The Evil Hours

by David J. Morris

  Modern trauma psychiatry has been influenced by this sea change in American attitudes toward mental illness, and not long after Prozac’s debut, doctors who had heard about the extraordinary results their colleagues were getting with depressives began prescribing ­SSRIs (Selective Serotonin Reuptake Inhibitors, the class of drugs that Prozac belongs to) to PTSD patients. This type of prescription is sometimes referred to as happening on an “off-label” basis, and this happened in the case of SSRIs because the drugs have few known side effects and it seemed likely that they might work, reducing the emotional numbing symptoms associated with PTSD. Zoloft, an SSRI fielded in 1991, is now the most prescribed drug for PTSD and was the first medication to receive FDA approval for such treatment.

  This accidental discovery, of a drug associated with a particular mental illness being effective with another disorder, is, it turns out, typical of modern pharmaceutical research, where the major drugmakers today will admit that they have no biological “targets” to shoot for in developing new drugs. This lack of a scientific basis for using SSRIs to treat PTSD confused more than a few practitioners, and in 2007, after the VA asked it to, the prestigious Institute of Medicine investigated the situation and found that “for all drug classes reviewed, the evidence is inadequate to determine efficacy in the treatment of PTSD.” In other words, regarding the use of drugs to treat PTSD, the jury is still out.

  Despite these huge gaps in scientific knowledge, public faith in the idea that biology is destiny continues to grow. Along with the dramatic growth and popularity of “cosmetic pharmaceuticals” like Prozac has come a dramatic lowering of the threshold for what people define as mental illness and an increasing popularity of the PTSD concept in the culture at large. As one Oxford University psychiatrist put it recently, “Society has rejected the stiff upper lip.” In 1992, the World Health Organization included a slightly modified version of PTSD in its International Classification of Diseases compendium, one of the most widely used diagnostic tools in the world, a step that virtually guaranteed that post-traumatic stress would see global acceptance. As an institutionalized form of compassion and a concept by which victims of violence can connect, PTSD has proved to be a formidable concept indeed. One Manchester, New Hampshire, physician and lawyer argued mid-decade that “post-traumatic stress disorder is the mental illness of the nineties.” Adding, “With the number of cases of PTSD being diagnosed today, it can almost be called a growth industry.”

  Since 1980, one of the greatest challenges for the field of trauma studies has been one of growth management. Like Prozac in the 1990s, PTSD began its life as a psychiatric trend and has become a cultural phenomenon, not only a way of understanding the self, but also a way of interpreting culture and history itself. Indeed, much of the recent criticisms of the PTSD “project,” as it is sometimes known, has focused on whether the diagnosis on an individual level has become too popular, too powerful, too readily exploited by the legal profession and whether it has, in essence, served to medicalize normal human adversity. In 1995, Cathy Caruth, a trauma scholar at Emory University, hinted at PTSD’s seemingly boundless expansion, saying, “This classification and its attendant official acknowledgment of a pathology has provided a category of diagnosis so powerful that it has seemed to engulf everything around it: suddenly responses not only to combat and to natural catastrophes but also to rape, child abuse, and a number of other violent occurrences have been understood in terms of PTSD, and diagnoses of some dissociative disorders have also been switched to that of trauma.”

  That the power of the diagnosis would expand even as the war that spawned it was receding into history is noteworthy. In retrospect, it seems that PTSD spoke to something in us at the end of the twentieth century, as if the diagnostic concept held up a fractured mirror to ourselves, revealed how fragmented human consciousness had become. In time, PTSD would break out of the VA clinics and begin to insinuate itself into the dream life of the culture in a distinctly civilian fashion. Every age finds its disease. Borderline personality disorder, a diagnosis common during the 1960s, seemed to capture the growing unease many parents felt about their children, their daughters in particular. During the 1980s, the specter of AIDS haunted Americans in part because the country was struggling with the legacy of sexual liberation that began the decade before. By the 1990s, PTSD as a concept had outgrown its close association with Vietnam and become a cultural meme, its various symptoms represented in a variety of media, including the memoir boom of the 1990s, African-American fiction, the “poetry of witness,” fine art photography, and cinema.

