Mental Health

“About that appointment…”

It was five to nine when I walked into the group therapy room and T.J. and Jim are the only ones in the long room, in a far corner. One week has passed since T.J. “worked” in the group and he is feeling much better. This morning while I was making rounds on the ward, T.J. took me aside and told me that the new patient Jim had also been a marine corpsman.

T.J. said, “He has something bad eating away at him that he wants to talk about but he’s afraid you might push him too hard.” I thanked T.J. and said I’d keep that in mind.

I arrange two chairs to be separate from the rest of the group: one for me and one for the “hot seat” which is for the patient I will work with.

I am about to sit down in my chair when T.J. theatrically clears his throat getting my immediate attention. He says to me, with a serious voice and a smile in his eyes, “Hey doc, you better tie your shoelace because if you trip over it Jim and I will have a mess of trouble picking you up off the floor.”

I looked down at my black sneakers and a long lace extended at least six inches out from my right foot. “Well you know, T.J.,” I smile and wink at him, “you and Jim were corpsmen in Nam and I’d be in good hands. Don’t you think?”

T.J. smiles broadly and Jim put his hand up to his mouth and shakes his head from side to side. Then, as I sit down, I say, “I’m not going to be your fall guy.” T.J. laughs, remembering how I fell down in the group a week ago, as part of my working with him, and he helped me to get back on my feet. And how that helped him get back on his own two feet.

I tie my laces and ask Jim, “Why’re you shaking your head? You don’t agree?”

Sighing long and slow Jim wipes his mouth and then dry-wipes his shaggy mustache and strokes down on his full beard. He is wearing thick-lensed glasses and has a round face, the face of a wise man or a guru. His bald head is crowned by thick gray hair. His hand again goes up to his mouth and in a quiet, deep voice thick with a southern accent, he says, “I don’t much feel like talking.”

Jim has been in the group for only a few days and he hasn’t spoken more than a few words. After his first group I approached him and said, “About an appointment with me, Jim, I usually see all the new patients for at least one session to get to know them.” I take out my appointment book and pen and ask him if he can come to a session with me that afternoon.

He is depressed and heavily medicated with tranquillizers and anti-depressants. After several seconds of slow rocking from side to side he answers me. He speaks with his hand covering his mouth and says apologetically, “Uh, about that appointment, I’m not ready to face you for a private session. You push and uh, I’m not ready to be pushed.”

The door opens and the rest of the group comes in, the new patient Jack taking his chair to a place next to the door, clearly isolating himself. This is his second day in the group and he is suspicious of me, having already criticized me for coming to conclusions about some of the other vets saying, “You don’t even know them and you ain’t never even been to Nam.”

With a scowling face and angry voice Jack wants to know why there is an empty chair next to me. I explain to him and the group that I have slightly separated my chair and the one next to mine from the group: whomever will work with me will sit in the “hotseat.” It accentuates the face to face encounter with me and my direct approach to their suppressed and repressed strengths and abilities.

I explain to Jack what I have already explained to the group that in order to get to the positive side of their personality we must confront their weaknesses in order to get through them to their strengths. Since I have only been working with the PTSD patients for several months I am still learning how to relate and communicate with them.

Having fifteen men in the same room, all of them suffering from moderate to severe PTSD is a new situation for me. What worked for me in almost thirty five years of experience hasn’t always worked with them: an eclectic approach using combinations of analytically oriented psychotherapy, Gestalt, Psychodrama, confrontation exercises, controlled physical exercises and spontaneous improvisations. Anything and everything that will enhance the rehabilitation process. Here is an example of improvisation.

Four days before, the first day Jim was in the group, I worked with a patient who had serious PTSD and psychosomatic pain in his lower back. All the tests he took did not indicate that he had any pathology in his lower back but he complained so much that he was issued arm crutches. He walks better though he still complains of chronic pain.

In a private session with him I explained the basis of his psychosomatic pain and he vehemently disagreed with me. In addition to his chronic, severe PTSD he has failed in three marriages, hasn’t been allowed to see his two children in seven years, and has made numerous suicide attempts.

That morning he had complained bitterly that he had more pain that usual and, “Besides I ain’t a part of this group. And none of you guys feel the pain I do.”

Hoots, catcalls and several direct rejections from some of the group; his next comment is, “Anyway I don’t belong and you don’t want me to.” Many catcalls again, along with several positive reinforcing comments, and then I say, “I have an idea.”

He agrees to take part in an exercise in which he stays seated as all of us get up and make a circle, arms around shoulders. Only Jack, the new patient refuses to take part. I tell the handicapped patient to use whatever strength he has, “to break into the circle. We’re not going to make it easy for you, but if you try you’ll find a way to get into the middle, to belong.”

He gets up slowly and arm-crutches the two steps to the tightening group. Then he lunges forward, brushing through a small opening, falling into the middle of the group onto the thick carpet, his aluminum crutches falling on top of him. He is red-faced for several seconds, grimacing in pain and clutching his back, and obviously holding his breath. I lean down, touch him firmly on the shoulder and say sharply, “Don’t forget to breathe. Let go.”

