After about three months in country Tom led his squad on a foot patrol through a rice paddy just before sunset. Suddenly a hail of gunfire spurted from the green wall of the surrounding jungle, hitting the men around him one by one. Tom told me how he had looked on in helpless horror as all the members of his platoon were killed or wounded in a matter of seconds. He would never get one image out of his mind: the back of Alex’s head as he lay facedown in the rice paddy, his feet in the air. Tom wept as he recalled, “He was the only real friend I ever had.” Afterward, at night, Tom continued to hear the screams of his men and to see their bodies falling into the water. Any sounds, smells, or images that reminded him of the ambush (like the popping of firecrackers on the Fourth of July) made him feel just as paralyzed, terrified, and enraged as he had the day the helicopter evacuated him from the rice paddy.
Maybe even worse for Tom than the recurrent flashbacks of the ambush was the memory of what happened afterward. I could easily imagine how Tom’s rage about his friend’s death had led to the calamity that followed. It took him months of dealing with his paralyzing shame before he could tell me about it. Since time immemorial veterans, like Achilles in Homer’s Iliad, have responded to the death of their comrades with unspeakable acts of revenge. The day after the ambush Tom went into a frenzy to a neighboring village, killing children, shooting an innocent farmer, and raping a Vietnamese woman. After that it became truly impossible for him to go home again in any meaningful way. How can you face your sweetheart and tell her that you brutally raped a woman just like her, or watch your son take his first step when you are reminded of the child you murdered? Tom experienced the death of Alex as if part of himself had been forever destroyed—the part that was good and honorable and trustworthy. Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships. After you have experienced something so unspeakable, how do you learn to trust yourself or anyone else again? Or, conversely, how can you surrender to an intimate relationship after you have been brutally violated?
Tom kept showing up faithfully for his appointments, as I had become for him a lifeline—the father he’d never had, an Alex who had survived the ambush. It takes enormous trust and courage to allow yourself to remember. One of the hardest things for traumatized people is to confront their shame about the way they behaved during a traumatic episode, whether it is objectively warranted (as in the commission of atrocities) or not (as in the case of a child who tries to placate her abuser). One of the first people to write about this phenomenon was Sarah Haley, who occupied an office next to mine at the VA Clinic. In an article entitled “When the Patient Reports Atrocities,”4 which became a major impetus for the ultimate creation of the PTSD diagnosis, she discussed the well-nigh intolerable difficulty of talking about (and listening to) the horrendous acts that are often committed by soldiers in the course of their war experiences. It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under the circumstances. They despise themselves for how terrified, dependent, excited, or enraged they felt.
In later years I encountered a similar phenomenon in victims of child abuse: Most of them suffer from agonizing shame about the actions they took to survive and maintain a connection with the person who abused them. This was particularly true if the abuser was someone close to the child, someone the child depended on, as is so often the case. The result can be confusion about whether one was a victim or a willing participant, which in turn leads to bewilderment about the difference between love and terror; pain and pleasure. We will return to this dilemma throughout this book.
NUMBING
Maybe the worst of Tom’s symptoms was that he felt emotionally numb. He desperately wanted to love his family, but he just couldn’t evoke any deep feelings for them. He felt emotionally distant from everybody, as though his heart were frozen and he were living behind a glass wall. That numbness extended to himself, as well. He could not really feel anything except for his momentary rages and his shame. He described how he hardly recognized himself when he looked in the mirror to shave. When he heard himself arguing a case in court, he would observe himself from a distance and wonder how this guy, who happened to look and talk like him, was able to make such cogent arguments. When he won a case he pretended to be gratified, and when he lost it was as though he had seen it coming and was resigned to the defeat even before it happened. Despite the fact that he was a very effective lawyer, he always felt as though he were floating in space, lacking any sense of purpose or direction.
The only thing that occasionally relieved this feeling of aimlessness was intense involvement in a particular case. During the course of our treatment Tom had to defend a mobster on a murder charge. For the duration of that trial he was totally absorbed in devising a strategy for winning the case, and there were many occasions on which he stayed up all night to immerse himself in something that actually excited him. It was like being in combat, he said—he felt fully alive, and nothing else mattered. The moment Tom won that case, however, he lost his energy and sense of purpose. The nightmares returned, as did his rage attacks—so intensely that he had to move into a motel to ensure that he would not harm his wife or children. But being alone, too, was terrifying, because the demons of the war returned in full force. Tom tried to stay busy, working, drinking, and drugging—doing anything to avoid confronting his demons.
He kept thumbing through Soldier of Fortune, fantasizing about enlisting as a mercenary in one of the many regional wars then raging in Africa. That spring he took out his Harley and roared up the Kancamagus Highway in New Hampshire. The vibrations, speed, and danger of that ride helped him pull himself back together, to the point that he was able to leave his motel room and return to his family.
