The Killing Floor (Audio Version)

On April 18, 2012, I posted The Killing Floor, in which I described my encounter with a soldier who had written a song about his experiences in Iraq.  Since that day, the post has had, as of this writing, 889 hits.  The soldier’s words are direct, vivid–and tough.  Few have been able to read them without experiencing their power quite strongly.

Two days ago, this soldier sent me a copy of the audio of the song, and I gladly agreed to share it on the blog.  I have added it to the original blog, but given how many people have already found his written words so moving, I wanted to make sure that all would have an equal chance to hear them as they were meant to be heard.

If you thought you were affected by the words in print, then prepare yourself.  We’re moving to a whole other level.

In his truly amazing book, On Killing, Lt. Col. Dave Grossman writes the following:

“I [once] discussed some of the psychological theories concerning the trauma of combat with one crusty old segeant.  He laughed scornfully and said, ‘Those bastards don’t know anything about it.  They’re like a world of virgins studying sex, and they got nothing to go on but porno movies.  And it is just like sex, ’cause the people who really do it just don’t talk about it.’

” . . . Killing is a private, intimate occurrence of tremendous intensity, in which the destructive act becomes psychologically very much like the procreative act.  For those who have never experienced it, the depiction of battle that Hollywood has given us, and the cultural mythology that Hollywood is based upon, appear to be about as useful in understanding killing as pornograhic movies would be in trying to understand the intimacy of a sexual relationship.  A virgin observer might get the mechanics of sex right by watching an X-rated movie, but he or she could never hope to understand the intimcacy and intensity of the procreative experience.”  (emphasis in original)

This soldier understands Grossman down to his bones.  When you hear the song, you will know what I mean.

In re-posting the song, I do so for all the men who are in the spirituality group that I attend with the Chaplain here at our VA.  In just the few weeks I have come to know these men (including the writer of this song), I have been deeply moved by their honesty, their willingness to speak whatever truth they need to speak, their nearly-palpable desire to find meaning again in this world.  It is an honor to be part of their lives, and I have come to care deeply about each of them.  So in their honor–and in honor of those whom they loved, but could not bring back with them–I present you again:

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.

A VA Psychiatrist at the Hunger Games (Spoiler Edition)

I take the word “spoiler” seriously: these three books are well worth the read, and part of the pleasure of the read is the relentless unfolding of the narrative.  Consequently, I am not writing my post in this section of the blog.  Instead, I have placed it on a separate page entitled Thoughts, and by clicking this link or the link above, you will reach the post.  You will therefore not be able to “stumble” onto plot details that you might otherwise not want to know if you have not read all three books.  You’ll have to spoil yourself purposely, in other words.

I do this for a simple reason: for me as a psychiatrist who treats combat veterans, the final chapter and the epilogue of the final book, Mockingjay, are nothing short of astounding.  Even now I can’t quite believe how powerful–and how instructive–these two chapters are.  I easily can imagine (and in fact know) that many persons are/will be quite disappointed in the events of these chapters.  Yet when read as a story of trauma and its aftermath, Collins’ final words are so relevant, so revealing, I can only shake my head in wonder–and deep admiration.

Therefore, to speak as deeply about these books as I wish, I have to mine these chapters (pardon the District Twelve pun, as readers would understand!) quite thoroughly.  I suspect that if I had followed the books as they were published, I would still find the narrative compelling.  Yet these final chapters have transformed the compelling into the rewarding–and richly so.

I have gone back and forth as to a recommendation whether combat veterans should read these books.  I’m afraid that I’m going to have to go with the assessment in Nicole’s comment on the previous post and recommend that they not read them.  I do not, however, recommend this in light of the books’ violence, for while violence is certainly within the stories, it is not per se overwhelming.

My bigger concern is the terror, the anger, the confusion, and the grief that the characters of the book must endure–and Collins’ quite effective prose that conveys these emotions throughout the entire narrative.  I repeat a word I’ve used more than once: these emotions are relentless, and these would more likely become  the present-day triggers of the painful memories and experiences that combat veterans have had to face.

Yet still, the ending.  It’s so right on target, so complex and yet so basic.  I wish every combat veteran could feel its impact.

So instead, I do strongly recommend this book to family members and friends of these veterans.  If you let the narrative grab you, you will finally have an inkling–a distant, but accurate one–of your loved one’s experiences.  And if you let the ending be what it is (and not wish for something different, for example, nor wish for more “clarity” or “closure”) you will have an inkling–now a near and accurate one–of what your loved one needs and why it is so hard for him or her to fulfill that need.  As the characters in the book discover (or at least some of them), though, hard does not mean impossible.  It just means hard.

