed that I could probably hit the next station and transfer to the line I needed, but I thought I’d better check with the attendant in the tiny closet we were all calling the station entrance.

“Good morning. I need to get to the 51st and Lexington station,” I said, “so I go down to such-and-such station, correct, to get on the Green Line?”

Sorry, New Yorkers who are now guffawing your heads off: that’s what we called it in Boston.

“What?” came the guy’s answer. “You need the 6 Uptown?”

“Uh, well . . .”

“You need to get over to Broadway and take the 4. I think you can change by the Brooklyn Bridge, maybe, and then get where you need to go.”

“Uh, Broadway? I . . .”

“Yeah, just go up the stairs, hang a left. You can’t miss it.”

Now, granted, I should have asked for clarification, but, look, I’m a guy, I’m proud, and I wasn’t quite sure it would be worth the few seconds of either of our lives to ask one more thing and then have each of us endure the answer he most likely would have given, so . . .

I walked up the stairs and hung a left. Well, then there was a right, but not that much of one, but fortunately I had the 4S, so I got to Google Maps and then . . .

Finally I made it to the requisite station. Uptown, OK, that’s it. 4 to 6, 4 to 6.

I get down into the station to find a handsome young man, maybe around twenty-five, dressed casually in jeans and a sweatshirt, standing arms akimbo before the station attendant behind the (I can only assume) bullet-proof glass, announcing “Are you sh**tin’ me?” in a relatively calm voice, all things considered, really. By the time I’d made it to the bottom of the stairs, though, he’d progressed to a more animated “F*** the MTA!” but then he turned toward me and quite calmly began walking toward the stairs (vigorously shaking his head all the while, granted).

The clueless, Westside Indianapolis in me must have been radiating forth, for as he reached me, he merely rolled his eyes and quietly stated, “There’s some train stuck down the track and they don’t know when it’s going to be fixed. You probably should head over to such-and-such station, that might work better.” Then he lunged up the steps and, poof, he was gone.

Well, OK . . .

So I got up to the top of the steps and said a thank-you prayer one more time for Steven J, as I ended up downloading this app that showed me which station I needed to find to get to “The 6″ directly. Consequently, proudly emboldened, I then lunged forward myself, only to hear to my far left, “F*** you, you f***in’ f***!!”, as some quite large woman was shouting down into a dumpster located along the street at God-knows-whom and as a motley crew of multi-coated individuals were kibbutzing about the whole spectacle from the 24-hour McDonald’s only feet away, small and medium coffees in hand, as I recall.

“All right,” I thought to myself, “now I feel like I’m in New York.”

So what does all this have to do with combat veterans and combat trauma/PTSD?

Fair question.

Solms had essentially talked about the art of “playing the cards one is dealt,” recognizing that we indeed get to deal sometimes, sometimes not. We take responsibility for our deals. We make everything else work as we can, but hopefully in light of not the truths we hope to know, but of the truths we need to know and can know, if we will only be brave enough to ask for them and then to listen to the answers we get.

Sometimes the answers are dramatic, leading to lives changed on massive, bucolic farms at the feet of breathtaking mountains. Sometimes they are far less so: walks longer than expected, plans for deep reflection that become wild goose chases in which rich and poor come and go on a Sunday morning.

Earlier in the week I had had the chance to have dinner with Mike Piro, a West Point graduate who writes the blog ptsdsurvivordaily. We spent a great evening together, and I had the pleasure of spending a few hours with a man who’s bravely faced his demons, come out on the other end, and is trying to make life better for his brothers and sisters-in-arms. He spoke of his experiences at the VA, both positive and not-so-positive. He spoke of his West-Point-grad wife, their sons, his family, his co-workers, the support he feels, the debt to others that he believes he owes.

Later that week, I also had a chance to speak at length to another combat veteran who is trying to make his life work. He too feels that he needs to do whatever is possible to make other veterans’ lives better.

Both men want to learn what they can and do what they can to accomplish their missions.

So here is the point, the result of an eye-opening, mind-opening week for me at a convention that should, so they tell me, have been irrelevant to the lives of combat veterans everywhere, a point even more especially meaningful to me in light of my thoughts in yesterday’s post, Military Suicide, Resilience, and The Song That Never Ends:

My current employer, the Veterans Health Administration, is doing all it can to provide the best care for combat veterans who suffer the effects of combat trauma/PTSD. By spearheading work in treatments such as prolonged exposure therapy (PE) and cognitive processing therapy (CPT), they are providing more and more veterans the opportunity to develop skills to manage their emotional lives more effectively. In addition, they are offering medication options that can also help accomplish those same treatment goals.

But we have to face reality: the VA is the largest single-payor healthcare system in the United States. It takes a lot of administration to keep that going. In addition, the VA is under the direction of the Secretary of Veterans Affairs, a member of the President’s Cabinet, a political organization first and foremost, dedicated to veterans, yet mired in the constant danse à trois among the Executive Branch, the Congress, and the media. Administrative bodies, even ones whose purpose is human in application, must maintain order, spend money wisely, constantly evaluate what is “wise” and what is not, record, report, analyze, report again, revise, start over, making Microsoft’s Excel, PowerPoint, and SharePoint, the sine qua nons of a stable global existence for us all.

Here’s the deal. Treatment for emotional dysregulation is evidence-based. It can be measured. It is good, therefore, in the “proper” way, one that can literally be carried by a lackey up to Capitol Hill to waive in the face of legislators (or administrators, depending on who’s doing the outraged J’accuse bit for the day).

“Treatment” for coherence is, however, at least for the foreseeable future, not evidence-based, or at least not so in the “proper” ways that play well for accountants and Senators. Therefore it may be good, but those who must report to those who control the purse string will always have to ask, “What use is it in the administrative-political context?”

