To Remember, Not Relive (Encore)

Silhouette of a soldier against the sun.

As I continue to remember with you Porthos, Athos, and Aramis, the three Army Musketeers, now three years later, I find that a good way to distance myself from my emotional responses is to critique my writing—which is, I must say, quite worthy of critique. Less noble it is, I guess, yet how more pragmatic to edit rather than to wonder what should have been, might have been, or to shed a tear or two.

One of the privileges of aging is to find that one can condemn oneself and then grant clemency to the offender, all within the same breath. Or paragraph, at least.

So, editing is for another day. Today, it is instead 03 February, 2013, and I’ll take my post’s advice: To Remember, Not Relive.

I have written about him before, most recently in the posts Merry Christmas, Reality Notwithstanding and Taking Him On Home. He’s Porthos, the fun-loving rake to the quieter, more relaxed Athos–and their deeply-loved, fallen comrade, Aramis.

Porthos and I have known each other for a while. Our relationship has always been warm–though, shall we say, complicated as well. As the middle of three strong-willed sons born to a strong-willed father, he knows how to make his wants and wishes known. Fear not that, I can assure you.

And I might add: I wouldn’t get into a scuffle with him. Some of the more foolhardy in his time have. They learned. Forthwith.

Yet can that boy pour on the charm, or what. His is a perfect mixture of the quite genuine and the quite consciously manipulative. He’s had more than his fair share of practice through the years.

He actually leaves me reeling much of the time, truth be told. I’m never quite sure whether I want to give him a warm rub on the top of his head or smack the living daylights out of him. Usually both.

Porthos, in other words, is one of those individuals about whom no one–and I mean, no one–can feel nonchalant.

I’ve taken my share of hits from VA colleagues about him. We’re a bit of a known pair, again, truth be told. Some have made it clear, for example, that they think that I “coddle” him. Many have intimated that I should be more “firm” with him, although none has been able to tell me exactly how such “firmness” should look.

Our struggles with each other have usually been around two subjects: medications, i.e., which kinds, how much, how often, etc., etc.; and psychotherapy, i.e., which kinds, how much, how often, etc., etc. Simple.

Although he and I have had our disagreements, he certainly has not been one merely to “demand” something and then pitch a fit if he were not to get what he’d wanted. Quite the contrary: he does his research, and our negotiations around various regimens have reached points of complexity that I can only call “admirable” on his part. Still, disagree, we have, and sometimes strongly. In the end, though, he has always acquiesced to the fact of life that ‘tis I, not he, who has the MD behind the name.

For example, about ten days ago.

Details are not relevant, but it had been one of our more intense, so-called discussions. He let me know in no uncertain terms that I had not started his weekend out on a pleasant footing. I let him know in similar terms that even though that had not been my intention, I could only be so upset thereabout.

We met the following Monday.

He had agreed to come in twice a week, at least for some focused, therapeutic contact, and he had agreed to hook himself up again with one of our intensive group programs. He had also agreed to two-week supplies of his medications, and he had agreed to the dosages I’d recommended.

But that was only a small part of the story.

He’d thought a lot during the weekend, about himself, his family, his sadness, his frustration over the physical limitations that have been plaguing him post-deployment. Of that, I had no doubt: when I opened the door to my office, he was standing there, with just enough of an impatient, “can we get going here, please?” edge to him to keep me on my toes, but with a countenance that more implored me to notice how worn-down he was, how very, very worn-down.

“Hey,” he said, most definitely without the exclamation point.

“Hey.”

“Do you mind if I put my leg up?” he asked, eyes darting to his left, my right, to the second chair in the room which often does its part to relieve his lower back of the pressure that can gnaw at him whenever he sits for any length of time.

“Of course. No problem.”

Soon we were both situated. For a few moments we just sat there, looking at each other, the semi-grin, semi-skepticism on his face, I’m sure, only a mirror of the same on mine.

“We still on speaking terms?” I finally ask, my semi-grin having turned full.

He rolled his eyes.

“I understand,” he replied, full-smiled as well, although for only briefly. “I know I’ve got to do something about myself. I . . .”  Suddenly, he shifted forward.  “Please, Doc, you understand, don’t you? How hard it is without her?”

“Her,” of course, is the young woman to whom he’d deeded not only his heart and soul, but a goodly portion of his every quantum of thought as well. They’d talked of marriage, of having children together, but then finally she’d decided that she could not make it work.