For those of you who have read the books–or for those of you who are just “game,” if you will–I hope you enjoy my Thoughts.

For all of us, though–but especially for the men and women who were willing to go when and where the rest of us either refused or resisted even acknowledging–may the games finally become the past, every day, for a lifetime.

A VA Psychiatrist at The Hunger Games (Non-Spoiler Edition)

When I told my older daughter that I was planning on doing a couple posts on Suzanne Collins’ Hunger Games trilogy, she smiled knowingly and purred, “Well, Dad, I guess there goes your street cred, huh?”

I suspect she probably knows whereof she speaks.

Yet before you join her in your own eye-roll of eye-rolls, consider this: first, I was never planning on reading these books until I ran across an entry in the blog, The PTSD Diary: Two People in Love, Dealing with PTSD/TBI, written by Nicole, the wife of JR, a veteran of the initial invasion of Iraq.  On March 13, 2012, she wrote that Collins had been inspired to write the books partially as a response to the current conflicts, and she then went on to say,

“I hope . . . that as teenagers and adults read the books and watch the movies, . . . there may be a greater understanding about how traumatic experiences affect people.  Yes, the books are fiction, but the subjects are surprisingly real.”

Then just last Friday, I was speaking with a combat veteran with whom I’ve been working for quite a while.  He told me that his son, just about the age of my own son, had just finished reading the first book of the trilogy, The Hunger Games.  (The other two books are entitled Catching Fire and Mockingjay.) When I told him my own reactions to the series, he looked at me in a way that I can only describe as “surprised by hope.”

“So when my son tries to understand all that I go through,” he asked, ” all that’s happened to me and all that keeps happening to me, could I say to him, ‘Remember the kids in those books, what they went through, how they felt?’”

The answer to those questions is, in my opinion, a most definite yes.

I’ll grant you: these books aren’t All Quiet on the Western Front, but neither are we talking Twilight here–not by a long shot.  Although of an entirely different genre and level of discourse than another war-trilogy-turned-blockbuster, Lord of the Rings, I give Collins credit: she’s not as far off from the latter as some cognoscenti of good taste might have you believe.

The books revolve around a straightforward–and horrific–central idea: in a post-apocalyptic North America, now named Panem (as in panem et circenses, the Latin for the “bread and circus” games of the Roman Coliseum), the twelve Districts of the region are kept in check by the centralized authority of the Capitol (located somewhere in the Rockies) through an ingenious little pastime that one could readily describe as “Survivor on Steroids.”

As punishment for having tried once to rebel against the Capitol, every year each District must send one boy and one girl between the ages of twelve and eighteen (called “tributes”)  to the Capitol to participate in “The Hunger Games,” a nationally-televised extravaganza in which the twenty-four young people are placed in an elaborate “arena” that is a huge, hellish world of its own, to fight to the death until one “Victor” emerges to claim eternal fame and glory (well, sort of, more on that next post).  Think of it as something like Nero playing Vegas.

The story revolves around the two tributes from District Twelve, the coal-mining district located in the area of the current Appalachia:  Katniss Everdeen (played in the film version by the ever-complicated Jennifer Lawrence) and Peeta Mellark (played by the ever-boy-next-door Josh Hutcherson).  They are joined in their adventures by Katniss’ best friend from childhood, Gale Hawthorne (played by the ever-luscious Liam Hemsworth) and their alcoholic “mentor,” the District 12 Victor from the games of twenty-five years earlier, Haymitch Abernathy (played by the ever-degenerate–ever-lush?–Woody Harrelson), along with a cast of attractive young co-tributes who range from the clueless to the sociopathic.

Two preliminary matters:

1.  I have only read the three books and have not seen the current movie.  Both my daughters have seen it and rave appropriately thereabout.  From what I can gather from comments on the Net, however–and my daughters agree–this is a movie best seen after you have read the book, just as were the Harry Potter movies.  Unlike those movies, which could not give full expression to the complex details of the books, The Hunger Games as a movie cannot give full expression to the complex thoughts and emotions of Katniss, which truly are the core of the books’ depths.

2.  Spoiler-lite: given this intro–and if you’ve had any exposure whatsoever to the magazines at the supermarket checkout over the past how-many weeks–you can figure out the following right up front:

a.  All four of the above actors are on contract for the next film.  QED: somehow both Katniss and Peeta get out of the arena alive, and

b.  If you start out with twenty-four teens and only one is to live, lots of people are going to die.  QED:  some of the more nasty antagonists whom you might or might not want to see die, do so (see 2(a) if you have doubts).

