The Evil Hours

by David J. Morris

  Part of this new, risky campaign against PTSD can be understood by examining the larger political situation that the VA finds itself in. As more veterans from the War on Terror come home and wrestle with PTSD, the VA has come under increasing pressure to respond to the crisis in a dramatic fashion. For leaders within the VA, many of whom came of age in the aftermath of Vietnam, the signs were all too familiar: a huge wave of veterans returning home from unpopular wars, greeted by a health care system whose resources were stretched to the limit. The 2007 Walter Reed hospital scandal, whose political fallout included the VA, helped bring about a sea change in the way PTSD therapies are delivered to veterans. The days when veterans were screened and then assigned to an individual therapist who would work continuously with them for years are probably numbered. (The revelations in 2014 of exceedingly long wait times for veterans at the VA hospital in Phoenix, which resulted in the deaths of several veterans and eventually led to the ouster of VA Secretary Eric Shinseki, has only increased the pressure on the VA to deliver quick and efficient care.)

  The focus within the VA now is upon large, scalable, “Evidence-Supported Treatments” like PE and Cognitive Processing Therapy (CPT), which together are frequently referred to as the VA’s “gold standard” PTSD treatments. This state of affairs also has a generational component. One senior VA official, who was trained as a psychoanalyst and has been treating PTSD for over thirty years, complained to me, “These new treatments have me worried that clinicians will never learn how to do actual therapy.” Jonathan Shay, one of the most highly respected trauma theorists in America, cited the recent focus on efficiency and what amounts to mass-produced therapy as one of the major reasons for his retirement from the VA.

  Nevertheless, there are good reasons for the VA’s transition to PE and CPT. The science behind them is held in very high regard by a number of experts, and because of their relative simplicity, they hold the potential to treat greater numbers of veterans than other long-term therapies. In 2008, the prestigious Institute of Medicine determined that PE was one of only a few therapies shown to be effective in reducing PTSD symptoms. Dozens of studies confirming the effectiveness of PE have been published in many of the world’s top peer-reviewed scientific publications. In an August 2002 study in the Journal of Consulting and Clinical Psychology, titled “Does Imaginal Exposure Exacerbate PTSD Symptoms?” Foa acknowledged the widespread safety concerns related to PE but concluded that “prolonged exposure has gained more empirical support for its efficacy than any other treatment for PTSD, and some studies even suggest that it is the most efficient treatment for this disorder.”

  However, the problem of PE raises a number of questions about how modern research into psychotherapy is conducted. For evidence-supported therapy researchers, who tend to view therapy through the narrow lens of simple empiricism, patient outcomes that can be easily measured in clinical trials are presumed to be indicative of the best therapies. Such results are to be taken at face value, according to a simple tallying of symptoms before and after treatment, a method that makes little allowance for nuance, ambiguity, or the nonspecific effects arising from the rapport between therapist and patient.

  In his book Manufacturing Depression, therapist Gary Greenberg singled out one of Foa’s experiments, which pitted PE against another kind of PTSD therapy, called “supportive counseling,” as an example of the flawed psychotherapeutic research that is often published today, arguing that comparative studies of evidence-supported therapies of the sort that the VA favors often fail to objectively compare one therapy against another and end up merely showing that “something intended to be effective works better than something intended to be ineffective.” Greenberg also rails against another statistical procedure common to clinical trials: “excluding from the bottom line the subjects who don’t complete the study . . . Rather than counting them as failures, most studies simply treat dropouts as if they never enrolled in the first place, which, mathematically speaking, makes the treatment look stronger than it would otherwise.” This sort of statistical cherry picking is especially problematic with a therapy like PE, which has the highest dropout rate of any PTSD treatment.

  The controversy surrounding PE also resembles in broad outline the problems with another post-trauma talk-it-out therapy that enjoyed a surge of popularity at the beginning of the millennium. The therapy, known as critical incident stress debriefing or CISD, was developed in 1983 by a volunteer firefighter named Jeffrey Mitchell and encourages recent survivors of trauma to talk about it, in some cases as soon as twenty-four hours after the event. The typical CISD session lasts around three hours and has a similar set of clearly spelled-out protocols to PE. As with Prolonged Exposure, the central idea is that openly talking about the worst parts of a traumatic event eases the pain. The problem is that, like PE, research indicates that it often makes matters worse. One U.S. Army study of 952 Kosovo peacekeepers found that CISD did not aid recovery and, in fact, led to more alcohol abuse. Another study, looking at how CISD impacted a group of burn survivors, found that the group that underwent CISD was three times as likely to suffer from PTSD as a control group.

  For his part, Roger Pitman remains skeptical of PE, saying that while it is has been shown to be an effective treatment for some forms of trauma, it seems to be less effective for combat PTSD, which is often produced by hundreds of individual stressors accumulated over the course of years, as opposed to PTSD caused by rape, which is typically the result of a single event. For all forms of PTSD, Pitman told me, Prolonged Exposure is “not as beneficial as advertised,” adding that “the complications associated with it are under-reported and under-represented in the literature.”