Therefore, I suggest that we let the VA do what the VA can do, hold it accountable for what it should be held accountable for, and not ask it to do what it cannot. It can be held accountable for promoting emotional regulation. It cannot, however, in my opinion (which, usual caveats, is mine and mine alone), be held accountable for promoting coherence.

That’s where veterans like Mike and others are going to have to come in.

You see, psychoanalysis, i.e., real, modern psychoanalysis that is lively, controversial, and ever-changing, does have a thing or two to say about coherence. Now, granted, like any discipline, it tends to say those things in a jargon-y way that can be off-putting at times. But all stories can become more coherent the more we are willing to look at all facets of the truth, objective and subjective, and then live with the consequences.

Combat veterans usually do not have a lot to say about the technicalities of emotional dysregulation. Thus, they usually need to depend on experts to help out.

They, however, do have a lot to say about coherence. Many have found it (or at least a satisfying-enough facsimile), and those who have are wanting to learn as much as they can so that they can share that coherence with their brothers and sisters.

I would like to do what I can to help them in the goal.

Therefore, I will be setting up a Tumblr and a YouTube account, and I am going to start posting five to six minute videos that will discuss and explain about ways to think about making life more “coherent” post-deployment. I will not be talking about treatment issues. My goal is not to turn combat veterans into amateur therapists.

It is my goal, however, to help veterans understand, in as non-technical way as I can, how to think more systematically about what can make life more coherent and what can make it less so. I want to give them a vocabulary that they can use to express what is working in their lives and what is not, not a jargon/psychobabble vocabulary, but rather a human vocabulary that has been, in my opinion, well-tested over time to help make more sense out of life for a lot of people.

As a result, I hope to do what I can to help veterans not only to share more effectively with their VA (or private) therapists what is going on, but even more to serve as “first-response encouragers” to help fellow veterans who may not yet be ready to seek formal treatment. By being able to express more clearly how life has become or can become better, these veterans can, in the well-worn phrase, “play it forward” again and again.

Folks, we need to face facts: the VA will never have enough money. Even if “evidence” comes forward of the effectiveness of ways to improve emotional coherence in veterans, that “evidence” is not going to be available for a long time, years maybe. No evidence, no money, no programs, period. One can cry foul about this until the cows come home. All it will get one is hoarse–and still cow-less.

The real future of American (and I would say also Canadian, British, Australian, and other) combat veterans will be in the hands of those veterans who have learned the techniques of emotional regulation in therapy and who will then be able to take whatever time is necessary to help other veterans regain meaning.

Like Dr. Solms in his endeavor, I have no clue whether what I will try to do in mine will make one whit of difference. I can only share ideas, not promises. I do trust, though, that veterans will let me know one way or another whether I’m being helpful or not. If I fail in one task, I will be glad to do what I can to change course and try another. This is a two-way street. I am hopeful that persons such as Mike and others will keep me on track–or, if necessary, politely (or not so) tell me to stick to highfalutin’ blog essays and otherwise shut the, well, up.

If I can be helpful, in other words, great. If I can’t, well . . .

I can at least find the 6 now. Next stop, the other Boroughs, and then,who knows, maybe one day Long Island? Connecticut?

Ah, the dreams that keep us going.

Combat PTSD, Pools of Emotion, and Putting the Truth Into Words (III)

Dear Sir,

Let’s now talk about the persons who should–sadly, I must italicize that word–be available to bear with you as much of the truth as can be spoken: your counselor or psychotherapist.

3. Decontamination and “Putting the Truth Into Words”: Loved Ones, Psychotherapy, Journaling (B)

As I said earlier, if medications are detoxifying agents of the pool, then psychotherapy (or its equivalent) is the decontaminating agent of the pool. I stressed “of the pool” because, as I said in the last post, the “contaminants,” i.e., the memories of the experiences of the War, still need to be detoxified. Psychotherapy, however, detoxifies outside the pool, on the observation deck. In Real World terms, that means that psychotherapy relieves the pain of the War by bringing it into the therapeutic relationship, feeling it, talking about it, and dealing with it there.

The Truth and Psychotherapy

First, let me say up front what every combat veteran already knows: not every therapist in the VA system (or for those of you in other countries, your national treatment system) is worthy of the name. I know that. In fact, one of my colleagues put it most colorfully when she described a VA clinician (fortunately) not at our facility as someone who “has all the empathy skills of a lower amphibian.”

Sad to say, I know the clinician whereof she speaks, and sadder to say, my colleague is spot-on.

I would ask you to consider, however, that sometimes the problem is more a mismatch between therapist and veteran. Just as combat veterans differ in how they rejuvenate, so do therapists. Perhaps through understanding this, you and/or some of your fellow veterans might be able to salvage some therapeutic relationships. At the very least, you might have a better understanding of why a particular relationship might not work, no matter how hard either party might try.

a. Psychotherapy, Kinetic-Energy/Extroversion, and Potential-Energy/Introversion

Generally speaking, psychotherapies geared toward helping veterans with combat trauma/PTSD are ultimately neutral as to whether they can be effective for kinetic-energy/extroverts or potential-energy/introverts. It is less about the therapy itself and more about how that psychotherapy can most effectively be used with any particular veteran.