Given all that, what can we possibly say about the books that can be relevant to the sufferings of the real men and women who return from real combat?  In fact, some very profound things.  I’ll give the “non-spoiler” thoughts today and the “spoiler” thoughts in a later post.

1.  The emotions of combat are ever-shifting, ever-confusing, and, in a real way, everlasting.  As readers/observers, we will either feel them–or we will do what we can to avoid them.  There is no other choice.

Collins does, in my opinion, a superior job of portraying the emotional roller coaster of Katniss at all stages of the narrative, as well as giving the reader a good sense of the emotional roller coasters of all the other characters, even when they are seen through the quite-shifting, quite-confusing gaze of our heroine.

I suspect it might be possible to leave the movie with a certain sense of “is that all?”, given the quite grotesque nature of the underlying premise.  One viewer might be insulted by the banalization of the suffering and the injustice.  Another viewer might be bored by the rapidity of the character development and the confusing nature of the oh-so-Twilight-looking love triangle (if that’s what you can call the Katniss-Peeta-Gale axis).  Good for them.

In the books, however, I would dare you as a reader to avoid the tributes’ feelings of horror and confusion.  Collins writes in an excellent, plot-driven, young-adult-novel style, with a lot of action and chapter-turning tension, especially in the first two books.  (My personal favorite, though, is the third, as I’ll explain next time.)   You will feel the terror, the anger, the deadly moments of hesitation.  My younger daughter, in fact, is still trying to decide if she wants to get beyond the opening chapter or two of the second book, for “I just don’t want everything to hurt like that again.”  She is an astute reader.

Nicole is therefore right, in my opinion, when she argues that the books will give readers a unique opportunity to “feel” combat and PTSD.  But be aware: the books are not being talked about much like that, and most readers with whom I speak get caught up in the action and don’t even dare take time to realize what the cumulative effect of the horrors are doing to themselves.

When I say to folks, “These books can teach a lot about PTSD,” I find that almost always people have never even entertained a thought of that–or have entertained it solely in reference to the source of Haymitch’s alcoholism, for example.  Believe me, though: my patient’s son now has at least some inkling about the terror of combat and its long-lasting effects.  Haymitch is far from the only character who has to find some way to exist “in spite of.”

2.  Not only is combat morally ambiguous by its very nature, it is more often than not the source of betrayal–even by those whom we think we should trust–and of crass moral calculations that can destroy the very foundations of a combatant’s belief in an “engagement” or even a “cause.”

About twenty-some years ago, the psychiatrist Jonathan Shay wrote the book, Achilles in Vietnam.  It’s an amazing book, well worth the read.  In it, he explains how he discovered in the Viet Nam veterans he was treating ways of experiencing combat that Homer described over two thousand years ago in his Iliad.  Interestingly, the first similarity Shay saw was in the crucial role of betrayal in the development of combat trauma, betrayal by “those above us failing in their tasks.”

In the Iliad, the king of the Greeks, Agamemnon, takes without any just cause the slave-lover of Achilles, Briseis.  It is an act of blatant dishonor, truly betraying the loyalty that Achilles had, to that point, shown the king.  In Shay’s view, this betrayal, this misbehavior by a superior set in motion the anger and the sense of injustice that eventually exploded into Achilles’ rage and murderous destruction after he learned of the death of his best friend in battle, Patroklos.

Like Shay, I too have found that many combat veterans who struggle with PTSD struggle in an important way with some sense that “this should never have happened.”  In other words, if others had been doing their job, especially those in the chain of command, a friend might still be alive, an innocent civilian might not have been harmed, a devastating injury might have been avoided.

The veteran is almost always furious at the omission or the indifference of the superior or the persons who “said they were going to be there”and moreover furious not only with the one who failed, but also furious with themselves–and with Fate/God/whatever–that nothing could have changed that.  It makes no sense to feel the latter, but betrayal and guilt never do.

Throughout the three books the main characters have to deal with subterfuge, betrayal, reversals of statements made, half-truths.  They themselves have to participate in just such activities again and again, sometimes for reasons they are proud to defend, sometimes for reasons that they hope no one will discover.  Sometimes deception saves lives.  Sometimes it destroys them.

Death in the midst of lies or in the midst of incompetence always comes back to haunt.  Katniss and her friends find this out, just as has every combat veteran who has doubled up in the most helpless, the most intense of rage, somewhere on a battlefield.

3.  When you watch the life ebb out of your enemy’s eyes, hear the wails of his or her family, he or she is no longer your enemy.

