The Evil Hours

by David J. Morris

  What the movement and Shatan, in particular, hadn’t counted on was a revolution in psychiatry on par with Freud’s “discovery” of the unconscious. In response to a series of scandals that had rocked psychiatry in the sixties and early seventies, the American Psychiatric Association decided in 1973 to let Robert Spitzer, a Columbia psychiatrist, oversee the next revision of the Diagnostic and Statistical Manual of Mental Disorders, which was due for its third edition. Spitzer, who had volunteered for the job, had never really liked Freudian psychoanalysis, even though he’d been trained in it, and felt the time was right to introduce a new guiding philosophy for the DSM, one that emphasized close observation of symptoms and clinical data collection over the Freudian theory that had dominated the DSM-II. An empiricist to the core, Spitzer had, during his childhood summer camp, graphed his attraction to various female campers. He also had a proven track record with tricky assignments. Prior to taking on the revision job, he had refereed the process that had deleted nearly all references to homosexuality from the DSM, which had for decades listed it as a mental disorder. “I love controversy! I love it!” Spitzer would say years later.

  Spitzer had had a number of opportunities to indulge this love of controversy during the homosexuality debate, and while psychiatry has always been a fraught discipline, the questions that the homosexuality debate raised continued to resonate in a way that gave fuel to psychiatry’s many critics at the time. Chief among the questions was how politics and lobbying by outside groups had driven the revision process. The removal of homosexuality was, taken in the larger context, the sort of clash that was deeply characteristic of the times: a minority group had for the first time found itself in a position to organize and mount an almost military-style campaign for redress. The difference in the case of homosexuality was that instead of the government being the target of the lobbying effort, it was a struggling medical discipline that was searching for a new identity and was only just finding its way out of Freud’s long shadow. In 1973, it was the National Gay and Lesbian Task Force leading the charge, and while the APA’s membership had voted decisively to delete almost all reference to homosexuality from the DSM, far from everyone was happy about it. “If groups of people march and raise hell, they can change anything in time. Will schizophrenia be next?” one psychiatrist complained.

  In June 1974, Shatan got a phone call from a public defender in Asbury Park, New Jersey, who was trying to use a “traumatic war neurosis” defense to clear his client, a Vietnam veteran who’d been charged with breaking and entering. The judge had thrown out his defense, saying there was no such disorder listed in the DSM-II. Shatan told the public defender to call Robert Spitzer, certain that the DSM czar had something in mind for the upcoming edition. Eventually, it came out that Spitzer had no plans for a “post-combat reaction” in DSM-III. Shatan was horrified. He, along with Lifton, had dealt with so many veterans at this point that they simply assumed that their case had already been made. The idea that they would have to grapple with this new diagnostic cognoscenti had never occurred to them. Part of this disconnect could be chalked up to the growing cultural rift within psychiatry. Lifton and Shatan had both been trained in the psychoanalytic tradition, where the well-written case study, which owed as much to anthropology as to psychiatry, was the lingua franca. To Lifton, this new sort of empirical approach was a form of psychiatric “technicism,” akin to the body counts the military had kept in Vietnam. Spitzer’s vision for the new DSM was more in line with the work of Emil Kraepelin, the father of psychobiology. Given that Kraepelin had once said, “Trying to understand another human being’s emotional life is fraught with potential error . . . It can lead to gross self-deception in research,” Lifton and Shatan had their work cut out for them.

  This clash of philosophies came to a head at the annual APA meeting at the Disneyland Hotel in Anaheim. “You don’t have any evidence. You don’t have any figures. You don’t have any research,” Shatan recalled being told by Spitzer. It was a grim time, and Shatan recalled that most of the researchers there seemed more interested in getting their pictures taken with Mickey Mouse than in talking about Vietnam. Also at Anaheim was a group of researchers from Washington University in St. Louis led by Lee Robbins, a psychiatrist who had conducted a study on Vietnam veterans and drug abuse. According to one psychiatrist sympathetic to Shatan’s view who was there, Robbins essentially argued that “these guys are all character disorders. They came from rotten backgrounds. They were going to be malcontents and dysfunctional anyway. Vietnam probably just made them worse, but Vietnam is not the cause of their problems. They’re alcoholics and drug addicts.” This Washington University group, which from Shatan’s point of view clearly had Spitzer’s ear, was, in essence, making the same argument that the Nixon administration had been making all along: the people who are having problems with the war were troublemakers. In other words, there is no need for a delayed stress entry in the new DSM.