  “After the formulation and extension of PTSD in the 1980s,” according to writer and trauma scholar Roger Luckhurst, there was a “marked disruption of linear temporality in 1990s cinema—with plots presented backwards, in loops, or disarticulated into mosaics that only retrospectively cohere—[a technique] partly driven by attempts to convey the experience of traumatized subjectivity.” Films like Quentin Tarantino’s Pulp Fiction and Harold Ramis’s Groundhog Day shuffled narrative sequences in new and disjunctive ways, splicing the story into a series of repetitive loops, mixing time signatures, making the flashback not only a cinematic technique but the conceit of the entire narrative.

  In Christopher Nolan’s innovative Memento, released a few months before 9/11, the main character, Leonard Shelby, suffers from anterograde amnesia after being assaulted in his home, rendering him incapable of creating new memories. Forced to live his life in a series of fifteen-minute segments, he exists, according to Luckhurst, in “the timeless time of the post-traumatic condition, whereby time seems arbitrary but is in fact undergirded by a repetition-compulsion that he cannot know or master.” (Repetition-compulsion is an idea, introduced by Freud, that says that survivors tend to reenact their traumas, both in real life and in their dreams.) The only sustaining memories he retains are haunting, disjointed flashbacks of his dead wife, whose death he is driven to avenge. In one poignant scene, Leonard asks, “How am I supposed to heal if I can’t feel time?” The film ends on a repetitive note, signaling that the loop of the story will continue, perhaps into infinity. Leonard kills one of his wife’s “murderers” and then selects another for elimination. Before the next loop begins, he asks, “Now, where was I?”

  By September 11, 2001, PTSD as a cultural phenomenon was so widely accepted, had so infiltrated the helping professions, that almost immediately after the towers fell, an estimated nine thousand trauma counselors flooded lower Manhattan in order to address what was expected to be a tidal wave of post-traumatic stress. The Federal Emergency Management Agency spent 155 million dollars to make psychological counseling available for the quarter of a million people who would need help dealing with their trauma and grief. To the shock of many, a mere three hundred people turned up, a development some observers chalked up to the national need to clean up lower Manhattan and gear up for the war to come.

  While this particular epidemic failed to materialize, it is now broadly assumed that survivors of traumatic events, and even those watching them remotely, will suffer some form of post-traumatic stress. To the dismay of infantrymen who fought in Iraq and Afghanistan, drone operators, piloting unmanned planes over Pakistan from air-conditioned trailers in the continental United States, are now being diagnosed with PTSD by air force doctors. In 2004, in the wake of the deadly tsunami that struck Sri Lanka, one Duke University professor of psychiatry told a reporter, “Based on prior experience from other mass disasters, we can expect that between 50 and 90 percent of the affected population will experience conditions like post-traumatic stress disorder and depression which, if left untreated, may last for years.” Robert Gates, the secretary of defense under Presidents Bush and Obama, in his memoir Duty wrote that he came to believe “that no one who had actually been in combat could walk away without scars, without some measure of post-traumatic stress.”

  Once the dream of a handful of Vietnam veterans, PTSD is now, as one observer examining the Sri Lanka tsunami describe
d it, “the lingua franca of suffering.”