In the first book, Katniss’ actions directly lead to the deaths of four of the six “Careers,” tributes who come from Districts closely allied with the Capitol, who pride themselves on their warrior natures: the girl tribute from Four, both tributes from One, and the boy tribute–the ultimate antagonist–from Two.

Both girl tributes die because of a clever plan on Katniss’ part.  The girl from Four dies off stage.  Glimmer, however, the girl from One and probably the most visible female antagonist, dies a horrific death right in front of Katniss, crying out for help from allies who are no longer to be found, screaming from horrors both in her mind and on her body.  Although Katniss is not at all afraid to take what she needs from the dead girl, she is also horrified by what she has seen happen in front of her, haunted by the memory of the beautiful girl who once had been.

She kills the boy from One in her very own Achilles-Patroklos moment.  Consequently she is not, shall we say,  particularly interested in his humanity at the moment.  Her realization of his humanity comes only much later, at a celebration of all things–a celebration, that is, unless you are the family of the boy, who only then does Katniss learn has a name:  Marvel.

It is the death of Cato, though, the tribute from Two, enraged, heartless, conniving Cato, that haunts her forever.  The movie spares the audience the worst of the scene.  The book is not so forgiving.  Cato was ready to kill Peeta, almost did so once before.  He would have killed Katniss in an instant.  Yet anyone who has read the book will never forget the final exchange between Cato and Katniss, when even his humanity finds it way into her soul.  No one, even Cato, should come to the point of death like that, have to depend on Katniss the killer.  Katniss the merciful.

Remember the veteran of The Killing Floor?  Remember his looking to his right, shooting the man whom he saw only once, yet who now visits him every day?  The Iraqi pointing the gun was without a history, without connections.  Yet in his witnessed death, one caused by my veteran patient, he became a son again, most likely a lover, perhaps even a father.  As long as the enemy is an anonymous District number, a hadji, a goon, you can move on to the next one, the next.

But as Lt. Colonel Dave Grossman reminds us in his book, On Killing, we are not a species born to kill one another.  When our “prey,” our enemy becomes human, so do we.  Ask many a combat veteran who screams in the night, wondering during the day whether he or she deserves that “human” categorization.

I still find myself debating whether to recommend these books to combat veterans.  They are relentless.  Yet because of the final pages of the final book, I do wonder whether the pain might be worth it.

But to consider that, we’re going to have to move on to the Spoiler Edition.

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.

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.

In Memory of Ryan

Last Saturday, Nicholas Kristof of the New York Times wrote a powerful  op-ed piece–an indictment, really–about the epidemic of suicides that are occuring among combat veterans., entitled “A Veteran’s Death, the Nation’s Shame.”  With the column, the Times published on its website a short film concerning the death by overdose of Spc. Ryan Yurchison, put together by the filmmaker Timothy Grucza, entitled “Good Night, Ryan.”  I strongly recommend both pieces to you.

The VA takes its hits in both pieces.  As I say in my “About Me” page, I do not in any way speak for the VA, DoD, or any other branch of the government.  My thoughts–my reactions–are of a man who happens to be trained as a psychiatrist and a psychotherapist, who happens to be a husband and a father and a son, who happens to have the privilege  of working with men and women who have been so willing to give of themselves–and who happens to work for the VA.

That is how I respond to Ryan’s story: as a man, a psychiatrist, a husband, father, son.  Who happens to work for the VA.

Ever since I was a lad, I have often been able not only to sense, but to feel the very hearts of others.  I have learned through the years how many times I have been mistaken in my understanding or interpretation of those hearts.  I can be quite petty and irritable, as those who’ve been following the blog from the beginning well know.

Yet from what people tell me, I’ve many times been accurate as well, even helpful.  When I was younger, I found this more curse than blessing.  Now, it’s the opposite (though I don’t want to overstate that point, believe me).  It’s an amazing opportunity, though, to be my age and to have so much of life come at me, infiltrate me, even–to a certain degree–lodge within me.  Thanks to a very patient therapist who refused to let me do anything but grow, I have managed to construct enough-of-a-self that I can now do for others what he did for me:  take in at least some of their pain, enough to give them a chance to find–and create– enough-of-a-self as well.  For that I am deeply thankful.

Yet I can only be silenced before Ryan’s mother Cherry DeBrow, his brother Michael Yurchison, his best friend Steve Schaeffer.  Though in a sense I can feel their hearts via their voices, their faces, in the deepest sense I haven’t a clue.  It’s precisely because I have my son that I cannot imagine life without him, my life without my daughters.  I don’t “go there” because I can’t go there.  One only goes there when, like Ms. DeBrow, one is there.