  Virtually everyone from the VVAW camp who attended the Anaheim conference remembers it as one of the most demoralizing experiences of their lives. In the minds of Shatan, Lifton, Smith, and others, they had the moral high ground. They had spent years grappling with the inconvenient truths of Vietnam and had unearthed some deep insights about trauma only to find themselves on the losing end of an institutional power play within the APA. There was a new game in town, and the game, in Shatan’s view, was about the rise of a biological model of human behavior. According to Shatan, “They were reluctant to accept the idea that social, psychological, political, and economic factors could have an influence on psychiatric symptoms in people.” To this way of thinking, there could be no traumatic stress category in the DSM because the idea that an external event could cause mental illness didn’t fit within their model.

  Shatan was bruised by the Anaheim experience, but once back in New York, he set to work gathering data to support the VVAW position. He and Lifton had spoken with Spitzer and grasped that the battle would now turn on the numbers, on hard data that would support their position. With the help of Jack Smith and Sarah Haley at the VA hospital in Boston, the new Vietnam Veterans’ Working Group began amassing data. What they found was astonishing. Sifting through stacks of VA records after hours, they discovered that, in the case of Boston, 90 percent of the Vietnam veterans admitted to the psych ward had been diagnosed as suffering from either a “depressive reaction” or “anxiety reaction.” Because many of the veterans were hearing voices and occasionally hallucinating, a number of them were diagnosed as schizophrenics. After the official APA-approved diagnosis, Haley almost always found a working diagnosis provided in parentheses by the VA psychiatrist—“TWN,” an acronym for the old World War II term “traumatic war neurosis.” Sending out questionnaires, the group was eventually able to collect records on 724 veterans.

  Invited to the APA’s annual convention in Toronto the next year, Shatan, Lifton, Haley, and Jack Smith came armed. After presenting their paper and a series of detailed tables, Spitzer called a meeting of the Reactive Disorders Subcommittee, including the VVAW cohort, a researcher from the University of Iowa, and a respected family therapist from Syracuse. After hearing their arguments, Spitzer finally relented, though he made it clear that the new DSM entry would not be called “post-catastrophic stress disorder,” as Shatan and Lifton wanted. When the committee finally released its findings to the APA a few months later, it recommended a new diagnosis, which deemphasized the distinction between manmade and natural disasters and made no reference to Vietnam, but otherwise was almost exactly as Shatan had dictated it to Spitzer. It was called “post-traumatic stress disorder.”

  It would take another two years before the APA published the official version of DSM-III (which had more than tripled in length over the previous edition), but as word got out and preliminary drafts began circulating, a smattering of VA hospitals across the country began diagnosing veterans with PTSD. Shatan would later complain that the diagnosis had been depoliticized, but the pub
lication of the early drafts was a victory that could scarcely have been imagined almost a decade prior when the first rap groups had met. Ironically, much of what ended up in the DSM’s entry for PTSD was simply a clinical elaboration of the work that Abraham Kardiner had outlined forty years before.