THE REORGANIZATION OF PERCEPTION
Another study I conducted at the VA started out as research about nightmares but ended up exploring how trauma changes people’s perceptions and imagination. Bill, a former medic who had seen heavy action in Vietnam a decade earlier, was the first person enrolled in my nightmare study. After his discharge he had enrolled in a theological seminary and had been assigned to his first parish in a Congregational church in a Boston suburb. He was doing fine until he and his wife had their first child. Soon after the baby’s birth, his wife, a nurse, had gone back to work while he remained at home, working on his weekly sermon and other parish duties and taking care of their newborn. On the very first day he was left alone with the baby, it began to cry, and he found himself suddenly flooded with unbearable images of dying children in Vietnam.
Bill had to call his wife to take over child care and came to the VA in a panic. He described how he kept hearing the sounds of babies crying and seeing images of burned and bloody children’s faces. My medical colleagues thought that he must surely be psychotic, because the textbooks of the time said that auditory and visual hallucinations were symptoms of paranoid schizophrenia. The same texts that provided this diagnosis also supplied a cause: Bill’s psychosis was probably triggered by his feeling displaced in his wife’s affections by their new baby.
As I arrived at the intake office that day, I saw Bill surrounded by worried doctors who were preparing to inject him with a powerful antipsychotic drug and ship him off to a locked ward. They described his symptoms and asked my opinion. Having worked in a previous job on a ward specializing in the treatment of schizophrenics, I was intrigued. Something about the diagnosis didn’t sound right. I asked Bill if I could talk with him, and after hearing his story, I unwittingly paraphrased something Sigmund Freud had said about trauma in 1895: “I think this man is suffering from memories.” I told Bill that I would try to help him and, after offering him some medications to control his panic, asked if he would be willing to come back a few days later to participate in my nig
htmare study.5 He agreed.
As part of that study we gave our participants a Rorschach test.6 Unlike tests that require answers to straightforward questions, responses to the Rorschach are almost impossible to fake. The Rorschach provides us with a unique way to observe how people construct a mental image from what is basically a meaningless stimulus: a blot of ink. Because humans are meaning-making creatures, we have a tendency to create some sort of image or story out of those inkblots, just as we do when we lie in a meadow on a beautiful summer day and see images in the clouds floating high above. What people make out of these blots can tell us a lot about how their minds work.
On seeing the second card of the Rorschach test, Bill exclaimed in horror, “This is that child that I saw being blown up in Vietnam. In the middle, you see the charred flesh, the wounds, and the blood is spurting out all over.” Panting and with sweat beading on his forehead, he was in a panic similar to the one that had initially brought him to the VA clinic. Although I had heard veterans describing their flashbacks, this was the first time I actually witnessed one. In that very moment in my office, Bill was obviously seeing the same images, smelling the same smells, and feeling the same physical sensations he had felt during the original event. Ten years after helplessly holding a dying baby in his arms, Bill was reliving the trauma in response to an inkblot.
Experiencing Bill’s flashback firsthand in my office helped me realize the agony that regularly visited the veterans I was trying to treat and helped me appreciate again how critical it was to find a solution. The traumatic event itself, however horrendous, had a beginning, a middle, and an end, but I now saw that flashbacks could be even worse. You never know when you will be assaulted by them again and you have no way of telling when they will stop. It took me years to learn how to effectively treat flashbacks, and in this process Bill turned out to be one of my most important mentors.
When we gave the Rorschach test to twenty-one additional veterans, the response was consistent: Sixteen of them, on seeing the second card, reacted as if they were experiencing a wartime trauma. The second Rorschach card is the first card that contains color and often elicits so-called color shock in response. The veterans interpreted this card with descriptions like “These are the bowels of my friend Jim after a mortar shell ripped him open” and “This is the neck of my friend Danny after his head was blown off by a shell while we were eating lunch.” None of them mentioned dancing monks, fluttering butterflies, men on motorcycles, or any of the other ordinary, sometimes whimsical images that most people see.
While the majority of the veterans were greatly upset by what they saw, the reactions of the remaining five were even more alarming: They simply went blank. “This is nothing,” one observed, “just a bunch of ink.” They were right, of course, but the normal human response to ambiguous stimuli is to use our imagination to read something into them.
We learned from these Rorschach tests that traumatized people have a tendency to superimpose their trauma on everything around them and have trouble deciphering whatever is going on around them. There appeared to be little in between. We also learned that trauma affects the imagination. The five men who saw nothing in the blots had lost the capacity to let their minds play. But so, too, had the other sixteen men, for in viewing scenes from the past in those blots they were not displaying the mental flexibility that is the hallmark of imagination. They simply kept replaying an old reel.
Imagination is absolutely critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word—all the things that make life interesting. Imagination gives us the opportunity to envision new possibilities—it is an essential launchpad for making our hopes come true. It fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships. When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility. Without imagination there is no hope, no chance to envision a better future, no place to go, no goal to reach.