That being said, therapists trained in most modern mental health training programs, i.e., psychiatrists, psychologists, social workers, mental health counselors, tend to have been schooled in a “world view”that is much more congruent with the kinetic-energy/extroverted style of rejuvenation rather than that of the potential-energy/introverted. As I have stated in earlier posts such as Treatment Plans and Is It Something I Said? (all right, I admit it: as I lamented), the ethos of much modern psychotherapy practice is get-‘er-done, get-‘er-done efficiently, and get-‘er-done fast. Even when particular therapists resist this type of practice mind-set, they often still have to justify to the powers-that-be why they in fact are resisting. “Expedient effectiveness” is the name of the game.

It is, of course, ridiculous for anyone (starting with myself) to argue that psychotherapy should not be expediently effective. All of us want suffering to end as quickly as possible, after all.

That’s not the point.

The point to remember in the following discussions is this one: kinetic-energy/extroverted veterans rejuvenate far away from the inner emotional pool. Potential-energy/introverts, in contrast, must rejuvenate right next to the emotional pool. Any particular decontamination technique (i.e., psychotherapy, especially an “evidence-based” one) might work equally as quickly for a kinetic-energy/extrovert as a potential-energy/introvert in terms of rate of pool decontamination. However, the former can escape the stench in order to rejuvenate, while the latter cannot.

To understand the ramifications of this, let us look at how the psychotherapies fit into our metaphoric system and then look at how the kinetic-energy/extroverted and potential-energy/introverted “environments” influence how these therapies may be most effectively used.

The Evidence-Based Psychotherapies

Two officially-sanctioned therapies for combat trauma/PTSD in the United States’ VA system are prolonged exposure therapy (PE) and cognitive processing therapy (CPT). (I would have also liked to have included in this list for my discussion eye-movement desensitization and reprocessing therapy, or EMDR, but given the time it would take to explain it, I’ll save that discussion for another day.)

Let’s go back to our pool analogy. Metaphorically, in PE the veteran dives right into the contaminated pool, with the therapist (hopefully) right there on the observation deck, gently pushing the veteran each time to swim a little longer, gather a few more contaminants, throw them out on the deck, and then get out of the water to sit with the therapist long enough to allow the toxins to seep out. In the Real World, that means that the therapist encourages the veteran to remember in detail the most traumatic experiences, usually recording them (e.g., cassette tape or digital recording) for later playback, so that with each episode of listening to the recording and remembering (i.e., jumping into the contaminated pool), at first in the therapist’s presence and then later on his/her own, the veteran can be less and less emotionally devastated by the memories and thus can be freer to experience a variety of emotions, both good and not-so-good, in that very same Real World.

In contrast, CPT is a bit more like both veteran and therapist sitting on the observation deck throughout the treatment, with the therapist giving the veterans lessons and guidance in how to use a net to fish out the contaminants and then bring them out to allow the toxins to seep away. In Real World terms, the therapist asks the veteran to observe the patterns of emotional responses, the thoughts and actions that trigger them and relieve them, all for the purpose of the veteran’s learning more effective ways to “think through” painful emotions before they get out of hand.

Kinetic-Energy/Extroverted Combat Veterans

In an earlier post, I wrote:

For kinetic-energy/extrovert veterans, [the “observation deck”] is not a particularly large one. It is an “area” that is large enough to allow them to take the time necessary to reflect adequately on their emotions–but that’s it. Again, they want to be back out in The Real World, using their knowledge of their changing emotional states to get “moving” into activities and relationships for the purpose of rejuvenation, of getting the energy/intensity they need to live out those emotions in the ways they most desire.

PE and CPT are more than just techniques, even though there is a “technique” aspect to how each therapy encourages the veteran to “decontaminate the pool” (“diving” for PE versus “net fishing” for CPT). Both rely heavily on the therapist’s and veteran’s having a good relationship within which to detoxify the contaminants once they are “out of the pool,” i.e., identified and discussed in the therapy.

Both therapies adapt quite nicely, however, to the kinetic-energy/extroverted veteran’s rejuvenation style. These veterans want to “get the job done” so that they can take back to The Real World better emotional states with which to live, interact–and thus rejuvenate. Being, in their classic form, very “goal-focused,” these therapies serve well the kinetic-energy/extroverted veteran’s goals by giving the veterans “something to do.”

The more trauma a kinetic-energy/extroverted combat veteran has endured (whether before deployment or during), the more contaminants there will be in the emotional pool and the longer the duration of the process will be. As the psychotherapy continues, however, there will be fewer and fewer contaminants to be removed and detoxified. Combine this with the fact that the kinetic-energy/extroverted combat veteran will always come “back” to the pool having rejuvenated “far away” from the pool, the veteran will almost certainly be able to take over the decontamination-detoxification process from the therapist more quickly than would have been the case if the veterans could not have rejuvenated in that way (i.e., if the veteran had been potential-energy/introverted).

Remember: it is not that kinetic-energy/extroverted veterans are not reflective, for many of them are. It is not that they do not ponder the existential and spiritual issues of War, for many of them do. It usually is the case, though, that they do not regularly seek to reflect and ponder, for (usually) they are much more focused on motion and interpersonal connection day-to-day. It’s not that they couldn’t discuss such “inner” issues in psychotherapy. It’s just that more often than not, they would prefer not to do that too much at all–and certainly not by having to take a couple hours out of their week to do so with a relative stranger.

Potential-Energy/Introverted Combat Veterans

In that same earlier post, I then wrote:

[For potential-energy/introverts,] the emotional pool sits in the middle of a figurative “inner spa” that is not solely about emotions. Like kinetic-energy/extroverts, we too need a space near the pool to reflect adequately on our emotions. However, [they] then need to move to an “adjacent” area in order to sit quietly within [themselves] and reflect not only on what [they] feel, but also on what [they] know, whom [they] know, what [they] might wish to do with such knowledge, all for the purpose of rejuvenation, of getting the energy/intensity [they] need to live out that knowledge in The Real World in the ways [they] most desire. In other words, for potential-energy/introverted combat veterans, their pool of emotions is an integral part of that rejuvenation spa, but it is not the only part of the spa.

