There are many different kinds of fathers, many kinds of courage. This is dedicated to my own father, as well as the many other warriors & fathers I have loved…
As a psychiatrist and a physician, this is the protocol for presenting a patient, an initial psychiatric evaluation. To maintain confidentiality, details have been altered to protect the patient.
Identification: Mr. Klein is a 27 year-old computer programmer with a recent history of worsening depressive and anxiety symptoms, presenting for evaluation of possible Posttraumatic Stress Disorder.
Chief Complaint: “I am not sleeping and my family says I am not myself anymore”
History of Present Illness: Tim states that his sleep keeps getting worse. He is now sleeping 3-4 hours a night on a “good night”. He sleeps 10-12 hours once every couple of weeks. His mind races and he can’t sleep without some noise or a light on. This has been going on for about 2 years. He does not feel rested. He does not take naps. Energy is low. He has tried taking over-the-counter sleeping pills, which make him feel hungover and still not rested. He is having nightmares 2-3 times/week.
Tim’s mood is labile, he switches from happy to angry almost instantly This can happen multiple times a day. He states that he is snapping at people all the time. Appetite is low, he eats about once a day, because his wife makes him, otherwise, he forgets or doesn’t care. He has lost 10 pounds in the last several months. He has decreased motivation and some difficulty with focus and concentration, is having to write things down more. He used to enjoy hunting, fishing, riding his dirt bike, working out and being with his family, but has not been able to enjoy any activities lately. He continues to function at work, however he does snap at coworkers more than usual and can’t always explain why.
He did have one experience of extreme hopelessness and sat looking at his gun about 6 months ago, and occasionally feels like there is not a point to living, but states suicide is not an option for him because he could not do that to his family and also feels like his dog needs him. He still sleeps with his gun.
Tim endorses trauma in Iraq but is hesitant to describe it, only saying he cleaned up dead bodies. He endorses re-experiencing symptoms and describes these as repeated, disturbing, uncontrollable memories of the trauma, nightmares of the same, and having physical symptoms of shortness of breath, chest tightness, sweating triggered by babies crying, large groups of people. These episodes occur a couple times a month, lasting 15-20 minutes. He has difficulty turning generalized worry thoughts off.
He describes avoidance symptoms as an inability to discuss events of deployment with anyone, inability to go to Wal-Mart or movies; feels distant and cut off from people, occasionally loses track of time. He describes hyperarousal as extreme difficulty falling asleep, jumping when someone comes up behind him, almost hitting people that tap him on shoulder, has to sit in the corner facing out at restaurants.
He denies manic/hypomanic symptoms, including hyperverbosity, euphoria, excessive impulsivity such as gambling/spending sprees, pressured speech, increased energy, decreased need for sleep.
He denies auditory hallucinations, but describes seeing shadows out of the corner of his eye occasionally. Denies paranoia per se, but also worries excessively about being judged by others in general. Denies reading others’ thoughts or concern for others inserting or reading his mind.
Past Psychiatric History: none
Past Medical History: history of ACL repair several years ago, otherwise healthy; no head injuries.
Medications: none, occasional multivitamin
Allergies: no known drug allergies
Family History: Father with coronary artery disease, died of myocardial infarction in his 40’s; Mother is healthy with possible anxiety, never treated.
Social History: Tim grew up in Salt Lake City. Describes childhood as “okay”. Is oldest of 4, with 2 brothers and one sister. Father died when he was a teenager. Father was authoritative, strict, occasionally spanked the kids. Mother was quiet & loving, but devastated by loss of patient’s father. She struggled to raise the kids. Mother remarried x 2. Once when pt was young and again more recently. Happily married now. Patient left home at early age and worked several jobs. Is still close with mother and siblings. Had several relationships with women, but married when his current wife got pregnant. Has been married 5 years and has two children, ages 5 and 3. Wife is supportive and works as bank teller. Patient graduated high school and has some community college, would like to return to school. He currently works as programmer. He denies sexual/physical abuse.
Military History: joined Marines at age 18 to “get life straightened out”, liked the people and the structure, was a combat lifesaver, deployed in 2003, 2006, 2007; honorable discharge, highest rank of sergeant.
Substance Abuse History: First drink of alcohol at age 17, “partied” a couple of times in high school, socially in military and since discharge, recently increasing over last couple of months to a 6-pack a night, most nights of the week and occasionally drinking to get drunk on weekends. History of blackouts on 2-3 occasions. Denies ever having withdrawal symptoms or DUI. Smoking tobacco since combat training, one-half pack per day. Remote marijuana experimentation, none recent. No other illicit. No misuse of prescription medications. Rare caffeine.
Mental Status Exam: Tim appears stated age. He is well-groomed, with good hygiene, in professional clothing. He had normal eye contact and was polite, appropriate. He was cooperative. He appeared mildly anxious throughout exam, with some foot tapping and hand-wringing. He was alert, oriented x 4, was able to attend. His speech was of normal volume, pace and pressure, with mildly shaky intonation at times. His mood was described as “irritable”. His affect mildly dysphoric and mildly anxious. His form of thought was linear. Content of thought was normal, no circumstantiality/tangentiality, perseveration, delusions or current suicidal or homicidal ideation. His perceptions appeared normal with intact judgment and insight. No gross cognitive or memory impairments observed.
Normally this is the point in the evaluation where the assessment, diagnosis and treatment plan would be in the outlined. Instead, here is more of the story. What is written thus far is how I see and formulate the patient after 50 minutes, but Tim grows and fills out over the months and years that he comes to me for follow-up medication management and talk therapy. Although parts of the story will circle around again and I hear them repeated, either he will add something new, deeper or I will ask a magic question and get more. We develop a relationship. He trusts me and lets me in. He gets to know me, in that I truly care about him, there is nothing that he can tell me that will make me turn away from him.