  6

  THERAPY

  TO REACH THE San Diego VA hospital from downtown, you drive fourteen miles north on Interstate 5 past a gleaming Mormon temple, exit at Nobel Drive, and pass the Whole Foods Market. Then turn right onto Villa La Jolla Drive and head up a steep hill, passing the Rock Bottom Brewery and UCSD’s Skaggs School of Pharmaceutical Sciences on the left, make another right, and there it is. The hospital itself is a white five-story building that has been retrofitted and expanded so many times that it has begun to resemble a giant Lego sculpture. Not all the parts match up. The parking lot is filled with Harley-Davidsons, RVs, pickup trucks, and SUVs, many of them with out-of-state plates. Located less than a mile from the beach, it is seemingly always sunny and seventy-two degrees, and you can smell the ocean while standing in the parking lot. Situated on the central coast of San Diego County, home to the largest constellation of military bases in the United States, including Camp Pendleton twenty miles to the north, the hospital is the centerpiece of the VA San Diego Healthcare System. The original building, completed in 1972, boasts an authorized capacity of 304 beds. It serves a regional veteran population of over a quarter million, including the largest concentration of Iraq and Afghanistan veterans in America.

  Inside the building, the beach feels a million miles away. Visiting a major American VA hospital is, ironically, a lot like arriving at a foreign airport; one immigrates through a maze of confusing signage and punishing bureaucratic rituals. Eye contact is avoided. Documents are inspected. Time slows. One is immediately surrounded by long-suffering faces, faces of a sort not seen in the typical American suburb. Entire families can be seen, three generations deep, clinging to one another like shipwrecked passengers. And there is, of course, a discernible sadness and resignation in the air.

  This is the VA story we all expect to hear if we bother to venture past the headlines, variations on the same three themes: the veterans are tragic, the facilities are outdated, and the staff are callous. To say that the VA hospital is where the final bill for every American war is paid is to state the obvious. The VA is like a morbid version of Disneyland: even if you’ve never been there, you feel like you have. And yet, as I would learn, the truth about the VA, an institution that serves as Ground Zero for PTSD, is far more complex and confounding and, for lack of a better word, fascinating than I had imagined. Joined at the hip to the academic medical establishment, the VA, the second-largest department in the federal government, is where the public and the private, the military and the civilian, and the real and the symbolic all meet. Yes, the VA is often a sad place, but then so are many foreign countries when you first arrive, a fact that makes them no less startling and enriching once you actually open your eyes, start looking around, and start talking to people.

  The first time I visited the San Diego VA hospital, I was going to see the coordinator of a study looking for the best combination of Zoloft and individual psychotherapy for the treatment of PTSD. The week before, having waited for months, I had finally been screened by a psych intern at the nearby Mission Valley clinic. This screening appointment, I would learn later, was the key to the realm. Once you made it through a basic introductory interview, you were in the system. You existed. Dealing with the VA, I would learn, is basically a patience marathon. If you give up, nobody stops and the race just moves on around you. At the conclusion of the hour-long interview, the intern told me that the fastest way, and really the only way, to see a therapist one on one was to volunteer to be a subject for one of the twenty-plus PTSD studies being conducted at the La Jolla hospital.

  “La Jolla. You mean the Death Star?”

  “Yes, the Death Star,” she replied, laughing.

  I entered the building in a state of rising awe, watching the generations of veterans walking and in some cases rolling by. It was history in motion. Old Filipino men in guayaberas and embroidered VFW hats. An amputee, who from the waist up resembled a college sophomore; from the waist down, he was pure science fiction, a half-android making his way down the bright corridor on a composite limb that resembled a stealth fighter wing. The generational strata were more or less recognizable by their clothing. The Iraq and Afghanistan vets were easy to spot. They were the ones with the skate shoes and the digital camouflage backpacks, looking like they subsisted on a diet of powerbars and Red Bull. Then there were the T-shirts, many of them displaying a variety of avenging bald eagles, terrorist hunting licenses and proclaiming their indifference toward their own mortality. The fashion grew progressively more formal as you went deeper into the strata until eventually you reached someone who looked like very much like your grandfather and was dressed in a tie and coat with elbow patches, procured in the dark ages before irony became a primary mode of communication.

  In a restroom off the main corridor, my breath caught. There was a piece of graffiti written in black laundry marker.

  “MAKE PEACE OR DIE”

  1/5 A. CO. 3D PLT

  FALLUJAH RAMADI KARMA

  THE LORD IS MY SHEPHERD

  EAS 15 AUG 05

  PEACE. I’M DYING.

