This lack of synthesis also struck me as odd because, apart from my own personal difficulties, I began to see that much as shell shock (a sort of precursor to PTSD) dominated the post–World War I imagination in Europe and Great Britain, so the phenomenon of PTSD dominates our culture today. As a cultural meme, PTSD is everywhere now, an inescapable part of our historical moment. As an expression of deeper anxieties, it defines our era in a way not unlike female hysteria defined late nineteenth-century Europe, a reality that was not lost on Freud’s contemporaries. As Otto Fenichel, one of Freud’s protégés, put it, “Neuroses do not occur out of biological necessity, like aging . . . Neuroses are social diseases . . . corresponding to a given and historically developed social milieu. They cannot be changed without corresponding change in the milieu.”
It would be foolish to diagnose an entire nation with a mental health disorder, but as Susan Faludi points out in her 2007 book The Terror Dream: Fear and Fantasy in Post-9/11 America, the country as a whole continues to exhibit certain aspects of post-traumatic stress, including a compulsion to reenact the events of September 11 in movies and television as well as nurturing obsessions with homeland security and surveillance that, according to many military analysts, is out of proportion with the actual threat and smacks of a kind of national hypervigilance. Moreover, the ongoing militarization of American culture—in the form of first-person shooter video games, the rise of the Navy SEAL “brand” in books, films, and other media, and martially themed endurance races like the Tough Mudder series—points to a fixation with the post-9/11 hyper-masculinity and ubiquitous violence reminiscent of the disorder.
In a related vein, some observers have drawn a connection between 9/11 and the recent helicopter parenting phenomenon, the overweening desire to protect our children from every conceivable danger to the point where we isolate them from the world and prevent them from having experiences that previous generations took for granted. Others point to the rising popularity of zombies in books and films as being symptomatic of a kind of paranoid “cultural PTSD.” (Zombies are like terrorists in that they look like us but have been tainted by death and can seemingly strike anywhere and at any time, or so the thinking goes.) Indeed, one can quite easily construct an entire theory of recent American culture using PTSD as a nucleus, all without mentioning the tens of thousands of veterans and their families who suffer from post-traumatic stress or the millions of rape victims who live every day amped up, numbed out, and generally haunted.
PTSD has become a bit like Prozac in the nineties: if you hear about it once, you hear about it a thousand times. We live now in an aftermath culture, a culture where being traumatized is presumed to be the appropriate response to just about any overwhelming event. “These are the days after. Everything is now measured by after,” a character in Don DeLillo’s 9/11 novel Falling Man says. This leads to the bigger questions: Why now? Why in the United States, a country that is, by any standard, one of the least traumatized on the planet? Is there something about the War on Terror, a war that directly involves less than 1 percent of us, that has made us all a little nuts? Is there something about the larger war against Islamic extremism that has made us fear the outside world? If war is a kind of symbolic violence, is PTSD a kind of symbolic penance? Do we so easily embrace the diagnosis out of a sort of “white guilt” about not having served overseas ourselves, as some have suggested? Or are PTSD and the threat of it simply another example of how modern therapeutic culture has forced its way into our lives and taught us how to perceive normal human adversity?
In trying to address these questions and balance the various academic disciplines that inform our understanding of post-traumatic stress, these pages may display a bias toward literature. Part of this is simply the result of my being a writer, but there is also the fact that for the bulk of human history, literature has been the primary repository of knowledge about war, famine, genocide, and natural disaster. From The Iliad to the Great War poets to the literature of the Vietnam War, writers have been wrestling—and wrestling quite well, I might add—with the mysteries of trauma. In a sense, nothing has changed, and today’s trauma survivors can take great comfort in knowing that they are confronting the same horrors that Achilles faced four thousand years ago. Moreover, as practically any therapist will tell you, many of the long-term effects of trauma are the product of the emotional interpretations of events by victims—interpretations that are informed by the archetypal narratives that exist within a given culture, a process that is explicitly literary. As Robert Stolorow, an influential psychoanalyst, argues, “The experience of trauma is context-dependent,” meaning its essence lies in the subjective experience of the victim; in other words, their story as they tell it to themselves.
By reading the stories of Ernest Hemingway, Alice Sebold, Tim O’Brien, and others, survivors are doing more than simply being entertained, they are reifying literature’s essential function: to remind us that we are not alone and in the process demonstrating how trauma was processed by previous generations. Medicine itself is founded upon a kind of storytelling; Siddhartha Mukherjee, in his “biography” of cancer, The Emperor of All Maladies, explains that “patients tell stories to describe illness, doctors tell stories to understand it. Science tells its own story to explain diseases.” A number of the trauma workers I spoke to over the course of writing this book called my attention to this point; namely, that part of trauma’s corrosive power lies in its ability to destroy narrative, and that stories, written and spoken, have tremendous healing power both for the teller and the listener. Stories in the form of literature help us to understand the enigma of survival in a way that no other technology can. In short, literature makes meaning out of chaos. One senior VA psychiatrist I spoke to, who has treated PTSD for over thirty years, went so far as to say that “the central image of post-traumatic stress is that of Ishmael at the end of Moby-Dick, floating atop Queequeg’s coffin, looking out over the vastness of the sea.”