“Dad tells me that I’ve got to move on, but . . . I just can’t get him to understand. It’s not that easy. I don’t want to move on. I know that if she just knew how hard I’m trying . . . But she won’t return my calls, texts, nothing. I’m not going to be a stalker-type. I’m not going to go over to her place. No one’s going to accuse me of that, no one. But if she could just see me, see how hard I’m trying, see how much she means to me–God, Doc, she’d understand, wouldn’t she? Wouldn’t she? I mean, Doc, am I wrong? Can you understand why I just can’t give up yet, why I just can’t move on? Please, tell me you understand, please!”

Porthos is quite a handsome man. How we think the attractive never have to suffer, don’t we? How wrong we are. Anguish is just anguish, whether on the good-looking or on the plain.

“Porthos, here’s what I would say: don’t give up until you’re ready to give up. When it’s time, if it’s ever time, you’ll know. What you’ll then have to do is live out what you will already know. That will be the hard part.”

He looked at me, with a face both steeled and tear-stained. He has all the gear in place for “Leading Man” status, yet I’m hard-pressed to come up with a modern exemplar for him, given that most A-list stars today are simply too “pretty.” Perhaps a young Mark Harmon as the surgeon on the St. Elsewhere of the 1980’s, even then oozing the NCIS Gibbs-attitude that would one day make him America’s favorite Marine, back then painfully walking down that hospital hall for the final time, his character well-aware that he might soon die of AIDS.

“I sometimes just don’t know if I can do this, Doc,” he finally whispered. “I’m not going to kill myself or anything, but sometimes I’m afraid I won’t make it. It just hurts so, her, Aramis, the War, everything. It just so, so . . . hurts.”

The final word had plopped out of him, as if it had been teetering on his lip all the while, not wanting to risk the reality that would result from its mental equivalent having found voice, sound, transmitted out to a world, to me, to . . . what?

And then it happened: in the middle of his anguish, he started to look as if he were ready to fall asleep, to look as I imagined he must have looked at the end of that twenty-four hours he and Athos had had to stand watch over the body of Aramis, waiting for the helicopter to arrive: too exhausted to run, too charged to collapse.

And I realized: he wasn’t with me. He was in Iraq.

“No one has any idea, do they?’ I finally asked, too exhausted, too charged myself. “You’re there, right now, aren’t you.”

He was staring off to the side, grudgingly allowing one tear at a time past the checkpoint, his eyelids in a bizarre, internal arm-wrestling, the upper halves determined to shut this show down, the lower halves determined not to give in ever, do you hear me, ever!

“I’m sorry, Doc,” he whispered, his tears, few as they were, so robust, so proud to be Army-strong, his eyes fixated miles away. “I’m trying, really I am. I hope you believe me. Please believe me, Doc. Please.”

“I do,” I answered, hoping perhaps that some information, meager as it was, would jar us both out of the grip of those tears. “Listen, this is neurologic, Porthos. You see, trauma separates the part of the brain that feels, sees, hears from the part that makes sense of events, of Time, of those very feelings.

“They then stay separated, physiologically. You can only ‘remember’ if the front part of your brain can pull the ‘you that’s you,’, that is, your experience of the trauma, of yourself–your ‘Self’–away from the trauma enough to get the whole brain on the same page, the page that says ‘OK, this has happened, but that was then, this is now.’ Until then, it’s as if your brain is experiencing the trauma in an eternal present. You’re reliving it, not remembering it.

“That’s where the nightmares come from, the flashbacks. When you hurt because your girlfriend’s gone, you’re hurting not only because she’s gone, but because Aramis is gone, because all your buddies who died in the convoy are gone, because you had to pick up what was left of them, all of them. It’s as if your brain is saying, “Oh, my God, here we go again! We’ll never escape!

“Even when the front part of your brain knows–knows without a doubt–that it’s today, not back then; that it’s about your girlfriend, not about Aramis; that you’re in Indianapolis, not the desert: even then, it cannot yet grab onto that other part of the brain that is still feeling, hearing, seeing, smelling, tasting the destruction, the confusion, the adrenaline. The death.”

Pretty good, eh?

One problem, though, a big one:  with each of those words, I knew that I was both helping and hurting him, both assuring him that he was not crazy, yet reminding him that he felt crazy even so. His energy, his intense drive, his inner push never to give up, never: there they were, torturing him, yet keeping him alive, simultaneously, right in front of me, with my every verbal reminder of the truth, the Truth.

It was horrible to watch.

