Semper Fi (x 2)

You gotta hand it to Marines: they’re Marines.  Really, what else can you say?

With an amazing amount of accuracy, you should be able to spot one from about twenty feet down the hall.  No one quite walks like a Marine, let’s face it.  Yet worry not: if you miss said Marine at twenty feet, you won’t at five, given that every article of clothing he’s wearing (almost certainly including his boxers) has some permutation of “USMC” emblazoned somewhere thereupon.

And you had better show proper respect for each article thereof, too, if you know what’s good for you.

I met him just this past week.  While probably a bit stockier than he had been right out of San Diego, he was not so by much.  I would have said “Yes, sir” to this guy no matter what my rank.  Every muscle on his face was advertising “resolve” in luminescence just short of neon lights.  He walked into my office with resolve.  He sat down in his chair with resolve.

And it was taking every last bit of his resolve to hold on to his resolve.  For the boy had been jonesin’.  And I ain’t talkin’ a little bit.

He had just made the decision: it was time to stop the pain pills.  They weren’t helping that much anyway, and they were taking over his life.  He’d come too far to let that happen.

And far he had come: he had partipated in engagements that every single one of you who is reading this either a). heard of, or b). had to work really hard not to hear of.  Casualties were many.  He lost men he was so close to, he could finish their sentences.

When he came back home, it was hard, really hard, on his wife as much as on him.  Two girls were born during the time.  He struggled, the usual, the nightmares, the flashbacks, the emotional outburts, the whole bit.

He came to the VA the first time and ended up with a therapist he didn’t find that helpful.  Yet he hung in there.  He’s a Marine, after all, once a Marine, always a Marine, hang-in-there Marine.  She assured him, after all, that if he just stuck with this “prolonged exposure therapy,” he’d feel better.  She knew it.  She’d seen it happen.

Finally he’d had it.  He called it quits.

Soon, however, both he and his wife had had it with how he’d become after he’d “had it” that first time.  So being a Marine, he tried again.

This time it worked.

He has felt understood.  He has felt that he has been taken seriously.  He has felt that he doesn’t need to worry about falling apart every time he walks out of the Clinic door.

The therapist meets with him and his wife.  There have been some challenging encounters.  But he and his wife are together, working together.  He’s even doing more than his fair share of the childcare.

“And you know what?” he said to me.  “I’m not that bad at it.”

Of course not.  He’s a Marine.

True, I know: many will not associate “Marine” with “caretaker,” and they will be right (and often, quite painfully so).  Yet this man is a Marine’s caretaker: he has taken on his daughters as a mission.  He has looked hard at his behavior.  He’s “loosened up”–I won’t say “quite a bit,” but “a bit” isn’t fair either.  He is proud of himself.

He still has bad days.  Certain days of the year are harder than others.  He and his wife still have their struggles.  Nightmares can still come to haunt.  But by his report, he is doing much better.

Day One, he started on Suboxone, the opioid substitution medication.

Day Two, I had a chance to meet his wife and daughters.  His wife is a pleasant no-nonsense, armed with very appropriate questions for me about her husband’s care.  The older girl actually sniffled a bit and crawled into Mommy’s lap upon first meeting me, yet within a good ten minutes, she was–well, not exactly warming up, and not exactly flirting, but more like, what, letting me know that she might give me a chance, but on her timetable, thank you.

And the younger daughter?  If that girl ain’t a general in the Marines by the time she hits retirement, then clearly there is no justice in this world.  She marched into my office, chatting full force, headed straight to the Keurig carousel and demanded to know the difference between Tazo Zen tea and Starbucks French Roast, and right now, buddy, understood?  She then began to inspect my bookshelf.  She was not impressed.  Fortunately a pen, a pencil, and some paper spared me further dressing down à la Full Metal Jacket.

By Day Three, our Marine was feeling much better.  And the General?  She was pooped, so she stayed in her stroller.  But both Papa and I knew that we’d better get our business done and fast, lest the demand for freedom come now, I told you, NOW!

I am indeed coming to the conclusion that Semper Fi has its own nucleotide chain on at least one chromosome.

Semper fidelis, however, “always faithful,” need not apply just to Marines.

I would also like to honor a mulier semper fidelis, i.e., an always-faithful woman: our Marine’s therapist.

While one may complain about the VA ad infinitum, one matter is undisputed: we have a great (and I mean, great) electronic medical record system.  With a few pecks on a keypad, I can get access to a veteran’s medical records from VA’s across the country.  And that is useful because, in this case, our Marine does not usually get his care in Indianapolis.

When I went to his full record, I counted up the number of sessions that our Marine (and sometimes his wife) have had with our faithful therapist.

Over the course of the past year, twenty-seven.

That’s 2-7.

Why, pray tell, you might ask, am I making such a big deal of said number?

Well, the answer is in the therapist’s notes.  For you see, with each note the therapist was assuring me, the reader, that she was performing “evidence-based CPT,” i.e., cognitive processing therapy.  She applied evidence-based CPT at her last session.  She applied it at the session before that.  I can only assume that she will apply evidence-based CPT at her next session (next week), as well as the session after that and the session after that.  I have no reason to assume otherwise (either as to her documentation or as to the fact that she will be seeing him at least three more times).

Let’s have some fun, shall we?  Check out this for link for Wikipedia, that final answer for all matters human.  It is to the article for, you guessed it, Cognitive Processing Therapy.

Read said article now.

Did you notice anything?

Did you notice the number 12 appearing in several places?

Pray tell, to what did said number 12 refer to?

What, you say?  The number of sessions needed to complete a course of said Cognitive Processing Therapy?

Hmm.   12.  27.  Correct me if I’m wrong, but 27 is 2.25x 12.