Like their kinetic-energy/extroverted counterparts, the more trauma a potential-energy/introverted combat veteran has endured (whether before deployment or during), the more contaminants there will be in the emotional pool and the longer the duration of the process will be. Similarly, as the psychotherapy continues, there will be fewer and fewer contaminants to be removed and detoxified. The stench of the toxic pool will lessen over time.

But the potential-energy/introverted veteran must rejuvenate in the midst of the stench, no matter how long it takes for that toxic stench, through therapy, to lessen.

Here is the essence of the potential-energy/introverted veteran’s dilemma with the evidence-based psychotherapies as they are often presented by some practitioners: just as the emotional pool is only one part of the spa, so is the decontamination/detoxification of that pool only one part of the veteran’s recovering his or her ability to rejuvenate in any meaningful way.

In other words, once potential-energy/introverted combat veterans have decided to open themselves up to trying psychotherapy, they are usually expecting their therapists to help them out with rehabilitation of the whole spa, not just the decontamination/detoxification of the pool.

For the potential-energy/introverted veteran, the therapist who relies solely (or essentially solely) on evidence-based psychotherapy techniques and interactions is like a specialized subcontractor for the spa rehabilitation, rather than the general contractor  that the veteran is so desperately seeking. It’s as if such a therapist is saying to the veteran, “Sorry, I just clean pools. If you need someone to freshen up the air while I’m getting the job done or help you renovate spiritual aspect of the place, you’ll need to call somebody else.”

In other words, veteran and therapist never had, as we say in Law-land, a “meeting of the minds.”

I am absolutely convinced that this is why many combat veterans, usually the potential-energy/introverted types, can “successfully”leave an evidence-based therapy, whether individual or programmatic, and yet still wonder aloud, “I’m supposed to be fine now? So why do I still feel so bad?”

The answer is simple: the veterans “still feel so bad” because the toxicity of The War Within not only poisoned their pool, but also poisoned their entire spa. It’s as if the toxic fumes have rotted the walls, destroyed all the furniture, made the whole place inhabitable, with no place to be fed, no place to be revived, no place to be treasured. They had thought that if they were going to be opening themselves up to the pain of psychotherapy, they were going to be getting a full renovation–not a partial job (though a competent one) with options for referral to other providers.

So how can such a mismatch/misunderstanding happen? I have three hypotheses.

Different Veterans, Different Therapists, Different Systems

Hypothesis One: Potential-Energy/Introverted Veteran + Kinetic-Energy/Extroverted Therapist (with standard, modern training)

Even if a therapist is kinetic-energy/extroverted, one should not assume that she or he cannot understand the rejuvenation strategy and needs of a potential-energy/introverted veteran. My longstanding consultant/supervisor, for example, is as kinetic-energy/extroverted as they come (you ought to see her do West Coast Swing dancing), yet she is a well-known, well-respected psychoanalyst who specializes in understanding the inner world of trauma victims.

Similarly, one should not assume that just because a kinetic-energy/extroverted therapist has been trained in more contemporary training programs, the therapist cannot sit for longer periods of time with veterans and do more generalized, “inner” work that is not solely focused on symptom management and emotional regulation.

Still . . .

I do think that many kinetic-energy/extroverted therapists from contemporary training programs have little to no understanding of the potential-energy/introverted veteran’s (or any other patient’s) need for more extended inner reflection in order to feel that anything of value is being accomplished. In fact, many such therapists, from my experience, do seem to believe–quite sincerely–that focused, goal-oriented, shorter-term treatment is not only something valuable, it is something superior in value.

Some of them–and I do mean only some–even seem to believe with all their hearts that if a veteran is not responding with reasonable enthusiasm to a more standard, evidence-based approach, then the veteran is either a). suffering from longstanding trauma that must have predated the employment, or b). resisting treatment because of personality disorder issues or a conscious desire to seek the sick-role in order to maintain an illness that will allow disability benefits to be paid.

I wish I could say that I have never heard a VA therapist say such things. Even sadder, though: it’s not only the occasional kinetic-energy/extroverted therapist who does.

Hypothesis Two: Same Veteran + Potential-Energy/Introverted Therapist who cannot tolerate strong emotion for extended periods of time

I wish this were not as common a scenario as it apparently is.

I am going to make a boldfaced, general statement: most modern mental health training programs do an atrocious job in teaching their trainees how to work with individuals who have been severely traumatized.

I cannot fault a relatively-new therapist for struggling to deal with the emotions brought on by sitting with any traumatized individual, let alone a combat veteran. Classroom education cannot adequately prepare anyone for those challenges.

Too many recently-trained therapists, however, have zero conceptual inkling of even how to understand such challenges. They don’t even know what they don’t know, and too many of them think they do. These are often the therapists who reduce PE and CPT to mere technique, almost as a way to assure themselves that they are a). competent and b). accomplishing something.

At one time, you could assume that therapists had undergone some type of more extended therapy themselves. You can no longer assume that. In fact, I’d say you’d be more often right if you were to assume that any particular therapist has not. That is not to say that the therapist has maybe not done a counseling session or two or three at some point in his or her life. But it is doubtful that he or she has done much extended work. The modern ethos of psychotherapy is “keep it focused, keep it quick.” You don’t need to have that much such self-understanding to do that relatively successfully and graduate from a decent program.

In fact, after a session or two of instruction, you could probably do all the rest of the therapy with an app on a good iPad, right?