  Toward the end of our conversation, I confessed to Pitman that I was anxious about criticizing what is, by many accounts, an effective therapy for PTSD, and I explained to him that another highly respected researcher had advised against it, lest I be seen as a “difficult” patient. Pitman was unswayed. “This is important. This is a gap in the research that needs to be addressed.”

  Two days after the knife incident, I returned to VA San Diego for my regular Thursday afternoon appointment with Scott feeling more than a little ill at ease. I was angry. Angry at the drivers ahead of me, angry at the VA, angry at myself for having rendered myself helpless, cut off from the world, phoneless. Angry in a stereotypically ridiculous way that I had always associated with clichéd crazy Vietnam veterans, people with anger control issues like John Goodman’s character in The Big Lebowski, a reference that, when I thought of it, failed to make me laugh. Before the drive from my house in North Park, conscious of my state, I had, in fact, walked the length of the alley behind my house to ensure that there were no obstructions, no trucks piloted by absentminded handymen that might block me in and cause an incident.

  On the drive, past the Mormon temple, past the Whole Foods on La Jolla Village and onto the UCSD campus, I debated what to say to Scott about what in my mind I was already thinking of as “the knife incident.” I had, in fact, already set the knife aside, placing it in a drawer, out of view of the neighbors.

  The knife at this point had ceased being a kitchen tool and was now something else altogether, having passed into the realm of symbolic objects. Objects tainted by violence. The knife was now a piece of evidence. An object needing to be removed from normal domestic circulation.

  I had done all of this without actually looking at it. I had, after walking down to the dumpster to throw away what remained of the phone, picked up the knife and placed it in an unused drawer in the far corner of the kitchen. I had not thrown it away.

  It had taken some concentration to make the drive, to keep my truck on the road, to keep what I thought of as “nausea” in check, though I recognized that nausea wasn’t the right word. It wasn’t that I was going to throw up, it was that I felt sick in some deeper way, as if my body was somehow at war with the world on an almost chemical level. “The force of the experience would appear to arise precisely, in ot
her words, in the collapse of its understanding,” wrote Cathy Caruth in Trauma: Explorations in Memory. In my journal, dated April 24, 2013, I had written, “Feeling raw and nauseous in some deeper way that defies description.”

  Back in the therapy room, after apologizing for the awkwardness induced by my raw emotions, I briefly outlined the details of what had happened. The knife. The phone. The loss of control, which was uncharacteristic for me, being someone with no police record, no history of violence. Being someone who had, in fact, hated the hand-to-hand combat training he’d undergone at Quantico. By all appearances, Scott was unsurprised. Had I been drinking? he asked. I told him I had drunk my usual amount, one or two beers afterward, but that I had deliberately avoided getting drunk because I didn’t know what I was capable of at that point.

  There was a pause.

  “You were not drunk at the time?” he asked.

  “No.”

  “Or had any beers?”

  “No,” I explained. “That came later.”

  I asked if we could try something else, treatment-wise. I mentioned that the imaginals were a problem. He seemed to sense that I was unhappy, and he switched metaphors again and began describing me as the driver of a figurative automobile and he as the navigator. “Now I might be a nagging navigator but we’re not going forward until you’re ready and your foot goes on the gas.”

  The problem, as I explained to Scott, had nothing to do with alcohol or metaphorical bandages being ripped off or pots being stirred or papers being blown into the wind or cars being driven or not driven, but instead a fundamental misapprehension of the nature of trauma as I experienced it in Iraq, trauma that to my way of thinking was far more about the cumulative effect of living under fear of death for months and then coming home and realizing that no one cared in the slightest about it than it was about a single close call with an IED in Saydia. In my mind, to continue the therapy after what had happened with the knife seemed “completely insane.”

  With this declaration, delivered through clenched teeth, I became what is known in the literature as a “noncompliant patient.” A patient resisting treatment. A patient who no longer conforms to the clinical regimen being tested. A patient who, as Gary Greenberg would later explain to me at length, is oftentimes no longer considered in the results of many studies and is essentially dropped from the rolls altogether.

  “It is important to emphasize that exposure may lead to serious complications.” So notes Harvard professor of psychiatry Bessel van der Kolk in Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society. Van der Kolk continues, “Vaughan and Tarrier (1992) reported this technique to be useful in seven subjects; two were not helped, and in one there was an increase in both intrusion and avoidance symptoms. Pitman et al. (1991) stopped a flooding study with Vietnam veterans because a number developed serious adverse reactions.” Six months later, I would listen as Roger Pitman explained these adverse reactions to me on the telephone, adverse reactions that he remembered vividly twenty years later.

  There is a lot of “good” science behind PE, science that extends in a clean, unbroken chain all the way back to the nineteenth century, science that has had every opportunity to be overturned by subsequent researchers and has not been. Science that has been embraced by the powers that be on a systematic basis. Science that has, nonetheless, in some instances, been shown to have made matters worse. Much worse.