Am I right?

Hmm.  But the studies say . . .

Ah, the studies.

Let’s have us a little chat about my world at the VA, shall we?

The VA is really into evidence-based therapies.  Really, really, really, really.  (So’s the Department of Defense)

Now, the evidence assures us that 12 sessions of CPT should be quite significant in reducing the symptoms of PTSD.  I do stress reduce, for as we know, there is always an escape clause in every application of a therapy study, i.e., it’s statistical and actual results may vary according to the clinical situation.

I love that.  I mean, as a lawyer, I really love that.  Really, really, really, really.

I mean, give me that clause, and I’m good to go.

Clearly, so is our faithful therapist.

For you see, if we were to be honest here, our therapist is misusing critical human resources in caring for our Marine.  Why, if she were truly following what the evidence shows, by this point she’d have sent two Marines into the world, filled to the brim with new schemata to counteract their maladaptive beliefs, thus allowing them to move forward, beyond their stuck points, now on their own, to apply their newly-formed coping skills to myriad newly-arising life situations.

And furthermore, a third Marine would, even as we speak, be preparing to leave mere psychoeducation to enter into a phase of practice and Socratic dialogue, his or her redemption being assured, naturellement, before Halloween.

OK, here’s where it gets really fun.

Let’s go back to our “clinical situation.”  OK, 27, twenty-seven.  All right, now all we’ve got to do is come up with why we’re still at 27–and counting!

Oh, let’s see, what could we say?  Our Marine did not fully incorporate his learning sufficiently during the first twelve sessions because, oh, what, he didn’t try hard enough?  Oh dear, no, that can’t be it.  He lacked the requisite cognitive capacities needed to do so?  Oh, ditto, shoot.  His clinical situation was more complicated than those who participated in said studies that produced said evidence for said evidence-basis?  What, more of his friends died?  He got knocked around more than the other participants?  His dad beat him senseless every third day as he was growing up?  (Oh, shoot, no, the initial assessment tells us that’s not the case, darn it.)

Well, how about . . . this:

How about, 1).  His therapist knows what to put in the chart to keep the honchos-who-know happy.  OK, check.

Now for 2):

His therapist takes him seriously.  She does help him learn to think more usefully before his emotions get away from him.  She sits with his tears, as long as he needs to cry, no shame whatsoever, knowing that, yes, one day the flow of the tears will slow, that then will be the time to think, and feel, and think, and feel, and maybe not say anything for a few minutes, and then feel, and then . . .

And she’ll do this week after week.  She’ll remind him of the progress he’s made so far.  She will assure him that setbacks are part of the game.  She won’t even think about when Session Eleven becomes Session Twelve becomes Session Thirteen, because at the end of each session he says that it’s been helpful to talk, to get new ideas, just to get all this sh** off his chest, and he looks forward to getting together in a couple of weeks, and then a couple weeks after that, and then after that, because each time they’ll talk, and he’ll get new ideas and will get all this sh**off his chest, and then . . .

Fidelis.  Faithful.  This resolute man, though still struggling, is proud that he has regained some of his resoluteness.  People can still irritate the you-know-what out of him.  He still really can’t handle Target or Wal-Mart, let alone a job in which he actually has to act as if this buffoon he’s working with truly knows his head from a hole in the ground.  But he can talk more with his wife about the “problems of daily living,” as many of my fellow mental health professionals so disdainfully spit out.  He can take some time before bed, pull himself together, and even sleep more nights than not without revisiting Hell one more glorious time.  And if he runs into problems, he’ll talk to his therapist about it in two weeks–wait, no, it’s this week, isn’t it?

Whew.

And he can even manage to take care of the General.  By himself.

Well, what do you know.

I have only one thing to say, to the therapist and to the General:

You go, girl.

2 responses

  1. As a former Marine, this entire entry makes me feel icky on the inside. The DoD spent a good amount of time, money and patience in convincing this man that killing another human being was a justifiable act and the loss of his comrades was “unfortunate”. You can’t convince people it’s alright to act violently and take life and then convince them that it’s, suddenly, not alright. I’m glad this guy is able to relearn how to be a father and I know it must be a weird dissonance to be inside an institution that is intaking massive numbers of service members, exiting veterans with a wide plethora of exhibited symptoms that require correcting before they are fit to not harm others or themselves (unless, let’s be honest, they’re told it’s okay).

    I think the DoD truly thinks that you can train humans like you train dogs: to attack on command and only at specified targets. And with the number of veterans and service members committing suicide as they, too, experience that dissonance, appears to speak louder than the statistics-based (“evidence based”) therapeutic approaches.

    It’s cool that your therapists are adapting to their environment versus just processing service members out the door. I’m sure some unsuspecting loud-mouthed guy at the neighborhood bar should also be thankful. Maybe even a sheriff’s deputy or two.

    Quick question: does the VA keep statistics on marital and child abuse from service members returning from theater? What’s the comparable figures versus a general population of Americans? What’s the ANOVA on spousal abuse, assault and battery charges, and suicide (attempted and otherwise)? Do they have the cross correlation of these figures and CPT?

    I’m not trying to be a dick. I’ve just tended to notice there’s a weird drop-off between the VA clinic and the street corner.

    • So sorry it took so long to get back to you. As I said in tonight’s post, it’s been one of those weeks. As to the VA specifically, I can’t speak for sure, but I’ll say I’ve not heard of anything like that. Things are changing (yes, and not) at quite a pace around here, so maybe there is something like that coming together, but obviously it’ll be a long while before anything of use comes of it. I do believe, though, that there are independent agencies/foundations at least trying to examine these issues. I’ll see what I can find and let you know back channel.

      I like your blog, and I look forward to following it. Keep telling it like it is.

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