For those of us who have the opportunity to work with combat veterans, we have both an advantage and a duty.  Our advantage is an obvious one: unlike the veteran’s family, friends, even the veteran him or herself, our time with the veteran’s  pain is limited, once a week if both of us are lucky, more like once a month–if even that.  The horror of war does not invade us hour by hour as it does the veteran and all those around him or her.  We spend our half hour or so with it, one hour if again we’re lucky.  Then we’re done.

But therein lies our duty.  In that half hour, that hour, we have to open ourselves as much as we can to all the terror, all the rage, all the shame that comes our way–that comes the veteran’s way 24/7.  It is our responsibility to be mature enough to manage those emotions as best we can, and it is our duty–if I might be allowed a more dramatic word, our “call”–to do just that.

Even then, sometimes it’s not enough

When I’m with a veteran in the worst of his or her pain, when the War threatens to engulf us both, right there in the middle of that cubbyhole I call an office, I always go in my head to the same image, the same experience.  I feel a steel rod ram itself right down my middle, implant itself in the ground beneath me, anchor me in some semblance of a here-and-now reality to allow both of us get through the next five minutes–what am I saying, the next five seconds.

And then in my mind, I just have to grab onto the veteran and hold on.  For dear life.

And when he asks me, “Why?  Why do you care?  Why should I care?  Why should anyone care about anything?”, I can only reply something to the effect of “Because I’m here and because you’re here–and because I’m not going to give up.”  Believe me, there has been more than one veteran who has questioned whether that morsel of pithiness should matter one iota to either of us.  Believe me, I’m in no position at that moment to debate the issue.

I can only give the man or woman a choice as to whether he or she is going to even consider whether I mean what I say and whether my being there matters–yes, as a psychiatrist and therapist who’s trained to weather the pushes and pulls of such encounters, but even more as a fellow human.  Nothing more.

Nothing more.

Ms. DeBrow, Mr. Yurchison, Mr. Schaeffer: I can never fully understand what happened, never even begin to understand what you’re going through.  I can only offer you this: I will remember Ryan.  I will keep doing all I can so that other mothers, brothers, buddies need not hurt as you have.  That I can promise you.

May God be with you.

An Open Letter to the Upcoming Generation

It’s been one of those weeks, with days long and tiring enough to call for sleep at their end, rather than typing.  In other words (as if you didn’t know already): I’ve been remiss.

But I’ll confess: one of the “one of those weeks” elements has been my finally succumbing to the Hunger Games trilogy.  I just finished the second book last night, and I’m already well into the third and final one.

So go ahead. Say it.  You’re right, you know.  I should be embarrassed.

I’m not, though–especially since I’ll have at least one post come out of this.  Who knows, maybe more.

On that note . . .

Brief side bar (a serious one): I would not recommend The Hunger Games willy-nilly to a combat veteran. The story has elements that are quite relevant to combat trauma and PTSD, and reading these books gives me a feel similar to one I often feel at my job every day.  More on this later, but, truly, word to the wise: these books could prove quite distressing to men and women who have weathered the traumas of war.

I’ve had some very thoughtful comments this week, to all of which I plan to respond,  One in particular I wish to address in this post, if only to remind myself why I do this blog and this work. A high school student, Stephanie Pieper, has created a Facebook page entitled Veterans With Post Traumatic Stress Disorder. It arose out of a class project, and she has created an excellent “deposit account” for information on all aspects of the challenges of living with and of finding hope for those living with PTSD. In her comment, which appears to have been sent out to a variety of individuals/organizations, she asked three very good questions–three very good questions that merit the following “letter.”

Dear Stephanie,

Thank you for your interest in my blog, and thank you for the work you are doing to increase the public’s understanding of the struggles that many combat veterans are facing. I especially commend you for your interest in making your peers more aware of these very difficult, very important issues. You asked me some questions, and I am glad to answer them as I can.

1. What drove you to start a blog?

First of all–though probably least noble of all–I enjoy writing. I enjoy entering inside a part of myself and seeing what words pop out. Sometimes I surprise myself. Sometimes I simply bore myself.

More importantly, though: as I say in the “About My Blog” section, I have had many combat veterans tell me that they can relate positively–even intensely–with the words I use to try to understand and describe their experiences. I claim no special knowledge. I just go to the same “place” inside me as I do when I write, searching for words to put to feelings that I can only barely comprehend–and never fully articulate. As long as the men and women whom I serve find these words useful, I will continue them.