  Thinking about all this over the months that followed, I began to wonder what had made such an extreme therapy seem necessary, a therapy that to the casual observer might seem cruel and unusual. And I began to wonder, what is it about post-traumatic stress that makes such sadistic methods seem reasonable? What is it about post-traumatic stress that so confounds the clinical mind that it resorts to methods that are virtually indistinguishable from torture? Could it be that there is some daemonic repetition-compulsion at work here? A desire to force a kind of mastery over it by obsessively revisiting it? Reflecting on this with a writer friend, then a PhD student at UC Irvine, she mentioned offhand that PE seemed in some ways to resemble an exorcism. Prior to undergoing PE, I had, in fact, read about some of the extreme measures taken by the British and French armies during World War I to deal with the epidemic of shell shock, measures that included the systematic use of electrocution, a therapy that, according to one historian of the subject, “seemed to work in that it could remove the symptoms.”

  Not long after I described to Scott my reactions, I informed him that unless we could locate another form of therapy, a therapy that did not involve repetitive imaginal flooding, this would be my last session. After debating the pros and cons of me dropping out, I described for him the other trauma survivors I had spoken to who also had adverse reactions to PE.

  “I would be careful saying that PE doesn’t work. We’ve had hundreds, even thousands of veterans go through this and it worked for them,” he said.

  I responded by saying that the British had electrocuted hundreds, even thousands of soldiers during World War I and that, technically speaking, it had “worked” for them as well.

  He did not seem pleased by this comparison.

  In his view, we were at a tipping point and were “getting into something dangerous,” and that this was “to be expected.” After several minutes of this back and forth—Scott insisting that PE was effective and the best possible treatment for me and me declaring it to be “insane”—we called it quits.

  Before we parted, in a deliberate tone, as if to make clear to any third party listening to the audiotape of our session that I was now “noncompliant,” he asked, “Would you like to terminate Prolonged Exposure treatment with me?”

  “Yes.”

  I began to feel better almost immediately after quitting PE therapy. The anxiety I had felt, knowing that I would be forced to mindlessly relive the ambush at Saydia, dissipated in an almost mathematical fashion. Every day I was away from the therapy, my anger and fear decreased by a few percentage points. After two weeks without PE therapy, I felt almost normal again. This, I would discover after reading Roger Pitman’s research and other published studies, was typical of those who suffer adverse reactions from PE—the feelings of building terror slowly evaporate, and the patient returns to the state prior to the beginning of the treatment. There are no documented cases of veterans or other PTSD survivors committing suicide as a result of PE, but I worried that as transient as my symptoms were, for a vulnerable person with fewer resources at their disposal, this downturn could prove destructive if not fatal.

  A few days after terminating PE, I called the VA to see what my options were. The next step, I was told, would be to try the other major evidence-supported therapy for PTSD, known as Cognitive Processing Therapy or CPT. Normally done in a group setting of around a dozen veterans, the next group began in three weeks.

  Meeting at the smaller Mission Valley clinic, across the street from the Office Depot and smack in the middle of one of the largest retail corridors in Southern California, CPT went every Thursday at noon for ninety minutes. The vibe was entry-level AA, except that instead of the usual looks of bland resignation and court-ordered contrition, there were some ten-thousand-yard stares, some guys numbed into near-statues, while other guys seemed to be tripping hard on one kind of stimulant or another. The dozen of us in the room were a study in what Judith Herman, in her classic Trauma and Recovery, called the “dialectic of trauma”—some of us were up, some were down, some were just . . . elsewhere. Whenever the facilitators said something about IEDs or snipers, a half-dozen legs would start jumping up and down like sewing machine needles.

  There were the usual introductions. There was Fernando, the recently retired Marine who had done seven deployments to the Middle East since 9/11. There was Greg, the young father who played with his aluminum cane after limping to his seat. Tim, the Iraq vet now at San Diego State. Kyle, seated in a plaid thrift store chair to my left, his eyes patrolling the room from underneath a camouflage baseb
all cap. I recognized Josh, one of the veterans from my in-processing exam months before. He struck me as being almost like an invalid. He was nearly completely immobile in the waiting room as his wife sat next to him, patiently guiding him through a thick stack of intake forms, line by line. To my right was a sign that read: PLEASE REFRAIN FROM TELLING WAR STORIES. YOUR STORY COULD BE A “TRIGGER” FOR SOMEONE ELSE.

  Yes, at first glance, this was what should have been a depressing scene, and yet I was secretly elated. This was a room of suffering, a room filled with enough anxiety to power a small city, filled with guys who had paid a lot for daring to sign up, probably a lot more than they’d ever expected to pay, but to me it was a room filled with a strange kind of almost poetic beauty: something we are so rarely allowed to see in this world, trauma and loss and the work of history written on the human face. It might’ve just been the odd buzz I got sometimes after an evening formation in the Corps, a kind of churchy feeling, but there was, it seemed to me, something noble about the scene before me, heroic in the ancient Greek sense. This room, I saw suddenly, was part of the journey, a waystation on a great odyssey: some of us were going up, some of us going down, but all of us in the room, every one of us, whether we wanted to or not, were going somewhere.