Gradually he begins to breathe slowly and deeply, as I speak to him softly and quietly, emphasizing deep, relaxed breathing. The group has stepped back to give him air. In less than half a minute he seems to awaken from a dream, shaking his head as he sits up letting go of his back.

Many hands help him to his feet, his crutches firmly clutched. He quickly strokes his way back to his seat. When he sits down the group breaks into applause and he waves a crutch above his head in a victory sign.

When the group has quieted I ask him about his pain and he looks surprised. “It’s still there, but by God I think it’s less. Yes, it hurts, but not so much.”

Jack is still sitting isolated near the door and mumbles loud enough for the group to hear “Nobody got the right to make a crippled vet fall down.” I choose to ignore him and so does the group. The exercise worked because the vet used his strength in a positive way to get back into life. He also learned that when he did that he also reduced his pain.

I’m still learning how to work with PTSD vets in a beurocratic environment. Yesterday I heard from the Chief of Psychiatry that Jack had complained to him about what I had done with the handicapped vet and he is threatening to sue the hospital.

Is he going to sue? Maybe. But my boss doesn’t think so. When I explained what happened my boss nodded reassuringly, saying, “Don’t worry about it Irv. Some of the vets think Uncle Sam is one big tit and they try to suck on it when they don’t deserve it. Things like that go on all the time. Don’t take it to heart. Fill out a report of contact, telling it just the way it was and don’t worry about it. You’re doing fine.”

I thanked him for the reassurance and vote of confidence and as I was leaving his office he called after me. “Don’t let it bust you up,” and raising his eyes to the ceiling he shrugged his shoulders. I’m learning.

Back in the here and now, T.J. leans towards Jim and stage whispers, “Go ahead. Talk.” Jim opens his mouth to say something, and before he can cover it with his hand I see a dark gap in his front teeth. He puts his interlaced hands across his abdomen and says, “Well, I guess you’re catching me at the right time, T.J. I’ll do it.”

He turns to me and says, in a helpless tone of voice, “I feel my life is aimless and I’m lost, you see Doc? And I don’t know where I’m going.”

Several vets respond by saying they’ve felt the same things. I tell Jim that I think I know where he’s going and he looks up sharply at me. “I’d say that your headed for the hot seat. Right?” For a moment he doesn’t understand and I look from him to the empty chair next to me and back to him.

“I see what you mean. You want me to sit there, huh?”

“Only if you choose to do so, Jim. You know me. I’m a pusher but you can stop me any time you want by saying ‘Stop,’ or by holding your hand up. But you must be clear and firm either in voice or gesture. Got it?” He nods yes. I lean slightly towards him, looking deeply into his eyes and then I dramatically look down into the empty seat. Then I look questioningly at him. He gets up heavily and walks slowly to the hot seat. He sits down, looks at the floor and sighs.
One of the vets tensely says to Jim, “Get him baby. We’re with you.”

I look around the group at each vet, nodding “Yes,” as I do so and then I turn to Jim and say, “Do you know the difference between fact and fancy?” He says he does and I ask him to give me some facts about what he sees when he looks at me.

“Well, your an elderly gentleman and - ”

“I said facts, not fancy. I am sixty-five years old, that’s a fact but compared to a man of ninety-five I’m pretty young.” With an exaggerated southern accent I say, “And as fah as mah being a gennlemun, suh, y’all do me a great honuh, yes suh.”

Jim smiles widely and there is loud laughter from the group. I notice that Jim is missing some upper and lower teeth. When he sees me looking at his mouth he shuts it and covers his mouth with his hand.

I say seriously to him, “It is a fact that you are missing a number of upper and lower teeth.”
Jim frowns, says, “I don’t want to talk about it, that’s all.”

“Got it. Can I push on about the difference between facts and fancy?” He says I can and I tell him that it’s important to recognize that very often we react in the here and now as if we are living in the past. For example when a vet has a flashback he acts as if he’s back in Viet Nam and he’s fighting off the threat to his life. If he learns to recognize that he is experiencing the threat of what was there and then in the present he can better deal with his experience. Does he understand what I’m saying? He mumbles that he does and I ask him to tell me some facts that have nothing to do with judgment, evaluation or estimation. He thinks for a moment and then says that I shave my head, I’m wearing a red golf shirt, dark gray pants, maroon socks and black sneakers.

“No arguing with that. Now you can tell me what you think of me, so you can judge, evaluate, estimate, give opinions? All you want.”

Suddenly he is serious as tears fill his eyes. “I keep apologizing to Billy since he died and I can’t stop doing it.” He is fighting back the tears. The tissue box is moved around the group until it comes to Jim and he takes one, puts the box in his lap, but doesn’t wipe his brimming eyes.