Admittedly, kinetic-energy/extroverted therapists usually can get away with minimal therapy of their own. Usually they do work that is focused, and they prefer to work with people who are able to stay focused. As I often say, no harm, no foul.

The ones I worry about are the potential-energy/introverted therapists who, by their very nature, spend a lot of time in their inner spa, yet who are not that particularly aware of what’s going on in there. My experience is that many of them do evidence-based therapies particularly badly with potential-energy/introvert veterans: at their core, the therapists know that a lot more than the emotional pool is at stake, but they can’t even keep their own inner world in order, let alone another person’s.

One can get away with such semi-blind-leading-the-blind therapy (sort of) with standard issues such as depression or anxiety. But with the horror of combat trauma? Usually bad news, all around.

Hypothesis Three: Same Veteran + Potential-Energy/Introverted Therapist who is caught up in a “do more with less” System

The majority of potential-energy/introverted therapists whom I know fall into this third category. I am not going to rail against my employer here. I work for the largest healthcare system in the United States, and it’s a very public-faced one within a highly political context. Everyone is doing what they can with what little they have–oh, yes, and we’re going to have to cut back, you know, spending beyond our means, so the wise ones of Congress and the think tanks say, and all that . . .

There are no surprises here: a (massively) underfunded War with no clear strategy for providing afterwards for the large number of combat veterans in general, let alone a strategy for differentiating treatments based on underlying personality dynamics (although there are those that hope against hope one day to find a blood test to figure it all out). Combine that with a challenging economy without a lot of leeway for those with interpersonal challenges or mild cognitive challenges, within a group of young men and women who have families that need to be not only provided for, but watched after, requiring packed schedules with little room for play in them, and what do you get?

Why, eight visits within fourteen weeks of focused, evidence-based therapy, with supplemental support through veteran-run groups, right?

Don’t get me started.

There are a lot of excellent, overwhelmed, and semi-demoralized potential-energy/introverted therapists out there in the public sector, trying to help potential-energy/introverted combat veterans who are looking for more than a few well-run individual sessions followed by groups of “veterans helping veterans” (only a kinetic-energy/extrovert could have come up with that line and felt it to be the self-evident goal so many want to make it out to be). Many such therapists  love their work and the veterans whom they serve, yet they are finding every day of work to be so very, very frustrating.

Well, dear Sir, even if all that does supply some valuable background information, it does not help you much with your challenge, does it?

At this point, I’m going to go out on a limb, speaking as an individual and not as an employee of the federal government: if you are a potential-energy/introverted combat veteran who, because of your emotional intensity, is looking for an opportunity to meet more regularly with a therapist to try to reconstruct your “inner spa” in as many ways as is feasible so as to maximize your meaningfulness in life?

Look outside the VA.

I wish that weren’t the case. But as of today, I believe I can say: it just is.

The following three national organizations might be able to help you in this search:

1. The Soldiers Project is an excellent organization that is continually trying to recruit experienced therapists to provide free, ongoing therapy for combat veterans who are looking for longer-term solutions to their inner turmoil. As of this point, they are primarily hindered by the relatively-limited geographic availability of therapists, but they are working to increase their supply of referrals daily. I cannot recommend them highly enough.

2. Give an Hour is a larger organization that provides similar services, i.e., referrals for free care in the community for veterans with a wide variety of needs. This organization tends, from my understanding, to draw on a variety of therapists using a variety of modalities, so it is not solely about therapists seeking to provide longer-term services for veterans who feel a need for them. Yet they remain ready to consult with veterans  to try to find a therapist who will best meet a veteran’s personality style and goals.

3. The Pathway Home is a superior, residential facility located in the Napa Valley of California that provides intensive, four-month-long, twenty-four-hour-a-day programming in an unlocked, residential setting to help combat veterans deal more intensely with their emotional struggles. It is a nonprofit organization using a variety of funding sources to provide care for veterans without requiring insurance or private pay, and they have access to a variety of national programs that help veterans with transportation to California, as well as to a nationwide network of alumni who provide 24-hour support to each other through texting, social networking, and other avenues.

I wish, dear Sir, that I could offer you more in the way of longer-term treatment options, but they remain limited at this time. I am thus fully aware that none of these options may turn out to be viable ones for you.

Therefore, in the spirit of the military’s “change course and keep going,” let me conclude with the next post on alternatives, including “spiritual”or “ritual” retreats, work with clergy, and, when all else fails, journaling.

A Mennonite at the VA?

As some readers know, just this past week I enjoyed my one Warholian fifteen-minutes-of-fame:  one of my posts made it to WordPress’s home page, sort of my version of being “on the cover of the Rolling Stone,” if you know what I mean.  It was in that Warholian post, Conical Combat Linkages, that I revealed that I’m a “Mennonite by choice.”  According to my stats, more than a few people now know this about me.

Interestingly, also last week Anna Groff, an editor of one of our Church’s national periodicals, The Mennonite, contacted me about an article she’s putting together on Mennonites who work at the VA.  Apparently there is not a huge crew of us, surprise, surprise.

For readers who may not know: Mennonites are a Protestant group who were originally known as “Anabaptists” during the Reformation.  Originally from Switzerland, southern Germany, and Holland, many came over to the United States in the eighteenth century, first living in the Pennsylvania area, then moving to the Midwest, especially Indiana and Ohio, with later groups settling in Kansas and points West, or in the western regions of Canada.  There also is a large group who live in Central America and in Paraguay.

Don’t ask about the latter two.  It’s complicated.

(I did feel compelled to mention the latter, however, given that a group of one of our more distant, conservative cousins, the Beachy Amish Mennonites, living in Nicaragua, were described in a not-too-flattering front page article in the New York Times today.  For those who have read the piece, just rest assured: when I say distant, I mean distant.  I’ll leave it at that.)