All I could think at the moment was, “My God, this is what they all go through, isn’t it, all these men and women, the ones whose Facebook posts, whose blogs I read, who talk of being walloped back and forth through Time, through emotion, psychically miles away from the loved one before them, then within nanoseconds careening right into them, then back, then in, tethered to a yo-yo only Satan himself could have manufactured–with a smile.”

I had to stop. Had to.

I had learned in a new way what I had never wanted to know. I was Katniss at the end of The Hunger Games, wasn’t I, gazing down at Cato, her nemesis, he nearly devoured by unearthly hounds, begging her, with his eyes only, to end it all, now, please, please.

Like Cato, Porthos looked at me, fortunately not devoured, yet no longer charged. Just exhausted.

“Will it ever get better, Doc?” he asked.

Fortunately, I am not Katniss. I have more than arrows to work with.

“Yes, it can,” I said as I leaned forward. “I’m learning a technique, EMDR, that stands for ‘Eye Movement Desensitization and Reprocessing.’ I’ll give you a website to read about it. Check it out. Go ahead and read other stuff about it on Google, too. I’ll promise you: you’ll find a lot of hot-shot people with M.D. and Ph.D. degrees who’ll swear on a stack of Bibles that it’s hogwash and witchcraft. I once thought that myself. But I was wrong. The technique can help link that experiencing part of the brain with the contextualizing part, maybe not perfectly, but for many veterans, well enough to allow some real, meaningful healing to begin. You’d be one of the first that I try it out on, but I work with a smart teacher, and together, the three of us will find a way to discover how that powerful intensity inside you can save you, not destroy you.”

Still exhausted, but somewhere, unbelievably, still rakish, he closed his eyes, took in a deep breath, opened his eyes back up, looked into mine, and merely whispered, “If you say so, Doc. If you say so.”

I do say so. And I do believe so.

As best as I can determine, remember comes from a Latin root for memory. Yet there is something about the English word, re-member, as if member were a verb to mean “piecing together, putting the members of a body, a group back together.” Horror and grief without context are horror and grief eternal. When re-membered, though, sown back into the tapestry of Time, they hurt no less, but they need hurt no longer. Re-living can then become mere living. How good.

Yes, Porthos, how good.

Until tomorrow, be well,

Doc

No Trouble at All (Encore)

Silhouette of a soldier against the sun.

 

Good to be back with you all.

A date is approaching, next month actually. Seasons move forward through the years, yet certain ones halt us, if only temporarily, reminding us again of what once was, of who was once.

It has almost been three years since I stood with my hand upon a young combat vet’s coffin. To this day, I cannot watch a Harry Potter movie without, at some point, feeling his presence. These next few days, I ask your leave to remember him again with you as well, from prologue to epilogue, with encores of blog posts from March 2012 through October 2013.

As a psychiatrist, I often come upon spots in my heart where certain patients have trod, some stealthily, some ploddingly. This one young former US Army soldier did both and more, through passageway after passageway, still now in memory leading me back to spots where we laughed together, even shed a tear together, always with that smile on his face that made me roll my eyes and smile as well.

There were once, you see, Three Musketeers: Porthos, Athos, and Aramis, united not in Dumas’s France this time, but in the United States Army, in a hot land far from home.

Two have since fallen. One is making the life he can. Here are the times we traveled together, in body and in spirit.

From March 11, 2012 comes the prologue, No Trouble at All.

Today I was in contact again with one of the veterans I work with, one who has struggled almost incessantly since coming home.  He’s a dashing rake, by anybody’s measure.  He comes from a well-educated family.  He’s smart.  He’s intense.  He was once a bit of a bad-boy, but he’s working now to pull his life together, to find love, to find a place back in his family, back in this world.

In a matter of days after landing in the Middle East, this man’s dearest friend—his brother to the core—was dead.  Others in his unit soon followed.  He wakes up in the night screaming, sweating, panicked.  Not a day goes by that he doesn’t think of his friend, often-—usually-—with tears.  To this day, when he promises me something important, he does so on that man’s memory and on his grave.

He’s been trying to get back to school.  It’s been anything but a cakewalk, to say the least, though that says absolutely zero about his talents and his potential, both of which are quite abundant.  He endures the lectures that many of us remember in those 100-level courses, trying to stay focused, trying not to wonder what these kids around him are thinking about him, kids who are just about the age he was when he walked off that plane.

When he sent his buddy’s body back home.

He’s trying.  He’s trying his darndest.

It’s the courses with the papers, though.  They’re the ones that get him.  Too much time to sit in front of a computer.  And remember.

