“Okay. Let’s go through it again,” he said.
I closed my eyes and went back into the Humvee and retold the whole story again, picking up a few more details here and there, like forgotten keepsakes in an old house. There was the heavy grinding noise of the Bradley on the street, the low cinderblock wall in front of the burning houses, Vollmer yelling up at the gunner, and the gunner not hearing him. Not hearing him because his eardrums had been blown out. Opening my eyes, I looked down at my feet and realized I was sweating. After a moment’s time, I came back more fully, then looked over at Scott, waiting to see what was next.
Telling the story was irritating. It was hardly a gripping adventure story to begin with. It was, in truth, a story without heroes or a moral point of any kind, just some tired soldiers driving on a dirty street and rolling over an old mortar round that had probably been made by the Soviets before most of the guys in the Humvee had even been born. Part of me was glad to finally talk about the war, to have it out, but chopping it down to this one tiny episode felt like an act of vandalism, as if we were turning the war into a snuff film. I decided some context might help set the scene a little better, help explain my emotional state at the time, so I began telling him about Saqliwiyah, what a crazy scene it had been, how I had left the company operations center and walked into the lobby of the old hotel and seen that it was filled with wounded Marines, most of them just six months out of boot camp. Then hearing the sergeant cursing, his fucks and goddams echoing off the high ceiling of the lobby as I walked away. Before I could really get into the meat of the story, however, Scott put a hand up and stopped me.
“Dave, now I know you saw a lot of crazy stuff over there but we need to get back to the imaginals. We need to get you back in the Humvee and get you really engaging those feelings. So, let’s do it again but this time I want you to really put yourself back in it, really engage those feelings, okay? Do you think you can do that?”
And so it went. We did another two repetitions before we broke for the day. Before I left, however, we briefly discussed my “in vivo” homework, which involved me walking through a dodgy neighborhood near downtown and seeing if it activated any of my Iraq memories.
When I stood up, I could feel my face starting to do strange things, my fists balling up. Leaving the hospital those early days was confusing, maddening. There were feelings happening that have no names. My blood felt different. Hot. The venom in my veins I’d felt in Dora was back. The whole process was strange, detached from what I considered to be any natural rhythm. In the therapy room, going through the imaginals with Scott, I felt annoyed with the monotony of it, bored even. The story of my getting blown up had never been particularly interesting to begin with, but now it felt staler than month-old dogshit. We would roll through it, and I would be back in Saydia for a few minutes, remembering the fear, then it would be over. But once I stepped out into the fluorescent corridor of the hospital and got a look at the people, a knot of anger and resentment would form in my stomach. My jaw would set itself, and I would begin patrolling my way back to my truck. And there was a bitterness, a sourness to it all, what I would later describe as a kind of “body nausea,” as if all the fear from Iraq had been trapped inside all that time, fermenting.
I began to think of the treatment not as therapy so much as punishment. Penance.
It went on like this for weeks. I would show up with some things I wanted to talk about, thoughts I’d had, questions that had arisen when I looked over the journals I’d kept during the war, and after hearing me out, Scott would invariably direct me back to the imaginals. At one point, I went in and out of the cul-de-sac in Saydia eleven times in one afternoon. I say “I” went in and out of the cul-de-sac because I always felt like I was alone in this activity. It soon became clear to me that this was not “therapy” in the sense that one traditionally thinks of it, as a conversation between therapist and patient where issues are raised and worked through, insights achieved. This, I saw, was a far more controlled form of treatment. Scripted even. Stage-managed. I had a role to play. The role was that of the patient diligently repeating his story, ad infinitum. The therapist’s role was to be “present” and reassuring, armed as he was with a set of calming and validating phrases and rhetorical gestures. It was, I would later learn, a “manualized” therapy. A therapy, in other words, whose results were designed by researchers for researchers, a therapy designed to be touted by medical administrators as being “efficacious” and scientifically tested.
For a few minutes every session, we would talk about my drinking, how I was managing my “cravings,” and then we would return again to the imaginals. It reminded me of a Spanish language tutor I’d had in college. I would talk about my difficulties with certain verb tenses: the preterite, the future conditional, and so on. My tutor would listen attentively, and inevitably we would dive straight into the verb charts, working our way through them. The point wasn’t how you felt about the verbs, why you were struggling with them. The point was to keep going through the charts. Prolonged Exposure was, I reminded myself, a therapy predicated on repetition.
It was also excruciating. And confusing. It seemed to be altering my body chemistry in ways that I didn’t understand. Everything was beginning to feel like an out-of-body experience, as if I were always hovering a few feet away from my body as it went on with its day.
I had sought out this particular therapy because I had been told by Mark, the research coordinator, and others that it was the most effective, that it would be one on one, and that it was “perfect” for someone with my experiences.