Traditionally Mennonites, like the Quakers, have felt strongly that the Christian faith requires its adherents to avoid violence, seek peace, and refrain from participating in wars.  In other words, we are usually referred to as pacifists.

Ergo the title of this post.

Anna sent me a list of thought-provoking questions to answer for her article, and so I decided: well, since I’ve identified myself as Mennonite on the blog, I might as well answer her questions in a post.  After all, readers–and even more, patients–should know whom they are getting when they get me so that, well, they can decide whether they even want to get me at all.

Because this is such a complex issue that speaks so directly to many areas of my life about which I feel strongly and deeply, my essay in answer to her questions is quite long, even for me!  Also, it has a certain in-group-ness about it which may not be agreeable to many readers.  Moreover, for many readers a discussion of issues of faith itself might not be the way you’re wanting to while away your next more-than-several minutes of your life.

Given that, I have posted the essay separately, under the title Letter to a Mennonite Pastor, which can be accessed either through the link just provided or through the “Thoughts” menu above.  It may end up of interest only to fellow Mennonites.  (It may end up of interest to absolutely no one at all.)  Still, as I deal in it directly with my role as someone who is both a member of a particular faith community and as someone who serves combat veterans, I hope that others might find that the discussion in it will, at least in some way, prove enlightening.

Many thanks to all those who have visited the blog these past few days, and especially many thanks to those of you who “liked” the Conical Combat Veteran post and to those of you who have subscribed.  I hope that I continue to write posts that each of you will find worthy of the respect and caring every returning combat veteran deserves.

Routine, So They Say

He’s not a combat vet.  So why write about him, right?

Actually, he’s the childhood best friend of another of my patients who is a veteran of the early invasion of Iraq.  They served in different branches.  They give each other no end of grief about that.  Well, no, what am I saying:  his friend gives him no end of grief.  I’m not sure that my patient gives anyone grief.

He’s too good-hearted.

He grew up in a very working class neighborhood of Indianapolis.  He did not have it easy.  He never knew his biological father.  He still remains connected with the stepfather of his childhood, although that man has long moved beyond my patient’s mother into another relationship, with a woman who’s not exactly that enamored of my patient.  His biological mother?  A long story, very long.

He’ll admit it: he has not exactly lived a life worthy of being enamored of.  Certainly the mothers of his children have not been.  It’s been ugly.

It was heroin, with painkillers thrown in for good measure.  He was a heavy abuser.

He also has recently been diagnosed (by someone other than I) with bipolar disorder, a mood disorder formerly known as manic-depressive illness.  Some in my profession believe the diagnosis is thrown around a bit too freely these days.  They have a point.

My patient, however, is the real deal, although of a more depressed type.  He cannot take standard antidepressants, as they cause his mood to shift into a very painful state of hyperactive mood shifts and racing thoughts.  His moods do respond relatively–stress on the relatively–to standard mood stabilizers.  Still, he has a rough go of it.

Yet his desire to get better is nearly palpable.  He’s hurting down to his core to try to get better.  And when I sit with him?  His core finagles its way right into mine.

I often talk about the problem of “countertransference,” i.e., the challenges I as a treater face when I experience within me the strong emotions of my patients.  Today marks the thirtieth anniversary of my beginning my career as a psychiatrist.  Thirty years ago I was standing at the VA Medical Center in Durham, North Carolina, across the street from the then newly-built Duke University Medical Center North Hospital.  Countertransference got to me more than once as that young, quite-insecure doctor back then.

It still does.

My patient is slender, but now well-built.  I suspect that as a much younger man he was, to put it mildly, lanky.  He has a Southern drawl typical of persons who grew up in his area of town, and he reminds me so much of those boys from Hillsborough and Butner and Rocky Mount who would make their way over to the Durham VA so many years ago.  He’s very deferential, with a good-old, Andy-Griffith “aw, shucks” way about him.

I suspect he was not at all that likeable when he was high.

But in the past, when he would get so sad, think about his life, the mistakes he made, that he continued to make, when he would regret actions taken, would miss his children so, so much: heroin made it all go away, even for just an hour or so.

There are only so many tears a man can shed–especially when he has to shed them alone.

It was about three months ago that he came to me, practically dragged to my door by his buddy.  He was a wreck.

“I’m so sorry, sir,” he kept repeating.  “I don’t mean to be like this, but I just can’t stop.  I shake and I shake and I shake.  I want to stop the drugs.  I hate my life.  I hate myself.  I want to see my son again, and his mama said she won’t let me see him if I don’t clean up.  I’m so scared.  Please help me.  Please.”

His wasn’t the most straightforward of cases medically, and I made some clinical decisions that some colleagues might frown upon.  (Lord, everybody’s got an opinion, don’t they?)  Yet he stabilized fairly quickly, and he was clearly relieved.

He lives, though, quite a ways from our hospital.  He long ago lost his driver’s license.  His father works constantly.  His stepmother can’t drive.  His buddy is his only means of reliable transportation, and the friend can’t get out there to my patient’s place very often.  We’re not exactly in a situation that allows for a lot of close follow-up.

But he does stay in touch with me.  And last week, he let me know that he was not doing well.  By hook and crook, he managed to bum a ride to the hospital, but he was about three hours late for his appointment.  He was panicked that I wouldn’t see him.

“I get so scared,” he told me.  “I miss my son so much.  His mama is just beginning to talk to me again, and I can’t mess up, I just can’t.  But I just sit in my room and cry.  I hate it.  I don’t want anybody to know.  I don’t want to kill myself.  I want to live for my kids.  But I don’t know what to do.  I can’t work.  I’m alone most of the time.  My parents are always thinking I’m going to start using again.  I haven’t, I swear.  I don’t want to.  I’m staying away from all those people.  But it’s so hard.  It’s so hard.”