  It seemed to say it all in just a few lines. The poetry of places and dates. Unit names, the lies you told yourself over there in order to make it through. Everything that was supposed to happen but didn’t when you got home. “Fuck this place, man. This war is over once I get home.” You heard this kind of thing every day in Iraq. There was the fever and afterward the long sleepless evenings, the emptiness of the return, or the refusal to return at all. First Battalion, Fifth Marines, or “1/5,” was the sister battalion to my old unit and was the second battalion I had visited in 2004. Karma, a small town just north of Fallujah, was where I had seen my first IED ambush, which resulted in two dead Pennsylvania National Guardsmen.

  After waiting at Two North, the same-day psychiatry clinic, for a merciful twenty minutes, I was met by Mark, the study coordinator. A spectacled man with the genial confidence of an executive, he explained the study to me. Designed to find the best combination of Zoloft and individual psychotherapy for PTSD, it was one of the largest of its kind ever done and would take well over a year to complete, involving hundreds of patients at four separate VA sites: San Diego, Ann Arbor, Charleston, and Boston. A therapist with an MBA, Mark loved doing research and spoke of the investigators running the study like they were rock stars. “The primary investigator for this study has a résumé that is thirty-six pages long.”

  As he explained to me later, “This study includes some of the very best researchers in the world. It’s interesting because I like working on studies where you’re not trying out new things. I mean, you have to try new things out but I like working on stuff where I can say to people ‘Look, this is research but our treatments aren’t experimental.’ That’s the cool thing about Prolonged Exposure [the form of psychotherapy being investigated in the study]. This is a treatment that we know absolutely works for PTSD. I know it sounds arrogant but if you get into this kind of treatment and do the work that your therapist tells you to do, you’ll have a huge improvement in your symptoms. If you don’t, you won’t. The research behind Prolonged Exposure, for example, says it works in about 85 percent of people. Those are some pretty darn high odds if you ask me.”

  After guiding me through a thick stack of surveys and consent forms, Mark passed me off to Sarah, a VA employee who, after giving me a water break, opened up a thick binder and gave me what is known as the Clinician-Administered PTSD Scale or CAPS. The most widely used diagnostic tool for PTSD, the CAPS is a structured interview format created by the National Center for PTSD that is often referred to, in the dialect of the VA, as the “gold standard in PTSD assessment.” Derived from the DSM-IV diagnostic criteria for PTSD, it consists of a thirty-item survey that takes around two hours to complete. For a trauma survivor, it can be a stressful experience.

  To complete the CAPS, the patient is asked to identify one or two traumatic events. The patient is then given a ser
ies of questions relating to these events, such as “Have you ever had unwanted memories of the event? What were they like? What do you remember?” After working through this first part, the patient is then asked to rate their answers in terms of frequency and intensity on a four-point scale. As with most things related to the treatment of PTSD, the patient is expected to condense their traumatic experience down to one or two distinct events that can be verbalized and subsequently recorded and scored by the interviewer.

  Here is where I struggle. There are certain moments from my months in Iraq that stand out from the others. These moments journey away, return, speak to me, on some level consume me, flood me with joy. Others continue to break my heart. There is the moment in Saydia, for example. There is the moment on the bridge near Karma, the long minutes waiting for the medevac helicopter. But there are other, less easily described moments. Moments with no clear narrative line. Moments of moral chaos. Moments when anything became possible. Moments where nothing was real. Moments that occurred over the course of months. Moments I am still waiting to end. Moments that have yet to be tamed by language.

  For my first CAPS, I chose one of the easy ones. An incident where I was riding in a Marine helicopter over Fallujah that was taken under fire, an event that has made it difficult for me to fly on some occasions. Shortly after I began describing this event, about which I have had nightmares, my blood began to heat up. My breathing became shallow, more rapid. It was as if someone, invisible to me, was turning up a heating element inside my chest.