For better or worse, the popular image of PTSD is derived primarily from the image of the war-torn American veteran. There are good reasons for this. The idea for what became known as PTSD sprang from a group of American veterans opposed to the war in Vietnam. This group, a clique within the Vietnam Veterans Against the War (VVAW), embarked on a decade-long campaign to have the disorder officially recognized by psychiatry. Without them, PTSD as we know it would not exist. For the first nine years of its existence, in fact, what we know of as “PTSD” was referred to as “Post-Vietnam Syndrome.” Since its inclusion in the Diagnostic and Statistical Manual of Mental Disorders, the bible of modern psychiatry, the condition has been somewhat demilitarized, but its connection to the most divisive American war of the twentieth century remains strong. This military connection continues into the present day. While most PTSD sufferers are not veterans and have never seen combat, the Veterans Administration, the second-largest department within the U.S. government, remains a global clearinghouse for PTSD research and has an annual mental health budget that hovers around seven billion dollars.
I have included aspects of PTSD from other causes, including rape, genocide, torture, and natural disaster, but have focused less on childhood and domestic abuse and PTSD arising from events like open-heart surgery and traumatic childbirth. By narrowing my view, I hope to sharpen it to probe into the origins of what some future “biographer” might simply call the problem of adult post-traumatic adjustment. Part of my reasoning behind this is strictly practical: a book attempting to address the causes and consequences of every kind of trauma would run thousands of pages and be filled with so many qualifiers and exceptions to every assertion that it would cease being a story with a narrative arc and become an encyclopedia. Further, as the definition of PTSD has continued to expand, including more and more types of stressors (some U.S. military psychiatrists, for example, have begun diagnosing drone operators with PTSD), the research community has struggled to keep pace. As a writer attempting to create some coherence in a
subject sorely in need of it, I have chosen to exclude certain newer forms of the disease that await scientific consensus and focus on what some have called the “classic” traumatic stressors: war, rape, and natural disaster. This is not an attempt to privilege one type of trauma over another (though the field of trauma studies remains heavily skewed toward war trauma); instead, it is an attempt to make meaning out of the cacophony of an emerging scientific field by deliberately limiting my data set.
This book is a biography, woven together with elements of my own autobiography, my attempt to tell the story of PTSD, beginning with the first glimpses of it in the historical record and then continuing as a sort of pilgrim to the battered temples our culture has erected to it, specifically the Veterans Administration, the U.S. military medical establishment, and the various civilian academic edifices that study it. But, before I tell the story of PTSD itself, we need to get a sense of the sorts of horrifying experiences that cause it and how it feels to a person in the middle of such an event. This is the subject of the next chapter, titled “Saydia” after the neighborhood in southern Baghdad where I spent a week as a reporter in 2007. The second chapter, “In Terror’s Shadow,” takes a slight step back to explore the broader medical questions of PTSD: Who suffers from it? Why do some people suffer from it and others don’t? Chapter 3 takes up the early history of trauma, beginning with the prescientific view of it, and examines the earliest traces of post-traumatic symptoms in Western history, a history that begins, ironically enough, in ancient Mesopotamia. In “The Haunted Mind,” we turn to the experiences of trauma survivors, including the hallucinations, the nightmares, and the altered states of consciousness that often define the post-traumatic condition. Stories of such hauntings have a substantial place in the literature of trauma, and in this book I argue that the post-traumatic state is one of liminality, an existence between realms that causes great confusion for both the survivor and the society to which he or she belongs. In Chapter 5, we explore the modern history of trauma, including its role in the American Civil War, the world wars, and the Vietnam War, the single most important event in the history of psychological trauma.
This book was written for very selfish reasons, as an attempt to answer some pretty basic questions: Why does the world seem so different since I got back from Iraq? Why do I feel so out of place now? What does one do with the knowledge gleaned from a near-death experience? But as a former Marine, I was also driven by a larger desire to understand how the current war on post-traumatic stress is being waged, to get a sense of how it is being run by the VA and the larger medical community, and to make my own independent assessment, my own reconnaissance, of the field. The second half of The Evil Hours is, among other things, the story of this reconnaissance. In “Therapy,” we look at the leading therapeutic modalities and how they work, which is based on my first-person experience with them and on my own research into the science and philosophy that inform them. In “Drugs,” we explore the various pharmaceutical interventions that modern medicine has devised to treat PTSD, a set of interventions that, it turns out, is surprisingly feeble, with one possible exception—a beta-blocker known as propranolol that is so old its patent expired thirty years ago. (Big Pharma, it turns out, hasn’t yet figured out a way to make much money off PTSD.) Given this fact, it is perhaps unsurprising that a wealth of therapeutic approaches outside the medical mainstream has emerged to treat PTSD. In “Alternatives,” we examine the stunningly fertile field of alternative trauma therapy and how many of these therapies challenge our basic Western assumptions about medicine. Some of the most successful approaches to trauma, in fact, aren’t really “therapies” in the normal clinical sense, as they are simply applied practices and activities that someone decided might be worth trying out on trauma survivors. Yoga, for instance, which is increasingly viewed as a powerful PTSD treatment, doesn’t really have much to say about trauma as a formal subject. Instead, yoga simply aims to bring the body and mind into greater harmony—full stop.