The Rorschach tests also taught us that traumatized people look at the world in a fundamentally different way from other people. For most of us a man coming down the street is just someone taking a walk. A rape victim, however, may see a person who is about to molest her and go into a panic. A stern schoolteacher may be an intimidating presence to an average kid, but for a child whose stepfather beats him up, she may represent a torturer and precipitate a rage attack or a terrified cowering in the corner.
STUCK IN TRAUMA
Our clinic was inundated with veterans seeking psychiatric help. However, because of an acute shortage of qualified doctors, all we could do was put most of them on a waiting list, even as they continued brutalizing themselves and their families. We began seeing a sharp increase in arrests of veterans for violent offenses and drunken brawls—as well as an alarming number of suicides. I received permission to start a group for young Vietnam veterans to serve as a sort of holding tank until “real” therapy could start.
At the opening session for a group of former Marines, the first man to speak flatly declared, “I do not want to talk about the war.” I replied that the members could discuss anything they wanted. After half an hour of excruciating silence, one veteran finally started to talk about his helicopter crash. To my amazement the rest immediately came to life, speaking with great intensity about their traumatic experiences. All of them returned the following week and the week after. In the group they found resonance and meaning in what had previously been only sensations of terror and emptiness. They felt a renewed sense of the comradeship that had been so vital to their war experience. They insisted that I had to be part of their newfound unit and gave me a Marine captain’s uniform for my birthday. In retrospect that gesture revealed part of the problem: You were either in or out—you either belonged to the unit or you were nobody. After trauma the world becomes sharply divided between those who know and those who don’t. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it. Sadly, this often includes spouses, children, and co-workers.
Later I led another group, this time for veterans of Patton’s army—men now well into their seventies, all old enough to be my father. We met on Monday mornings at eight o’clock. In Boston winter snowstorms occasionally paralyze the public transit system, but to my amazement all of them showed up even during blizzards, some of them trudging several miles through the snow to reach the VA Clinic. For Christmas they gave me a 1940s GI-issue wristwatch. As had been the case with my group of Marines, I could not be their doctor unless they made me one of them.
Moving as these experiences were, the limits of group therapy became clear when I urged the men to talk about the issues they confronted in their daily lives: their relationships with their wives, children, girlfriends, and family; dealing with their bosses and finding satisfaction in their work; their heavy use of alcohol. Their typical response was to balk and resist and instead recount yet again how they had plunged a dagger through the heart of a German soldier in the Hürtgen Forest or how their helicopter had been shot down in the jungles of Vietnam.
Whether the trauma had occurred ten years in the past or more than forty, my patients could not bridge the gap between their wartime experiences and their current lives. Somehow the very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past.
DIAGNOSING POSTTRAUMATIC STRESS
In those early days at the VA, we labeled our veterans with all sorts of diagnoses—alcoholism, substance abuse, depression, mood disorder, even schizophrenia—and we tried every treatment in our textbooks. But for all our efforts it became clear that we were actually accomplishing very little. The p
owerful drugs we prescribed often left the men in such a fog that they could barely function. When we encouraged them to talk about the precise details of a traumatic event, we often inadvertently triggered a full-blown flashback, rather than helping them resolve the issue. Many of them dropped out of treatment because we were not only failing to help but also sometimes making things worse.
A turning point arrived in 1980, when a group of Vietnam veterans, aided by the New York psychoanalysts Chaim Shatan and Robert J. Lifton, successfully lobbied the American Psychiatric Association to create a new diagnosis: posttraumatic stress disorder (PTSD), which described a cluster of symptoms that was common, to a greater or lesser extent, to all of our veterans. Systematically identifying the symptoms and grouping them together into a disorder finally gave a name to the suffering of people who were overwhelmed by horror and helplessness. With the conceptual framework of PTSD in place, the stage was set for a radical change in our understanding of our patients. This eventually led to an explosion of research and attempts at finding effective treatments.
Inspired by the possibilities presented by this new diagnosis, I proposed a study on the biology of traumatic memories to the VA. Did the memories of those suffering from PTSD differ from those of others? For most people the memory of an unpleasant event eventually fades or is transformed into something more benign. But most of our patients were unable to make their past into a story that happened long ago.7
The opening line of the grant rejection read: “It has never been shown that PTSD is relevant to the mission of the Veterans Administration.” Since then, of course, the mission of the VA has become organized around the diagnosis of PTSD and brain injury, and considerable resources are dedicated to applying “evidence-based treatments” to traumatized war veterans. But at the time things were different and, unwilling to keep working in an organization whose view of reality was so at odds with my own, I handed in my resignation; in 1982 I took a position at the Massachusetts Mental Health Center, the Harvard teaching hospital where I had trained to become a psychiatrist. My new responsibility was to teach a fledgling area of study: psychopharmacology, the administration of drugs to alleviate mental illness.
The Body Keeps the Score Page 3