The Handshake

Finally, I’m back.

The movers have driven away. Much to the relief of our children, my wife and I have returned (somewhat) to the world of the living and semi-human. A very good thing.

Now . . .

First, my thanks. Second, the news. Then, the Marine.

The Thanks

I cannot begin to know how to express adequately my thanks to the editors of WordPress for having spoken well of the blog and specifically of my tribute to my veteran-patient, Ethan, in Reporting for Duty, Sir. Similarly, I’m in the same position thanking all those who have begun to follow the blog as a result. Your encouragement means a great deal to me, and I hope that I can continue to honor the men and women whom I’m privileged to serve through the blog and all those whom it reaches.

The News

With a great deal of mixed emotion, then, both excited and pained, I announce to my blog readers that as of June 28, 2013, I will be leaving my position at the Richard L. Roudebush VA Medical Center in Indianapolis.

First, the excitement.

On July 1 (or some time thereafter, the bureaucratic gods so willing), I will be taking up my new position as the Medical Director of the Warrior Wellness Unit at the TriStar Skyline Madison Campus in Nashville, Tennessee. TriStar Skyline Medical Center, a division of Hospital Corporation of America (HCA), has at its Madison Campus in northern Nashville put together a program for active-duty personnel and veterans that I can only describe as abso-stunning-lutely amazing, offering quite comprehensive behavioral health services for military persons, male and female, current and former. As a private facility, it does depend upon third-party reimbursement for the maintenance of these services, yet the Hospital Administration remains committed to monitoring the implementation of the Health Care Affordability Act over the coming years so that as many persons as possible who have sought honorably to serve in the military might be able to benefit from the Program’s high-level, acute care.

Many of the staff members (RN’s and Masters-Level Counselors) are themselves former military, and in just my few meetings with them so far, I’ve been far-more-than-impressed with their commitment to the highest quality care and treatment of any who are serving or who have served in the Armed Forces.

Nashville is a great town. This is a great job. My wife and I have found a great school for my youngest. We are actually moving into a great place that is reasonable in size and quiet in location. Great.

Now, the pain.

I had had no plans whatsoever to leave the VA system. In spite of my periodic gripes about some bureaucratic meshugaas or another, I have appreciated deeply my colleagues and, even more, have appreciated and cared deeply about the men and women whom I’ve had the opportunity to serve.

My wife and I made our decision to move based on personal, family factors that thankfully meshed well with the professional opportunity that the Warrior Wellness Unit offered. Yet I’m haunted by the feeling—never once validated by any veteran whom I’ve served, I might add—that I’m leaving all the veterans I’ve served behind on the battle field.

As is said colloquially, this is not my first rodeo, so I am quite aware that my haunting does not mean I actually deserve any spectral visitations, whether of the Patroklos kind, the Christmas kind, or any other kind.

And I am also quite aware that simply because the veterans whom I’ve served have not overtly validated those feelings, I cannot therefore blithely assume that there is not at least a part of each of those veterans that feels that I exactly deserve any ghostly chain that might be rattled at me.

Eventually almost all of them—sheepishly—will most likely ‘fess up to the latter. Good for them.

There is much to discuss over the coming days and weeks, not the least of which is how the blog will both change and not change. Yet just as my life with these brave men and women has progressed in the past months and years, so it will progress now: one encounter at a time.

Therefore . . .

The Marine

I haven’t written about him since last fall, when he went off to an intensive treatment program to help with his combat trauma and opiate dependence. To longer-time readers of the blog, however, he is no stranger:

1. Will the Real Me Please Stand Up?
2. Location, Location, Location . . .
3. Youth Remembered, Youth Blown Apart, Youth Renewed
4. 2K, 1 by 1
5. “The Ghost of My Innocence”

We began working together again a few months ago, after he had returned not “cured,” by any means, yet still much better, less tormented.

Until recently, the opiates had remained a problem—but that means, of course, that recently they have not been. Good for him. Very good.

He came in for a scheduled appointment just a couple days after I had published “Taps” and the Last Musketeer, the post in which I had described the funeral of my patient, Porthos, and my interactions with Athos, his battle buddy, the “last one standing.”

“I cried like a baby probably four different times while reading it,” my Marine told me. “One was especially bad.”

“And that one was?” I asked.

He looked both down and off, as if he were conjuring up the screen inside his head, perhaps much more.

“When Athos said to you that he didn’t want to let Porthos go,” he said quietly. “And then when he went over and saluted the casket. I . . . I don’t know. I just didn’t think I could take it, reading it.”