He tries not to overuse his medications.  He’s put his family in charge of them.  Yet there are the times that he wakes at night and can’t stop shaking, can barely move, barely swallow.  He knows a pill won’t save him.  But, God:  it’s so awful.  A war raging, smack dab in the middle of his bedroom.  In the middle of his soul.

He always apologizes when he contacts me.  He’s so ashamed to do so.  But he gets so desperate.  And he hopes against hope that I won’t hold the contact against him, one more time, another, another.

Honestly, they’re indeed no trouble at all.  He knows the drill:  if I can get back with him, I will.  If I don’t right away, he knows that I’m with family or with other patients.  He knows I’ll get back to him eventually, even if it’s just a “hang in there.”  He knows he’ll have his time later that week to come see me, to try somehow to find that devilish smile of his one more time, to remember when it was all easier, to borrow as hope what is my certainty:  that he will find a better day.  One day.  Not today.  Most likely not soon.  But one day.

I can say that because he’s a warrior’s warrior, through and through.  Behind that Abercrombie facade (albeit a brunette one), there’s a force of nature.  He was a handful as a kid.  He’s a handful now.  He won’t give up.  Never did.  Never will.

All I can say is:  good for him.

We took care of today’s matters in short order.  He thanked me quite genuinely.  “I’m sorry,” he said again, “to mess up your weekend.”  I heard the break in his voice, quick, but definitely there.

“No trouble at all,” was my reply.  I had a few minutes on the way to the Starbucks, after all.  I have a few minutes now on the porch, absorbing this quite pastoral Sunday afternoon for mid-March in Indiana.

What else do we have, really, except time, a future.

He doubts he has a future, of course.  My job—our job, as professionals—is to disabuse him and those like him of that notion one day at a time.  No guarantees of any particular outcome.  Just life, with its joys, its challenges, its months off, its back-to-works.

We’ll see each other tomorrow.

And so the story went on.

Until tomorrow, be well,

Doc

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

Recently I received the following comment to one of the posts of The War Within (TWW) series, in the Thoughts section, above.

Doc,

I can’t thank you enough for putting this website together, it may have just saved my life. You have really got something here. I find this article a very accurate narrative of my personal existence. After reading this I’m an introvert for sure, and I feel like I’m losing it again.

I was doing very well for a while. I went from being homeless to completing a program at the Chillicothe VA hospital (during which time my wife divorced me) and getting a great job. I did so well there I got picked up by another company and now I have a bright future. From the day that I left I the VA hospital I felt great but TWW, as you call, was always right there.

I went to counseling and met with my doc for a few months after until I got my job and then I focused on that and the counseling went by the wayside. The echo of my past was always right there but I was able to focus on my job. It was very fast paced and revolved around helping others and working with highly motivated people. I recently ended a relationship and switched to a new job.

The new job is super slow paced corporate job. People, quite transparently, whine and complain at this job and make up excuses to avoid doing work. I feel myself getting lost and falling back inside of myself. My apartment used to be immaculate and now it’s a mess, and I am finding it harder to go to work even though it’s ridiculously easy and pays very well. I feel unworthy of asking for help from anyone, but I feel like you really get what’s going on. What can I do? What should I do?

Thank you,

The veteran who wrote this comment has given me permission to answer it via a regular post. As I have a lot to cover, I will be dividing the posts into two. Here goes:

Dear Sir,

Thank you very much for your courage in sharing with me some of what has been happening in your life and heart. I do hope these thoughts can be of some help.

First, let me share with you an analogy I often use with both patients and trainees. I like to think of the emotions as an indoor pool within each of us. When functioning well, there is a certain temperature variation to the pool’s water, but nothing drastic or too uncomfortable. Like a well-running whirlpool, it also has a certain circulation going on within it all the time, again nothing too drastic or too uncomfortable, yet enough to keep the water from stagnating. Some pools are brightly lit. Some are less so.

Next to the pool is a deck for observation. This is where we “get out of the emotional water” and from where we can “observe” our emotions and take actions vis-a-vis them (e.g., change behavior, alter ideas, consider medical intervention).

Second, let me share a passage from the book that I’m writing, The War Within: Different Veterans With PTSD, Different Missions To Recovery:

I would have you consider the usefulness of thinking of certain combat veterans as kinetic-energy veterans. Like the extroverts that most of them are, kinetic-energy veterans are energized/rejuvenated by movement, literal or figurative, usually via participating in group interactions. Talk = Life for them. If such a veteran feels emotionally empty, depleted, then it’s time to slap a few backs, make a couple calls, gather ‘round ESPN, head down to the local pub.