He was doing everything he could not to weep, and to give the boy his due, he was succeeding.  Hearing him say those words, though, in that Kentucky accent, all caved in on himself, even though he’s actually quite muscular and attractive, in a farm-boy kind of way–he ripped my heart out.

“Who calms you,” I finally asked him, “when it gets this bad?”

I was afraid of the answer to that question.  I almost didn’t ask it.

He looked up from the floor that he had been staring at so long.  The word puzzled has ne’er been so well embodied.

“Excuse me, sir?” he whispered.

“I said,” now whispering myself, “who can calm you when it gets this bad?”

He swallowed.  He didn’t want to say it.  I didn’t want to hear it.

“Nobody, sir,” he finally said.  “Everybody’s just mad at me.  I did it all to myself, sir.  I’ve got nobody to blame.  I just . . . no, sir, there’s nobody.”

“Who’d you live with growing up?” I asked him.

“My mom, sir.”  He paused.  “When I was wasn’t in a foster home.”

I didn’t ask more.  I knew enough.  He didn’t volunteer more.  He knew all too well.

I can’t begin to tell you the number of stories there are like his.  The VA’s full of them.  Mental health centers (what few are left) are full of them.  Emergency rooms are full of them.  It’s routine, so they say:

Child, usually a boy, is caused trouble, causes trouble, all in an endless cycle of in-home/out-of-home/run-from-home.  Sometimes he finds stability in the structure of the military, but ghosts come back to haunt within days of discharge.  Eventually he makes himself clear enough to a person who’s ready enough to listen, and the pattern emerges: the dramatic mood shifts, the family history of substance use and emotional chaos, the boy’s, the man’s own personal history of the same, obediently re-enacted as the next generation’s example of all the forefathers’ (mothers’) chaos and suffering.  Medications help stabilize him.  He gets better.  But still, there has been so much pain endured, that is yet enduring.  There’s only so much a poor, little pill can do, after all.

Many guys with this story just blow up, over and over and over.  My patient’s buddy struggles with that.

He, however, is the opposite.  He just caves in on himself, over and over and over.

Heroin used to help, that’s for sure, even allowed him to muster up some good, old-fashioned obnoxious sneers and threats when he was high, a sort of “jackass’s relief,” if you will, from all his misery, his self-condemnation, allowed him to spread his misery around to all who dared venture into his vicinity.

Now he’s clean.  Now at least he’s not jonesing.  But now he’s hurting, 24/7.  He doesn’t want to die.  But he has no clue how to live.

Thirty years ago today, I was the age he is now–a little younger, in fact.  We grew up in the same city, in some ways even in similar cultural worlds.  Now I sit with him, old enough to be his father, same city, worlds apart.

I want to fix everything for him.  I want to fix him.  I can’t.  I know that.  He knows that.  I do my best.  He does his.  We’ll keep trying.

No combat trauma today.  Just life’s routine trauma.  So they say.

I wish.

The Killing Floor

You’ve got to give credit where it’s due: I didn’t see this one coming, no way, no how.

The veteran and I had been “introduced” long before he’d known it.  I had been on back-up call for our service, and I had received a page from the resident on-call about a man whom she had just seen in our emergency room, a veteran a few years out of his last deployment who was “not doing too well” (his words).  She told me that he had been working closely with the Chief of our Chaplain Service, as well as with one of my colleagues who specializes in treating combat trauma.  According to the resident, both my colleagues had been urging the veteran to consider a brief hospitalization for stabilization.  Finally, that night, the veteran had decided he was in agreement.

The problem was: because of staffing issues, our inpatient service was “full,” and the veteran would have had to have been referred to another VA hospital in our area.  The resident doubted he would go for that–and I doubted that the referral would have been helpful in the least.  I know both his treaters well and trust their judgments implicitly: if they thought the veteran could benefit from an inpatient stay, he could benefit from an inpatient stay, period–but only at the one where these well-trusted treaters worked.

I won’t bore you with details.  Let’s just say that “full” can be a relative term, and although there was, shall we say, dissent within the ranks, the veteran was eventually admitted.

I have my ways.

And an M.D. behind my name.

Then what do you know: the next day there I was, minding my own business, when lo and behold, a new guy showed up in a group that I’m attending that is being run by the Chief Chaplain.  The group is geared for Iraq/Afghanistan veterans who are struggling with their spiritual identity and beliefs.  When he introduced himself, I knew exactly who he was.  After all, the embers of the controversy I’d sparked in his honor were still glowing on the other side of the hospital, as far as I knew.

He was strikingly handsome, in a certain, young Brad Pitt kind of way, although unlike Mr. Brangelina, his hair was dark and graying–albeit a very Pitt-esque graying, if you know what I mean.  He wore a baseball cap as if he’d been born with it, and his intensity marched right from the entry of our clinic into the entry of our group room like Caesar taking Gaul, all three parts.

And he was in pain.  A lot of it.  He couldn’t have hidden that had God come down and ordered him to.

Today, a week later, he came in and took his place around the table.  There was a bit of a riled edge to him, but nothing drastic, and without much effort he bantered with the other men of the group until the festivities began.  Soon after that beginning, however, he asked us all a question.

“Do you guys mind if I tell you the words of a song I’ve written?  I play the guitar, and it helps me cope, and, I, well . . . it’s been a bad week.  The worst, really.  Would you be willing to hear it?”