  III. The Culture of Trauma

  The post-1980 history of trauma has, to a certain extent, been a continuation of the methodology championed by Robert Spitzer in the early 1970s. As Matthew Friedman, executive director of the VA’s National Center for PTSD, explained in a 1988 interview, most of the early pioneers of the PTSD diagnosis perceived it as a “psychological disorder, rather than a biological disorder.” According to Friedman, the first director of the National Center for PTSD, a seven-campus system created in 1989, his job was to bring PTSD into the psychiatric mainstream, which by the 1980s had become increasingly focused on the biological characteristics of mental illness. Accordingly, the global research agenda for PTSD, heavily influenced by the budget priorities and interests of the U.S. Veterans Administration and the Department of Defense, has tended to favor exploring the neurological and biological foundations of PTSD rather than the psychoanalytic, cultural, and cross-cultural aspects of the condition. The narrative of trauma has become less about politics and inner psychic conflict and more about stress hormones and the chemical dance of synapses. These stark budget realities have also resulted in a tendency to study the struggles of the individual American military veteran and to apply the results to the global population.

  In 1983, as the nation continued to struggle with a number of painful issues related to Vietnam (including the legacy of Agent Orange, a toxic defoliant used extensively by the U.S. military in Southeast Asia), Congress ordered the VA to conduct a comprehensive study to assess the war’s impact on veterans. Covering more than one thousand male subjects, the seminal National Vietnam Veterans Readjustment Study found that 15.4 percent of Vietnam veterans had diagnosable PTSD at the time of the study and that 31 percent had suffered from it over the course of their lives. The first study of its kind, the NVVRS helped to create a statistical foundation for the modern study of trauma and is still widely used as an epidemiological benchmark.

  However, as with all things Vietnam, the NVVRS remains controversial, its numbers and meaning open to more or less continuous reevaluation in the same way that the Warren Report on the assassination of President Kennedy remains open. In 2006, a Columbia University epidemiologist reworked the data in the study and concluded that the lifetime PTSD rate for Vietnam veterans was closer to 18 percent. A subsequent reexamination by a Harvard psychologist, who had served as a field interviewer for the original study, found that the NVVRS overstated the PTSD rates by nearly 300 percent, arguing that many of the veterans included in the study were “generally functioning pretty well.” To hear the debates about the study (which was covered extensively in Scientific American) is to get a visceral sense of how elusive our knowledge of trauma is and how subjective the art of psychiatric diagnosis remains despite all the advances of modern neuroscience. And there is, in these statistical debates, something that goes beyond the numbers, something that goes beyond the particulars of what was, until very recently, America’s longest war.

  At issue in the NVVRS is nothing less than the creation myth of PTSD itself, the widely accepted narrative of a war that was so obscene and so damaging to the psyche that it forced society to finally sit up and acknowledge trauma as a part of the human condition. Much like the Civil War in the nineteenth century, the Vietnam War opened up rifts in American society that remain unhealed. We visit and revisit these old wounds in somewhat the same way that individual sufferers of PTSD revisit their old wounds. Going to Iraq and seeing an American war fought in the first person taught me many things, one of which is that Vietnam and the divisions it created will probably always be with us. Vietnam and its aftermath opened up a number of new avenues of intellectual, political, and cultural experience, avenues we are still mapping today. In 2000, Robert McNamara, the divisive secretary of defense under President Johnson, published his second reconsideration of the war, titled Argument Without End, an appellation that seems to describe the debate about the psychological aftereffects of the Vietnam War as well.

  Beyond the recent emphasis within psychiatry on biology, there is a larger social interest in saying that PTSD is primarily a brain event dominated by internal chemical processes. If an underlying biological basis for PTSD were discovered, if it could be described, as depression is so often described today, as “a chemical imbalance in the brain,” then the stigma associated with it could be virtually eliminated. Further, if a “cure” for post-traumatic stress can be found, then society as a whole won’t have to bother with trying to deal with the events that cause trauma, which have deep roots in social justice issues. More often than not, it is the powerless and the disenfranchised who are traumatized, and as Arthur Egendorf liked to point out, any honest attempt to deal with the problem of PTSD must begin with a commitment to reduce the sources of trauma that are under human control: war, genocide, torture, and rape. Robert Lifton, echoing this sentiment, said, “There are always moral questions, which are inseparable from political questions that are at issue. I think some psychologists may make the mistake of imagining that it’s all a technical matter.” A number of the original leaders of the VVAW, in fact, worried about this very thing, that post-traumatic stress would in essence become viewed as a manageable medical condition, like lupus or arthritis, an outcome that would encourage governments to wage wars and commit torture and genocide.