Finally, there is a technical reason for the blog. Today there are many very effective psychotherapeutic (counseling) therapies for combat-related PTSD, and the VA, where I work, is at the forefront of promoting their widespread, competent use. These therapies arise out of a tradition that focuses on the importance of understanding what and how we think about our emotions, as well as on taking appropriate, helpful actions based on those thoughts.

I was, however, trained under a different tradition, one that focuses more on the stories we tell about ourselves, on the way we can make sense of our lives, and on the importance of powerful, personal relationships in bringing about a more coherent sense of ourselves. This has definitely become the “secondary” approach to the treatment of combat-related PTSD (and I’m not going to say for bad reasons, especially given the resources we have at hand). Still, I hope that this blog, the way that I talk, the way that I express my own experiences when I am with these veterans–all will give the next generation of professionals a taste of the wisdom I received from my teachers so that some of that wisdom can be effectively brought into some aspect of the care of veterans over the coming, many years.

2. What motivates you to work with veterans with PTSD on a daily basis?

To be truthful, I found my way to working with combat veterans quite unexpectedly.  Like many individuals who work for themselves (I also have a private psychotherapy practice), I was looking for a part-time job that would provide health insurance for me and my family. I knew my current supervisor well, and one day (before she became my supervisor) I asked her about any availability of staff psychiatrist positions at the Indianapolis VA. And tah-dah: here I am.

That is only a small part of the story, however. I have long focused my psychotherapeutic practice on the treatment of men who are struggling with interpersonal issues. I like the intensity that many men bring into their counseling work–and certainly no one, in my experience, brings more intensity to any encounter they have than do combat veterans.

In addition, I am the age of the parents of most of these individuals.  Thus I often find myself feeling a certain paternal enjoyment of the veterans.  In my line of work, you have to be cautious about overdoing this: you don’t want to end up burdening veterans with your own needs.  Yet similarly you cannot be “cool and distant” when you are sitting with persons who have been involved so closely with so much horror.  My task hour by hour is to try to find the right emotional distance with the veterans: close enough to be affected by them, but not so close as to become overwhelmed or demanding myself.

Finally, though, I do work with these veterans out of a definite sense of duty–although I need to clarify that word carefully.  The duty is not a patriotic one or a civic one, for I’m not one to feel a strong affinity toward the “nation” in the abstract.  Instead I feel it to be a human duty, arising out of who I am and what I value.  To me, it doesn’t matter whether or not this current conflict is a justified one.  These men and women believed that the honorable task for them was to protect those of us who are not willing (or able) to take up that task.  They do what they do so that we can do what we do.  You may or may not believe that this current conflict is such a task.  No matter: these men and women agreed to protect us by doing well what they are led to do, wherever, whenever.  They gave their youth–and some of them, their lives–for us, whether we wanted them to or not.  I believe strongly that all of us owe them our best efforts to make home “home” for them once again.

3.  What is one thing you would like my generation to know about PTSD?

If I may be so bold, I’d like to suggest two things: one about military life in general and one about PTSD in particular.

As a father of teenagers, I am well aware that most high schoolers these days have no thoughts whatsoever about entering military life.  I do ask, though, that your generation embrace from the start those of your peers who indeed believe that military life offers them the best hope for a meaningful career.

I know that some younger people think that people go into the military only because they lack structure or seek education.  Others think that people go into the military only because they are foolhardy.

Remember, though, as I’ve said in previous posts: some individuals have always been intense by their very nature, “warriors-in-spirit” as I have called them.  For these individuals, the military is not just a fall-back option.  It is the option, a chance for them to focus their energy into activities that can be meaningful and worthwhile.  Granted, combat often complicates–if not obliterates–that meaningfulness.  That’s where the PTSD comes in.  Nevertheless, they still feel the honor of protecting even those who don’t want (or at least say they don’t want) their protection!  Therefore I urge your generation to make combat veterans’ return to civilian life–both now and in the years to come–as seamless and rewarding as it can be.

As to PTSD, though: never forget that the traumas these men and women endured will be with them–and thus with your generation–for the remainder of your lives.  Your generation will never be free from these challenges, and thus I strongly urge each of you to begin preparing for these challenges right away, no matter what professional or personal choices you might end up making.   Learn what you can about the consequences of trauma.  Understand personally and professionally how you can help veterans come to grips with those consequences in ways that are both realistic, yet still hope-filled.

I am fifty-four, and I have about fifteen more good years to help prepare your generation for the work ahead.  Currently I treat men and women who are in their mid-twenties to their mid-thirties.  In fifteen years, they will only be in their forties–and there will be younger ones still, the ages of your generation.  The job of my generation is to transmit to your generation all the wisdom, the hope, and the patience our mentors have instilled in us.  The job of your generation is to make it work for these veterans–for a lifetime.