It is in his telling, testing, trusting that he begins to allow himself the peeling away of the layers.
Tim was the good son. The boy who had had the perfect life, hunting, fishing, camping with his father – idyllic, reliable. His father strict and authoritative, Tim always knew where he stood, how to succeed and exactly when and how he failed. He also knew his father loved him. He had something he could count on. After his father died suddenly of a heart attack, in Tim’s adolescence, he had to learn as a kid, a junior in high school, how to be his own man. His mother, so lost in her grief, she could barely care for the young ones, and Tim concerned that he was a burden to his mother, he left home at an early age and worked to support himself. He lost not only his father, but his mother and his home. He spent many years taking pride in the fact that he cared for himself and only now, many years later begins to sidle up to the sadness of it. The emptiness and loneliness of it.
Struggling to make his way, he supported himself. But also lost years to parties, girls and occasional drugs. He met an older man at one of his menial jobs, who, like a father, encouraged him to get his life back on track and consider the military. Tim loved the military. Once again he had something he could count on. The military replaced the father, mother and family he no longer had. He didn’t have to wonder what his job or purpose was, what was expected of him, how to succeed. He was a good and strong worker and rose in the ranks. Happy, satisfied and motivated. He was able to support his family and give his kids what he lost as a child. He was a good dad, he took care of them, they could count on him and he ran a tight ship.
Then, he was deployed to Iraq. Not once. Not twice. But three times over the course of several years. The things he saw and did were so terrible he could not speak them to me until he knew me almost a year. They are not things a young man, with the world by the balls, should have to see, do, or say. These are the things he can not confess to his wife. He wouldn’t be able to bear shocking, disgusting or horrifying her. Or worse, receive a blank stare. Not getting it, instead with the now you are home, you can get over it, hold your child, move on. In his protecting himself, protecting her, protecting his kids, he becomes more isolated, alone, irritable, angry. More distant from who he was before he left. Which gets further and further away from him. He becomes panicked.
He wakes up kicking and screaming. He wife begins to fear him. Already used to being alone, because she was without him during his multiple deployments. She had to learn to be the mom and the dad while he was gone, so she continues to live independently and doesn’t really need him, come to think of it. She manages the house, the kids. They live like roommates. Tim is no help to her. He feels more broken. Tim unable to comfort his children when they cry, soothe or hold them because of what it reminds him of, he usually escapes the house. He abandons his family and yet feels grossly abandoned by them. But he only does what he has always done. What he did to stay alive at 16 and again in the “sandbox” and ever since.
What he is left with is memories. They haunt him in waking and in sleeping. They chase and terrify him. Trick him into thinking he is dying and in the most public of places, a Smiths or Wal-Mart. He becomes the monster he imagines he must be. Alone and lost in his head, his brain continues to play tricks on him. He tries to solve the puzzle but can’t. He used to be able to plug in A to get B, now just gets him cra-Z.
I know. Not because I have been there, done that. But because I have inhabited these stories, over and over again. Not just Tim’s story. But the Vietnam war vet, the Iraq or Afghanistan veteran, even a Korean War vet. I sit with them. I hold the space. I hold on to myself. They need not be anyone for me. I do not judge them, hurt them, abandon them. I understand that walking through that door of the clinic, that first time we meet takes more courage than stepping off a plane into Fallujah. Admitting he needs help, terrified he may be crazy, sitting still in the chair across from me, may be the harder of things Tim has done lately. But it is often at the point when they are getting closest to nothing-to-lose that they risk it. And then, that act alone may give him the confidence to keep moving through. Which is what I keep asking him to do.
Tim, like all the soldiers, were good, strong boys, if not mildly damaged, hurt before they found the military or the military rescued them. And he, like most, was a very good soldier. He survived didn’t he? Or part of him did. His hyper-alert senses helped him stay alive. His compartmentalizing, keeping his family tucked safely away. To keep them too close might distract him from his mission, as would emotions, his humanness, tucked away too. His strong, taking-care keeps him from asking for help, admitting weakness. So even when the plane brings him back to safety, his well-trained, well-behaved soldier does not turn off like a switch. Iraq may not have made sense in his head or in reality, but ironically, the chaos of his life now is what makes him feel crazy. There is no logic. No structure. His strong betrays him. Around him are insanely petty problems. Gossip. Intensely stupid drivers in traffic. His wife nagging at him or worse, ignoring him. All confuse him further. He loses track even more. Becomes more angry, let down, feels betrayed constantly. Lost. And touching on a lifetime of loss: dad, the three boys in his unit he watched get blown to bits by an IED, his wife, his kids, himself, his sanity, his strength and his “surviving”. Confused. About what he did, gave, and got in return. Trapped between worlds. Between here and there. Between who he was and who he may become. Between avoiding grief and getting to the other side of it.
I listen to the stories. Witness. Inhabit. Keep them close. Keep them safe. The medications I offer may turn down the fight or flight, get him sleeping, keep him off the bottle, help him stay married or keep his job or keep him out of a bar fight. But it is what I do with his story, which will help him come home, help him find his way back to himself and hope. Help him make sense of the senseless, understand the completely illogical. Speaking the all of it, aloud, layer by layer, and bravely. And then held preciously.
Moving through it, and not-alone, helps him grieve, get unstuck, out of the in-between. And for me, it is a deep and abiding honor.