I gave him a few seconds, then “You never got to see their caskets, did you, Mike’s, Keith’s, the other guys’. You were struggling to stay alive after the blast and you didn’t even know they were gone, you in a coma, your body desperately clinging on to your arm, refusing to let it go, just surviving.”

He took his own few seconds, finally raising his head, slowly, looking me directly in the eye.

“You know, Doc, people tell me all the time how grateful I should be to be alive, to have my arm, to be able to use it. And I am. I really am. But somehow, when you’re the only one left, nobody can get it. I stayed alive so that they could stay alive. They stayed alive so that I could stay alive. Now I’m alive, and they’re not, and I . . . I . . .”

His deep sigh, his looking downward said it all.

“Failed?” I finally asked.

“You know,” he said, looking back at me, “I know that’s not true. In my head, I know it’s not. But in my heart? Those were my men, Doc, my men.”

His intensity, his sincerity: they made it both easy and hard to listen to him, take all of him in, his words, yes, but also his breathing, his cadence, his posture.

“In some ways,” I said, “it could be easier to imagine being in the coffin than outside it, couldn’t it, with him, flag-draped, the whole ordeal over, the War, Life, united with them again, somehow, maybe?”

His gaze drifted off. “I don’t know, Doc. I just don’t know.”

Athos and I have had similar conversations since Porthos’ death. The metaphor came quickly to me, so visual.

“It’s as if you’re either in the casket,” I finally said, “or you’re standing guard right next to it, as if it were your very own Tomb of the Unknown Soldier, keeping vigil 24/7, never leaving your man behind, faithful to the end, refusing to leave the casket’s side and live, not only to show your solidarity with all of them, with Mike, Keith, the others, but even more to promise them that you will always—always—hold them in your heart.”

“We knew everything about each other,” he whispered, still looking off. “Absolutely everything, and I . . .”

“And you,” I whispered, “are the last one left to hold them in your heart just as they were in War, with their fears, their bravery, their goofiness, their love, everything, when they were at the most real, in some ways their most alive, right?”

One more time he turned to look at me, without tears, though, as if his eyes, his lacrimal glands were telling me that they just no longer had it in them any more—that I should therefore just fill in the blanks, and I’d get the gist quite fine, thank you.

“You just can’t imagine what it’s like,” he said, “not to be able to punch on them, joke around with them, just . . . just see them there, right in front of me, laughing, cussing, you name it. I . . . I miss them so much.”

It was then that it finally hit me.

My Marine has known for a while that I will be moving. Like many of the men and women whom I serve, he knows my e-mail address, my text number. He knows that I have gladly offered to stay in touch, by Skype, by FaceTime, both of us knowing that even though I will no longer be able to be his “doctor,” I can still be an older friend, willing to listen, even willing to shed a tear or two of my own every now and then, living as we do in these times when The Jetsons is beginning more and more to look like a documentary

But pixilated image does not a body make.

“And now,” I finally said, as calmly as I could, “once again another man leaves you behind, not giving you any choice whatsoever in the matter, this one promising to stay in touch, sure, to go eye-to-eye if necessary, but still, not “there”-there, not . . . embraceable.”

This time the familiar tear returned, the familiar bite of the lip, the familiar look that shouts “I don’t want to deal with this now.”

“I know it’s going to be OK, Doc,” he spit out, scarcely audible. “I know that I’ll see you again, that you’ll only be a few hours away. It’s just . . .”

The swallow took too much effort, took too long to allow the thought to conclude.

“It’s just,” I added, “that it won’t be me, will it, the physical me. All you have to touch now of Mike, Keith, the others are their gravestones. Physically, they are gone, never to return. For me, all you’ll have to touch is a computer screen. Yes, you know that it’s a simple interstate that will separate us, nothing more, no bugles, no folded flags. We may both know that in our heads, but the heart . . . it’s not so sure, is it. It says that this whole ‘moving’ on my part smells an awful lot like another set of forced separations several years ago, ones that closed down any possible Skype connections for good.”

He looked at me for a good ten seconds or so. His question, when it came, was emotion-drenched, sincere, felt in the heart far more than the mere word heartfelt could ever even begin to describe.

“Are we going to make it, Doc?”

I leaned forward, as sure then of my answer as I am now typing it.

“Yes. Yes, we will. Your body will begin eventually to get it, that virtual presence can still be real presence, that the past is not doomed to repeat itself, that two people who care about each other and who work together toward growth will find a way to make it work— not just survive, but really work, finding-some-kind-of-meaning-in-this-crazy-world work.”