In contrast, think of other combat veterans as potential-energy veterans. Like the introverts that most of them are, potential-energy veterans are energized/rejuvenated by stillness, literal or figurative, either via solitary or one-on-one activities, or via watching group interactions. Quiet = Life for them. If such a veteran feels emotionally empty, depleted, then it’s time to sit back, make one call at most to a close friend, open a book or fire up a computer, sip a glass of wine or a nice Pilsner and take a deep breath (even if you find yourself in the middle of the pub!)

With that as background, let me say this:

1. The Role of Medications

Although my “role” at the VA is “prescriber,” I do not see myself as a “pill pusher.” Instead, I believe that my job is to help combat veterans understand what, at least for most individuals, medications can or cannot do.

Medications are about “pool management,” nothing more, nothing less. They can warm up overly-cool water, cool down overly-warm water, add a certain flow to stagnant water, calm down waters that are too stirred. In other words, they manage the physical part of emotions: the muscle tension that will not go away, the emotional heaviness that will not relent, the pit-in-the-stomach sensation that accompanies the loneliness of rejection and despair.

Traumatic experiences–the worst that Reality can offer, whether in combat or in any other of Life’s events–are, in this metaphor, pool contaminants that continually release toxins. The toxins they release can change the emotional water’s flow, temperature, volatility. Thus, as these are physical-like phenomena, the effects of the toxins open up the possibility that medications (also physical “phenomena”) can be of partial (although, hopefully, significant) help.

Genetics and environment–Nature and Nurture, if you will–play their role in setting up the basic “chemical structure” of the emotional pool before any traumatic contaminants have been introduced. Some pools are naturally more “active,” for example, some more “still.” Some have a temperature that always runs on the warmer side, others on the cooler side. Some have already had other Life-contaminants added–abusive homes, assaults, poor educational experiences, drugs and/or alcohol– that have already been releasing toxins into the mix.

In a word, it’s complicated, this emotional-pool “stuff.”

Two important take-home messages, therefore: first, particular emotional states most likely arise from a complex mixture of traumatic toxins with the inherent qualities of any particular individual’s emotional pool. Cleaning up certain toxins with certain medications might or might not help the inherent qualities of the emotional pool, and vice versa. In other words, medications can often help a lot–yet at the same time, paradoxically, can sometimes help only so much with any particular physical manifestation such as tenseness, emotional heaviness, and physical despair.

Second–and for combat veterans, more important–medications are almost always detoxifying agents, not decontaminating agents.

I ask my patients to understand the “emotional pool” as located within their whole bodies, not just their heads. Anger, terror despair, shame, even joy: these are full-body experiences, not just head-ones. Detoxifying agents can often help relieve the body of the consequences of those contaminants, their “toxins,” by reducing the effects of external triggers and by putting a damper on the emotional volatility and reactivity that can destroy the interpersonal lives of so many combat veterans.

But the contaminants themselves, those actual traumatic memories that either linger or are reignited by a particular scene, sound, smell: rarely, if ever, do medications remove them. That’s where psychotherapy comes in.

The tasks of the different therapies are usually quite distinct, then. Medications, something physical, detoxify. Psychotherapy, something interpersonal, decontaminates.

Bringing this back to your case, Sir, I do wish to say, therefore, that I am concerned that you may be becoming increasingly physically depressed. Depression as a physical illness is much more than simply sadness. It is a physical tenseness, heaviness, interpersonal loss that can be felt in the musculature and the gut. When the body gets involved in that way and does not recover after a few days, one is more often than not in a physical depression–and physical depressions often do respond at least somewhat to medication interventions. Not always, of course, and sometimes the side effects of the medications are not worth what little relief they might provide to the physical aspects of depression.

Yet you wrote that you’re finding it hard to keep up with activities that you once did without much thinking (e.g., maintaining a clean environment), to start activities you once had little trouble starting, whether or not you particularly liked them (e.g., going to work). You find that you’re feeling “unworthy” in a deep, physical sort of way. These sound, to me, like indications that you might benefit from speaking with a prescriber–a psychiatrist, a clinical nurse specialist, a physician assistant, a primary care provider–about either a medication trial or a re-examination of your current medications, if you are already on some. I’d recommend that you check back with your former counselor to see to whom she or he refers–or if your former counselor is prescriber, to see what that person would recommend vis-a-vis more physical (i.e., medical) responses to your challenges that might be available.