Again, I thank you for your energy and for your willingness to learn and to share.  If your generation has many like you–and I know it does–the futures of these combat veterans will be all the better.  Good for them.  And good for you.  All of you.

My best to you in your future,

Rod Deaton

The Slide Show

Truth be told, he and I never should have met in the first place.

Working at a VA associated with a major university has its perks, the most glorious being–residents!  Believe you me:  I am more than thankful to have the opportunity to work with young psychiatrists-in-training, not only because of their energy, their intelligence, their curiosity–but also, yes, I admit it, because of their being on-call in the hospital every night.  We staff psychiatrists have it nice as a result, I do grant you.  Even though we’re on call for a week at a time, four to five times a year, it’s all by beeper.  The men and women slogging it out in the trenches at 2AM are half my age.  They might beep me at 3AM to discuss a case, but, hey:  I fall back asleep easily.  Hallelujah.  For residents and for sleep.

In the latter part of 2010, however, it was not always so.  For reasons too complicated to explain, the staff psychiatrists had to serve as the first-call person on the weekends.  Poor us, I know.  Still, another glorious perk of Med Center VA life?  Having  very competent social workers working through the night in our emergency department, triaging and making life livable for all.  Sweet.  Plus, since we are able to access our VA computer accounts via a secure website, we doctors were able to manage all other matters that fall from the quiet of our homes.  Sweet x 2.

I did, though, cover one particularly memorable weekend:  ten admisions to our inpatient service in the span of two days, with two discharges.  None of the admissions was easy.  None of the discharges was.  By late Sunday evening, both I and the very competent, always-faithful nursing staff had just about had enough, thank you.

It was about 9:30 that evening when the ER social worker called me.

She had interviewed a young man who was struggling with acute drug intoxication issues (among other quite complicated matters, it should be added).  This social worker is quite savvy, yet she was struggling to know what to recommend for the man.  Given his impulsivity, she was quite concerned for his safety.  Still, he had “a way” about him, she told me, that made her wonder whether it might not indeed be OK to release him that night to his family, with outpatient care to be scheduled within a day or so.  I remember her words well, listening to them as I was while sitting in an easy chair in our family’s spare bedroom:  “It’s times like these that I miss having the residents here.  Sometimes that was all it took:  having an MD sit with the patient and convince the guy face-to-face that he’d be better off if he’d just come into the hospital for a while and get himself settled down.”

She was right.  I knew that.  I too was not pleased with the thought of this guy’s just going home in the condition he was in.  I knew I was on solid ground to ask the social worker to contact hospital security and then tell the patient that he was going to have to stay, whether he wanted to or not.  I knew that our VA police, our ER staff, and our inpatient staff were all quite competent enough to make that happen with only the minimal Sturm und Drang.  Nevertheless, I also knew:  Sturm and Drang there would be.  The kid was “strong and wiry,” according to the worker, and “he wouldn’t go down without quite the fight.”   “Code Orange” is what we call such a melee in our neck of the woods.  No good comes from such high drama, for anybody, certainly not at 10PM on a Sunday night and certainly not with an already overworked nursing staff (two admitted patients were already on one-to-one nursing monitoring).  I knew that.

Still, I’ve got the initials behind my name.  All I had to do was to say the word, hang up, and go back to reading my Kindle.  The inpatient doctor would have had to have picked up the pieces in the morning.  Wouldn’t have been the first time.

“OK,” I finally said.  “I’ll be there in a half hour.”

I have colleagues who still roll their eyes on hearing that–and rightly so, I might add.  Their knowing half-smiles say it all:  only you, Rod.  Only you.

After arriving and then enduring the knowing half-smiles of the ER staff, I walked into the young man’s room.  He was lying on his side, facing the wall.  He barely turned his head to look at me.  He wasn’t hostile, but believe me, he wasn’t impressed either.  “I don’t know, man,” was about all he could say.  “I don’t know.”

He eventually did turn to face me.  It had been Afghanistan, I finally learned–that, and a quite, quite complicated life pre-deployment.  Bad, the whole scene, really bad.  He just couldn’t take it any more, the waking up screaming, the never-ending newsreel of blood and body parts in his head, the absolute certainty that it would never end, that it never should end, given what he’d seen, what he’d done, halfway around the world, just the other side of town.  He wasn’t going to kill himself, or at least not really.  He just didn’t care.  About anything.

His family had brought him in.  I sat with them for a good half-hour or so in a secluded corner of the waiting room.  I still can see his father, fighting back the tears that he was too worn out to hide:  “We just don’t know what to do.  I love him more than anything, but . . . we just don’t know what to do.”