We all said yes, of course–out of curiosity, true, but also, admittedly, out of a certain kindhearted tolerance, you know how that goes.

So without skipping a beat, he recited the words to us, just a touch out of breath, yet slowly and clearly, with a cadence worthy of the meter, never sing-song, always with a distant gaze that seemed to place him somewhere between Indianapolis and Baghdad, if I had to take a guess.

I didn’t see it coming until it came.  His lyrics.  Him.

When he finished, the room was silent.  All I can remember is sitting there like a fool, my mouth hanging open, looking directly at the Chaplain, who was sitting there like a fool, his mouth hanging open, looking at me.  Our eyes spoke in unison to each other:  Oh, my God.

Oh my God.

He went on to talk a fair amount today.  He was a bit embarrassed at how much he spoke, yet never did he monopolize the group.  His heart was simply pouring forth his pain, his confusion, his anger at a world that should be far more reliable than it is.  The other guys nodded in agreement, murmured in assent, freely added their thoughts, their elaborations.

I don’t think any of them noticed the tear streaking down my right cheek.

When the group was over, I asked him if I could publish the lyrics in my blog.  I promised him that I would read him the text of the entry.  He seemed genuinely touched, excited even.

“I wrote it for the regular soldier, the guy trying to do the right thing, trying to stay alive.  I’d really like to make a video of it, you know?  Share it with other soldiers, like a gift, all of us trying to make sense of it all.”

I was about to give him my e-mail address when I realized that he was getting a piece of paper so that I could write down the lyrics as he dictated them to me.  Clearly he was wanting to speak the words to me again.

His delivery was a bit slower, in deference to my aging hearing, I suppose, yet just as intense, just as desirous of a listener–any listener–to get it, please, get it.  Please, sir.  Please.

The Killing Floor

Driving through the sand
In an 1114,
My men and I are true killing machines,
50 cal and a Mark 19.
We can take out anything.

Death is near,
I can feel it in my bones.
Contact right, coming over my headphones.
I look to the right, and what do I see?
I see this Iraqi man staring right back at me.
He raised his weapon, I had to blow him away.

I still think about him every day.

Was he a father, or was he a son?
I wonder if he’d ever even held a gun.

What are we fighting this war for?
It’s a one-man show on the killing floor.
The killing floor is what you need.
The killing floor is what you believe.

Have you ever heard a mother’s cry?
Have you ever seen a father’s tear?
Who are we kidding,
We’re killing children here.

Have you ever seen that father’s tear?
Or have you ever heard that mother’s cry?
That will tear you up from within.
Then I look at the killing floor again.

Beauty is within the selfless sacrifice.
Have you ever seen a dead soldier’s eyes?

What are we fighting this war for?
It’s a one-man show on the killing floor.
The killing floor is what you need.
The killing floor is what you believe.

He stopped, smiled sheepishly, just barely.  Then he started to pick up his things as if to make a quick exit.

In theory, I needed to go.  I had a private patient about to arrive soon.  But I just sat there.

He stopped again and looked at me.

“Do you . . . can you talk a bit more?”

I paused.

“Let’s go down to my office.”

I opened the door and asked him to take a seat while I made a call.  I left my private patient a voice mail and sent her a text.  “I need to stay at the VA.  There’s a guy I need to keep talking with.  I’m really sorry.  I’ll call you when I can.”

By the time I got back to my office and to him, I had my text reply.  “Don’t worry.  I’m glad you’re there for him.”  The woman’s a straight-shooter.  She says what she means.  I appreciated those words.  Still do.

We ended up speaking about fifteen minutes more.  It had indeed been a, what, eventful week for him, with a capital E.  He knew that he’d been the cause of a lot of his problems.  He was not shirking one microgram of responsibility.  But still, he was feeling betrayed.  He was wondering why he’d put his life on the line for this.  He was wondering why he had lost the men he loved for this.  He was wondering why there were Iraqis dead by his hand for this.  For life in the America of the marketing campaign, where your every move at Target is studied.

For this.

“You just can’t go to war, you know, as if you had nothing better to do.  We veterans have got to make people understand that.  We’ve got to communicate.  I thought combat was going to be some . . . well, I don’t know what.  I was gung-ho, though, all the way.  Then I saw the kids.  They were everywhere, asking for food, for candy.  There was this one girl.  I always gave her muffins.  It was like her whole world had been made by me, just for some muffins.  And then one day she never came back.”

He paused, his eyes tethered to the ground, as if trying to dig his way back to a doorway in the Middle East.

“I think about her every day.”

Slowly he looked up at me, his eyes moist.

“I’m a good man, really.  I never got into trouble in high school–oh yeah, maybe a cigarette here and there, every once in a while some weed.  But I made good grades, and I wanted to be a soldier.  I went to basic the summer before my senior year, while everybody else was just goofing off.  And then 9/11 came, and I knew: I had to go over there.  I had to.”

I could see him in my mind, the sophomore, the junior, playing baseball, knocking off home runs to impress the girls.  In rural Indiana, of all places.

“I was the only one to carry on the family name,” he barely whispered.  “Now I have a son to carry it on.  I take that stuff seriously, really seriously.  I want to be an honorable man.  Sometimes my morals and my orders crossed.  I . . . I just want my son to know that deep down, I was once a kind man.  I think I’m still good.  I think.  I hope I am.  For his sake–I hope I am.”

Good God, I can only think, even now: where did this guy come from?  A field somewhere east of town?  Seriously?

Yes.  Seriously.

You know what his favorite word is?  Perspective.  I kid you not.  Perspective.  He wants to understand, to “wrap his head around . . .”  Around what?

The killing floor.

And a name.  Borne faithfully from father to son.

The name of a good man.

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