2. Potential-Energy/Introvert Veterans and the Contaminated “Inner Spa of Rejuvenation”

As to issues particular to your being a potential-energy/introverted combat veteran, let’s get back to the metaphor of the “observation deck” surrounding the emotional pool.

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

It’s a totally different world for potential-energy/introverted combat veterans.

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

Kinetic-energy/extroverted veterans go inside primarily for reflection on the emotional pool in order to focus on rejuvenation efforts out there in The Real World. Potential-energy/introverted veterans go inside primarily for rejuvenation efforts, stopping by the emotional pool as a first step in those efforts, in order to live more effectively and meaningfully in The Real World.

So what do you, as a potential-energy/introverted combat veteran, do when a dump truck called The War unloads a few tons of painful experiences–some of which may be inhumanly horrifying–into your emotional pool, creating a toxic quasi-cesspool called TWW, or The War Within?

Rule Number One:

NEVER, ever forget, no matter what or how you feel: your emotional pool has not turned into a cesspool. It may look like one. It may smell like one. It may feel like one. But it is not one. In other words, it has changed its state (i.e., how it is now), not its trait (i.e., it has not turned into something different permanently).

As I said in an earlier post, many veterans feel that The War Within was all that returned from the combat theater. That is never the case. Always two “people” return: the troop/veteran and The War Within. Nothing has changed inside the troop/veteran in function, even though a lot has changed in form.

Rule Number Two:

NEVER forget that you are military; that once you are military, you are military; that those lessons you learned in boot camp about focused energy are no less true today than they were on the day of your graduation ceremony. While TWW smells so bad that it is hard to remember anything, your not remembering your capacities for focused energy does not mean they are no longer so. Yes, you have a very hard mission ahead. Yes, The War Within is contaminating not only your emotional pool, but your whole place of rejuvenation. Yes, you’re going to have to find a way–temporarily, but likely a long temporarily–to rejuvenate the best you can in the midst of stench.

But think of it this way: you survived those God-awful latrines (if you were lucky enough to have even them) in the middle of Hell-temperatured nowhere without showering for days. You’ve been there. You’ve done that. True, this one’s inside you now, so in some ways it’s a totally different ball game. I know that. You know that. But in many ways, it ain’t different at all. It’s just another fun-time day in Paradise. You had what it takes to make it through the first ones. You have the same to make it through this one.

Rule Number Three:

Accept that this day, i.e., this day in which you have to reduce your activity in The Real World and face The War Within, is going to arrive one day, whether you want it to or not. Ask many of the Viet Nam vets: sooner or later, Life catches up with you. If the day is here, take it. It ain’t ever gonna be fun. See Rule Number Two: you’ve got what it takes, whether or not you feel like it.

Therefore, Sir, for you: although this job is hard for you, in that the relative quietness has brought you to this point, my advice is to stick with it for now, get started on your road toward recovery, and then play it by ear day-by-day. No, you won’t like that. But remember: that’s often how missions go. You’re military. You know that. You keep focused on your goal–and you adjust. Granted, this is the longest mission you’ve ever had to or will ever have to go on.

Again, see Rule Number Two.

I cannot strongly enough recommend that you read and follow the blog of Max Harris, Combat Veterans with PTSD. Max is an Army veteran from early in the current conflict, an Arabic linguist who saw more than his fare share of what War can bring. Max is as intense a potential-energy/introverted combat veteran as you can get, and he’s been brave enough to share his life and struggles in all their ups and downs in his blog, both for his own sake and for the sake of his fellow combat veterans. Recently Max has begun his own personal psychotherapy with a private therapist who volunteers for The Soldiers Project, as well as has been participating in a Cognitive Processing Therapy (CPT) group at his local VA clinic. Max has been struggling these past six to nine months quite honestly with his emotional intensity and symptoms, and he has demonstrated how looking honestly at his employment–and dealing honestly with his employers–have made a difference in his life. I know that he’d be more than happy to share privately with you about his challenges and about how he is learning–day-by-day–to meet them.

In the next post, then, I want to talk about what it means to take all this and then apply it to the problem of how kinetic-energy/extroverts and potential-energy/introverts approach differently the combat veteran’s task of “putting The Truth into words.”

Routine, So They Say

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

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

He’s too good-hearted.

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

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

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

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

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

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

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

It still does.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Excuse me, sir?” he whispered.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I wish.

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