When I went back to the patient and told him what his family had said, he looked genuinely shocked.  “You mean they’re still here?” he asked.

“Yes.  They’re worried.  Big time.”

Wiry and strong as he was, he dropped his head and began to cry.  “I’m so terrible to them,” he finally whispered.  “They love me so much.  I don’t deserve it.”  Slowly he raised his head.  “OK.  I’ll stay.”

By the time all the admission dog-and-pony show was over, it was about 1AM.  I was about to head out of our inpatient unit when I saw him sitting by himself in our day room, clad in the standard-issue hospital pj’s, staring at the floor, strong, wiry–and anything but.

All right.  I’ll confess it to the entire world.  Here it goes, ready?

Sometimes the Dad in me takes a gut punch whenever I look at these guys, see that far-off look in their eyes, watch their slow breathing, their mouths slightly opened, with just enough shortness of breath to remind both of us that it can all be so tiring, life.  Death.  These are the sons and daughters of my peers.  Each one of them could have been mine.

There.  I said it.

It’s called “countertransference” in the lingo of my trade, the all-too-human feelings that arise in us all-too-human treaters in our all-too-human work.  It can be a problem.  It’s not always, not by a long shot.  It just happens.  I’m no neophyte to this.

Still, it had been a long night.  For him.  Strong, wiry, lost–him.

I went over and sat across from him at the table.  He looked up, a bit confused, even.

“You don’t have to stay, you know,” he said.

“I know.”  We just looked at each other.

I launched into my spiel, the one about feeling so intensely, so deeply that a group of men can almost think the same thoughts simultaneously, not quite knowing where one of them ends and the other one picks up.  About love.  About having a part of your soul ripped out of you when you realize your brother of brother’s not there any more, not even in one piece any more, never again to laugh, cuss, get drunk, stare at a computer screen, reading an e-mail.

“Were you in the military?” he finally asked.

“No.”

Once again, he looked genuinely shocked.  “So how do you know all this?”

“You guys tell me.”

It was his first smile of the evening, skeptical though it was.  “You actually listen?”

I wasn’t quite sure what to say.  I suspect I smiled as well.  “Yeah, that’s sort of the point, you know,” is what I think I finally said, something like that.

The smile disappeared, yet replaced not with a frown, but rather with this look of puzzlement that had a sort of “well, who’d-a thought . . .” quality to it.

“Thanks, man,” he finally whispered.  We shook hands.  I went home.

It’s been a long road since then.  Really long.  Good stuff.  Not-so-good stuff.  He’s told me more than once:  “I think about that night a lot, you sitting there with me at that table.  I really do, man.  I really do.”

It had been a while since I’d seen him.  Stuff.  Not-so-good kind, at least recently.  He looked good, though, better than I’d seen him in a while.  He was so proud of himself, of all the work he’d been doing trying to get his life together, of his dreams to help other veterans.  He was wearing a well-worn Indiana University soccer outfit, still strong, still wiry.  He has one of those “Yeah, I know, I’ve been bad, but you still like me, don’t you?” smiles.

He’s right.  And he knows it.

He handed me a CD.  “Here, man.  I want you to have this.  It’s pictures, from Afghanistan, different stuff.  Just us mainly messing around, you know.  Not really any combat.  I just want you to have it.”

“Thanks.”  I took it.

After he was gone, after I’d written my encounter note, I opened up the D: drive of my laptop and pressed the CD down into it.  My photo program opened up the first picture.  He  was lying on a cot, shirtless, clearly just waking up, clearly not that impressed with the photographer.  I hit the slide show button.

My photo program eases one picture into another, like moseying along through the family album, giving you a few seconds to prepare yourself for the ridiculous look on whoever’s face is about the grace the screen, a sort of retrospective, “This Is Your Life” quality, know what I mean?

It was his smile.  Over and over.  He’s quite photogenic, actually.  Combat fatigues, physical training outfits, swimming trunks, goofy T-shirts, posing with local troops, robed men at fancy hotels, cute kids, even with President Bush, no lie.  There was this family wedding picture.  He was in a tux, holding what looked to be the ring-bearer, his hair slightly longer than Army-issue, sun-bleached just enough.  Went well with the smile.  The whole look.

I didn’t cry.  Yet there was something inside me, that Dad something again.  It’s a sincere smile, his is, one of those “you gotta love me” types, one of those that says–not shouts, mind you, just says–“Here I am, world.”  Here I am.

God, I wish he didn’t know what he knows.

Please, dear God.  Let him find peace.

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.

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