The overarching design of this book is to take the reader from the underworld of trauma, its dark and confounding depths to the various stages of its aftermath, considering the ways that scientists and other thinkers have conceptualized it over the years, and continuing to perhaps the most radical proposition of all: that many people do, in fact, grow from trauma and become better human beings as a result of almost dying. The idea of post-traumatic growth was one I came to grudgingly. Like many of the leading clinicians, I found the idea of essentially flipping PTSD on its head, looking for a silver lining in the emotional carnage, to be insulting at first. Nevertheless, after interviewing a number of survivors of near-death experiences, I came kicking and screaming to the conclusion that much of what we call “post-traumatic stress” is, in fact, the failure of our culture to encourage people to seek wisdom in their loss and adversity and to consider trauma in anything other than a narrow medical context.
I have called this book a “biography” of PTSD, a description that is apt given the life the disease has taken on, a life far beyond what its VVAW architects could possibly have imagined. And as much as this book is an attempt to tell the story of PTSD, to recount the basic history and science of this surprisingly complex condition, it is also an attempt to examine the disease’s other life in the culture at large and how it has become a sort of global lingua franca, a label, an identity, a way of understanding the self, a cultural meme, a political interest group, a scientific mythology, and even a theory of time.
1
SAYDIA
THROUGH THE SMALL, thick Humvee window, the city was dirty and gray, a charcoal drawing sketched across the horizon. Sand moved over the blacktop. Along the roadside, the sagging arms of dead power lines hung from one blackened light pole to the next. The sun beat down on everything: the palm trees, the cinderblock houses, the dirty boulevards that led from nowhere to nowhere. There was something almost cunning in the layout of the city, in the way it could swallow entire armies, reduce them to chaos, as if to repudiate the idea that fortresses needed walls.
“When were you in the Corps?” a captain named Vollmer asked from the front passenger seat.
“’94 to ’98,” I said.
“Infantry?”
“Yeah.”
“Ever go to Okinawa?”
“Yeah, I did a pump there with Three-Five.”
“I was stationed at Schwab, up-island.”
“No shit?”
“Third Recon. I was a jarhead before I went into the army.”
I had resigned my commission so long before that it felt almost shameful to bring it up. My time in the Marine Corps had been brief and uneventful, boring even—nothing of consequence had happened, a fact that even now brings a sense of regret. I served in no war, took part in no raid launched under the cover of darkness. Most of my time in uniform was spent in garrison, staging mock patrols into the hills of Camp Pendleton and the jungles of Okinawa; occasionally we rappelled out of helicopters, as if to remind ourselves what real danger felt like. We called this training, but really we were just waiting, waiting for the call that never came. After four years, I left the service feeling vaguely disappointed, incomplete, as if some secret in me had been left unrevealed.
I was an unpromising lieutenant, not the worst, but a slacker. Most of my peers wanted to command, to lead Marines in combat. They believed, as others had before them, that their lives would be freed forever from the trivial and the mundane once the bullets started flying. The idea of “leadership,” the endless posing and pretending, the trading of steely-eyed glances, bored me. Military leadership is a solemn responsibility, but in peacetime it can seem ridiculous, an exercise in fascism. Twenty-three and fresh out of college, I didn’t want responsibility, I wanted adventure—adventure and the stories that came out of it. I think of one story an old sniper in my rifle company told about being in Beirut in the eighties. From a position inside the city, he had held Yasir Arafat in his crosshairs for several minutes as the PLO
leader made his way through a refugee camp. Following Arafat through his scope, he began to cycle through his breathing drill, beginning to imagine the shot, the shot that would change history. He never pulled the trigger, of course, but having the man in his sights for a few moments had given him an almost erotic sense of power. It was a feeling I never forgot.
Looking back, I can see that what I really wanted, as much as the adventure or experience or medals, was something far less noble: I wanted to be like that sniper. Not a killer, really, but a man with a history. I wanted to make other people envious. Envious of my experience. Envious of what I had seen. Envious of the stories I could tell. There were other desires, to be sure, some more honorable than that, but what I coveted more than anything was the power of a certain kind of silence, the silence that fell over a room when a veteran launched into a story that began, “Back in the Mekong . . .”
This desire clings to me still and was even stronger during my first years out of the Marine Corps. I was finishing graduate school, still dreaming of faraway places, when the towers fell. Like everyone else, I woke on September 12 and saw a different world. I had begun working tentatively as a writer, and it was the writer in me, not the Marine, that sensed an opportunity. The world was at war, and I saw that the logical thing to do was to become a war correspondent. It would be a way of revising my past, correcting an oversight in my record; without having to don a uniform or suffer any orders, I could collect the experiences I’d hungered for as a young man. I would be in a war, but on my own terms. It felt like I’d discovered a trapdoor in time.
The Evil Hours Page 3