  An influential 1995 article in the American Journal of Psychiatry, by Rachel Yehuda and Alexander McFarlane, seemed to address this tension, arguing that a conflict has arisen between “those who wish to normalize the status of victims and those who wish to define and characterize PTSD as a psychiatric illness. The future of the traumatic stress field depends upon an acknowledgment of the competing agendas and paradigms that have emerged in the last 15 years since the inception of the diagnosis, a clarification of theoretical inconsistencies that have arisen, and a reformulation of the next generation of conceptual issues.” Perhaps unsurprisingly, the authors, after acknowledging the work of Lifton, Shatan, and company, come down on the side of privileging hardnosed science over other forms of inquiry into post-traumatic stress, concluding that “now that PTSD’s place in psychiatric nosology is safely established, it is the scientific process that must provide the organizing philosophy for the field.”

  This renewed focus on the hard stuff of brain science is not without its drawbacks. Chief among them is the lack of emphasis placed on the highly subjective experiences of survivors, experiences that are difficult to listen to and do not easily lend themselves to scientific measurement. And because it is instigated by an external agent, PTSD is, almost by definition, less of a “brain event” than schizophrenia or manic depression or virtually any other mental illness. Yet to look at the field of trauma research today, one gets a clear sense that brain-imaging technologies are not seen as useful instruments in a larger toolkit but as actual windows into the mind of the survivor. It is not uncommon to hear researchers today voicing the hope that such technologies will be able to “prove,” once and for all, the existence of PTSD. We live in an era where the hard sciences are valued far and above other academic disciplines and where the humanities are frequently treated as luxury pursuits. This has resulted in a clinical culture, especially within psychiatry, that tends to treat neuroscience as the only rubric for understanding human experience, a clinical culture that applies the language of chemistry to describe patients’ suffering, as in “titrating” a patient’s emotional response to “prolonged exposure” therapy, as if a person suffering from a mental health disorder can be balanced like a chemical equation.

  This surge in biological thinking has, in the minds of some, reached the point of absurdity. As one senior VA clinician with the National Center for PTSD joked with me recently, “So tell me ab
out the war, so I can better work on your hippocampal transplant.” As William Normand, a practicing psychoanalyst in New York, said succinctly, “Psychiatry has gone from being brainless to being mindless.” Oliver Sacks, the popular author and neurologist, put it this way: “All of us have our own, distinctive mental worlds, our own inner journeyings and landscapes, and these, for most of us, require no clear neurological ‘correlate.’” In 1979, at the dawn of contemporary neuroscience, Nobel laureate Eric Kandel argued a similar point, saying that all academic disciplines require “antidisciplines” in order to advance human knowledge: “The hard-nosed propositions of neurobiology, although scientifically more satisfying, have considerably less existential meaning than do the soft-nosed propositions of psychiatry.” The human mind is perhaps nature’s most complex creation, and no single academic discipline, however promising, should be relied upon to explain it in its totality.

  Around the time that Yehuda and McFarlane’s article was published, there was an increasing recognition of what some observers have called the coming of the “Age of Prozac,” an age dominated by both a biological materialism and a growing faith in modern pharmaceuticals and their ability to solve a growing number of personal problems, many of which hadn’t previously been considered mental illnesses. In his bestselling book Listening to Prozac, psychiatrist Peter Kramer described a number of his patients who under the influence of the drug “were not so much cured of illness as transformed.” Based on his experience with such transformations, Kramer began referring to Prozac as a “cosmetic pharmaceutical,” a term that neatly described the driving force behind a new mental health culture in the United States, a trend that increasingly sees patients as consumers and seeks ways to serve their needs. This new orientation has had an impressive effect on psychiatry. Between 1987, the year Prozac was introduced, and 2007, the number of Americans diagnosed with a mental disorder increased by almost 250 percent.