He smiled. It was good to see that. “I’ll hold you to that.”

“Roger that,” I replied.

It was only as he eventually got up to leave that I realized, however, that “making it work” was going to have to start right there, right then.

For often at the end of sessions, we have embraced, no big deal, but meaningful (yes, to both of us). Not exactly kosher in the view of many, I readily acknowledge, but for us, it has worked. (You’ll either believe that or you won’t, and I won’t hold either view for you or against you, promise.)

As I looked at him at that moment of imminent departure, though, all my training, all my supervisors’ admonitions began to mosey their way from my frontal lobe and its associational memory circuits down to my limbic system, my emotions, to the place whence all life arises as my day dawns, the place whither all life seems again to return after a solid day’s work.

I didn’t want to say what I knew I had to say. I’m human, after all.

But there you have it.

“You know,” I began, pressed forward by every clinical aphorism traipsing off my neuronal staircase, “given all we’ve talked about today, it probably makes sense . . . not to embrace now, like we often do. If we’re going to work together to learn that sight and sound alone can be enough to make a relationship work, after all, then, I think, well, we should probably start now. You know what I mean?”

So definitive, so decisive. I know. But again, there you have it.

I awaited his response, enduring in my head the countless “I told you so’s” from colleagues and mentors, present and past. Once again, as if on cue, his smile rescued me.

“I think you’re right about that, Doc,”he said, thankfully with at least a bit more definitiveness, more decisiveness than I’d been able to muster. “Why don’t we . . .

He offered me his right hand, a simple motion, forward.

“Why don’t we just shake on it?” he said.

Thank goodness that sometimes in therapy, our patients rescue us at our moments of greatest need.

“Sounds good,” I replied.

And so we did.

Life is full of decisions. Life is full of decisions thrust upon us. Life is full of events that force someone somewhere, perhaps us, perhaps not, to make decisions about something, sometimes again and again.

There was a time in my professional life—and not so long ago, I might add—when the last gesture I would have ever thought of offering a patient would have been, dare I even type the word, a hug. Believe you me, I would not have thought  that simply because of some unwritten rule somewhere, either. I would have thought the action unwise. I would probably still think it unwise.

Most of my veteran patients have been men far younger than I. As veterans who successfully completed their term of service with either an honorable discharge or its equivalent, they had learned to be respectful of older men, even when those men had yelled at them, taunted them, harassed them. They had even found a way to act respectful of the older men who had betrayed them.

They had learned to be deferential to men who had made decisions for them, who had transferred them to parts unknown without warning, who had ordered them to do what some of them had not been sure they ought to have done.

They certainly had learned that life is very, very often not fair, that they could not expect to get what they wanted, not only when they had wanted it, but perhaps ever. They had learned how to say, at the drop of a hat (to avoid the drop of a body to “do fifty”), “Yes, sir” and “No, sir” and “Thank you, sir.” As a result they had learned right down to their bone marrow the lesson that countless young soldiers and Marines have recited to me: it is what it is.

As an older male professional, therefore, I can get away with metaphoric murder with these veterans (and probably could count on them to help me cover up a literal one). I can give them a hug at session’s end and they won’t freak out (just as long as I follow their lead for how long it should be). They will say, “Thank you, sir.”

I can look them in the eye and say, “Sorry, I’m moving two states away in a matter of weeks.” They will say, “Good luck to you, sir.”

After all, many of them know what it is to have the best friend they could ever imagine die right in front of them. They will say, “It is what it is.”

“Sir.”

My job is to know—and to give them the permission both to know and to express directly to me—that it’s all a bit more complicated than that.

The old psychoanalysts did not warn therapists about the physical touching of patients just to be prudes. In fact, they did not warn us just to keep us away from “boundary violations” that can destroy our patients’ lives.

They warned us also because even gestures well-intentioned and well-received can nevertheless have consequences unforeseen, complications that all will have to address. And by “all,” they meant all.

I don’t know if I’ll ever forget that moment that my Marine and I looked at each other and offered each other a hand. In that moment, the ghosts of young men long-departed whispered to us both, reminding us that Life is not always fair, is never predictable, is always to be lived minute by minute. In that moment, two men had to understand both in action and in word that we all hope for a total rescue that nevertheless can only come in bits, can only be achieved imperfectly at best. And in that moment, we both expressed to each other that each of us was going to continue to keep trying to find a way, even when neither of us has a clue whether a way will be available, to acknowledge that it is what it is, to hope, against all hope, that—just maybe—it will be what it will be.

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