He tightens his lips and the cords in his neck stand out. I whisper, “Let go. It’s all right to let go.” The flood of tears come. T.J. gets up to move towards Jim but I head wave him back. I say, “As long as he’s letting go of the negative he’s doing fine. I’ll ask him. Do you want to stop Jim? Am I pushing too much?” He shakes his head from side to side and sobs loudly. After a number of seconds I begin to question him and he tells the story, crying and talking. And talking and crying.

“We were in half-tracks and we got ambushed. When the first incoming hit, our half-track stopped suddenly and my mouth and teeth were smashed when I hit the helmet of the grunt in front of me. But I didn’t care. I was so angry with that fucking company commander because he kept us three days in the same area and the N.V.A. finally zeroed in on us.

“I was the corpsman and I knew there was going to be a lot for me to do when the mortars and rockets came in. I wasn’t afraid for myself since I believed in God and I believed in what I was doing. Suddenly I see the half-track in front of me go up in a ball of flame and one guy, Larry, comes jumping out all on fire. I yelled at the guys to roll him in the grass and they did. I was busy as hell cause we took lots of wounded and I didn’t have time to think, just do. Just take care of the guys because they were yelling ‘corpsman, corpsman,’ and I was running from one to the other. Then finally the firefight stopped and like a flash it hit me. Where’s Billy? He was my best friend.

“Then I looked at the burnt half-track and I knew Billy bought it. I went over to it and sure enough he was there and all burnt so that his skin came off when I pulled him out.” There are hard sobs, his chest is heaving, his fisted hands are beating on his thigh. Again I ask him if he wants to stop and after a slight hesitation he grunts, “No, no.”

He body-bagged Billy and pulled him about one hundred yards away from the rest of the marines and called in a medivac chopper. When it came he wouldn’t let anyone help him load Billy onto it. Then he says that Larry was put on it also, along with a number of other wounded. Larry died on his way to a burn ward in Tokyo.

Jim is exhausted. I tell the group, “He’s resting. Maybe now it’s time for you guys to give. Does anybody have any feedback for Jim?”

The first response is from Jerry who tells the group that he was wounded three times and the last time the medic saved his life. He was bleeding heavily and the medic stopped the bleeding and hooked him up to an infusion, in the midst of a small weapons firefight.

For the next five minutes vet after vet tell personal stories of the dependability, trustworthiness and occasional heroism of corpsmen and medics. Jim is sitting up straight in his chair now, wiping his glasses with a clean tissue. He looks calm, his body relaxed, as he listens carefully to the group’s feedback. Several vets have told him that he did his best and one asked him, “Can you do more than your best?” and Jimmy said, “I guess not,” nodding slightly in understanding.

“Okay,” I say, “just one more thing. I don’t want to push things too far, Jim,” and I smile at him.

“Cut the bull doc, you ain’t pushing and you know it.” He grins and exposes the gaps in his upper and lower teeth.

I reply, looking at him from the corner of my eye, “You’re putting some teeth in what you say.” Jim laughs loudly, along with the rest of the group. When the group is quiet I say, “If any of you want to express your feelings about Jim directly, personally, you can do so.” I pause for a moment and then I say, “But after me.” I shake Jim’s hand quietly saying, “Yes, Jim. Yes.
”
For the next two minutes, one by one, sometimes waiting in line, everyone comes up to shake Jim’s hand. Some of them embrace him. When everyone is back in their seats I recall the events following the death of my son, Yussie.

“Listen up, guys. I just realized what I did. When we all made personal contact with Jim it reminded me of the Jewish custom for mourning the dead, it’s called Shiva.” I explain that the word Shiva has two meanings: the first one means the number seven, the mourners grieve the dead one for seven days. The second meaning of the word is sitting. The family of the deceased sit together at home, shoeless, and they receive condolence calls for seven days.

“Last week I told the group about the death of my son, Yussie, but for those of you who are new to the group, he was seventeen years old when he got leukemia and in three months he died.” I sigh deeply and then I continue. “My wife and four children sat in the living room of our house in Israel for one week and we received condolence visitors.

“None of them knocked, they just opened the door and walked into the living room and they didn’t say hello and they didn’t say goodbye when they left. Some of them brought food since it is the custom that the bereaved family doesn’t cook. Sometimes we cried, sometimes we laughed, but the subject was always Yussie. At the end of the Shiva we went to the cemetery and that ended the week where we did almost nothing but remember Yussie, remember what was. Then it was back to the real world of the here and now, work, home, family life, what have you.”

I look at Jim and he is staring out the window, unmoving. He blinks his eyes, wipes his mustache and pulls lightly at his beard. Then he says, “Thanks. You pushed just right.”

The group is over. There is a babble of voices as the group members mingle in the middle of the room. No one moves to the door. I get up, saying, “I’m pooped. I have to do something. They’re waiting for me to do a consultation in the outpatient clinic. See you tomorrow, men.”

I walk out and stride down the hall. I hear my name called and I stop, turn around. Jim is hurrying towards me.

He lowers his head, looks at me above the top of his glasses and says, “About that appointment…”

© 2008 by Jane Chin, Ph.D. (email) All Rights Reserved.
Abstract logo images by Asif Akbar