It was, I had been told, the “gold standard” of PTSD therapies.
After a month, I complained to Scott.
“I haven’t felt this bad in years,” I began. “Honestly, I don’t remember even feeling this bad in Iraq. Is there something else we can try?”
Scott listened patiently, nodding along as I went through my litany of complaints, how this wasn’t helping, how I was having trouble sleeping, how I was unable to work, how I was unable to read, how new symptoms that I’d never even had before were emerging.
“I appreciate your honesty,” he said. “I appreciate that you’re thinking about all this stuff. Because this is important, what you’re saying. What’s happening now is we’re stirring the pot, activating those memories. It does get better. Trust me, this therapy has helped a lot of people.”
This argument didn’t seem to have the desired effect and brought about one of his trademark metaphor change-ups. “What we’re doing right now is cleaning out the wound. So, let’s say you have a cut on your arm and it’s infected, it’s festering, what are you going to do?”
“You’re gonna clean it out,” I said, playing along.
“Now, when you first take off that bandage to put that antibiotic in there, how’s that gonna feel?”
“It’s gonna fucking hurt.”
“Right. So it’s gonna hurt for a bit when we first get in there. It’s going to burn. But then it’s going to get better. We just need to stick with it and clean out that wound.”
Then, five weeks into therapy, it happened. One evening, a few hours after our afternoon session, I picked up my cell phone and tried to dial a number and it died. I flew into a rage and began pounding the phone into the corner of a nearby bookcase, knocking it over and making a mess out of my bedroom. Rushing into the kitchen, I grabbed a large stainless steel knife and, like a murderer in a Hitchcock film, began stabbing the phone over and over again, screaming obscenities.
And I continued to stab my phone until I had bent the knife blade fully ninety degrees. Outside the window of my apartment, I could hear my neighbors debating the pros and cons of calling the police.
Prolonged Exposure, one of the VA’s top-tier or “Schedule A” PTSD therapies, is one of the most thoroughly researched and empirically validated psychiatric treatments in existence. The body of science supporting its use is over a century old and reaches back to the very dawn of psy
chology, when the fledgling discipline was still trying to carve a niche from the fields of philosophy and literature. It is no exaggeration to say that PE has the best scientific pedigree of any trauma therapy protocol. Derived from the classical conditioning or “learning” theories first described by Pavlov in the late 1800s, the principle behind PE is very simple: almost all human behaviors are learned, and they can be unlearned by manipulating the stimuli that a person is exposed to.
Applying behavior learning theory to PTSD, researchers have created an extensive model of how the disorder develops and persists. These theorists posit that once exposed to a traumatic stimulus, a person suffering from post-traumatic stress will continue to avoid situations reminiscent of the original trauma, a process that can prevent the victim from ever healing or moving on. In time, the original traumatic stimulus can begin to evolve, metastasize, to include a number of random stimuli associated with the trauma, until vast swaths of the world become fear inducing. This effect is depicted in Jonathan Safran Foer’s novel Extremely Loud and Incredibly Close, where the narrator, talking about the aftermath of 9/11, says,
Even after a year, I still had an extremely difficult time doing certain things, like taking showers, for some reason, and getting into elevators, obviously. There was a lot of stuff that made me panicky, like suspension bridges, germs, airplanes, fireworks, Arab people on the subway (even though I’m not racist), Arab people in restaurants and coffee shops and other public places, scaffolding, sewers and subway grates, bags without owners, shoes, people with mustaches, smoke, knots, tall buildings, turbans. A lot of the time I’d get that feeling like I was in the middle of a huge black ocean, or in deep space, but not in the fascinating way. It’s just that everything was incredibly far away from me.
Within VA circles, it is not uncommon to hear something similar to this “huge black ocean” effect, and one often hears clinicians describing their patients as living inside a “PTSD bubble,” a severely limited range of activities that doesn’t trigger their symptoms. For one Iraq veteran I interviewed, who lost several of his buddies in Fallujah, this “bubble” consisted of a single bedroom in his apartment and nothing else. Just being out on his balcony triggered bad memories.
One of the more recent therapies derived from classical learning theory is what is known as “flooding.” Created by psychologist Thomas Stampfl in 1967, flooding involves exposing a patient to a concentrated dose of a frightening stimulus, such as putting a person with arachnophobia in a room full of harmless spiders. One of the classic examples of successful flooding involved an adolescent girl with a phobia of traveling in a car: she was driven around for four hours until her fear disappeared. During World War II, a group of American soldiers who showed an aversion to loud noises and even music were hospitalized and forced to view documentary war footage that featured an increasingly loud soundtrack of combat noises. Most of the soldiers, while terrified at first, eventually grew bored and all but one showed a decrease in symptoms. Flooding has since been shown to be an effective treatment for a number of phobias and for obsessive-compulsive disorder.
The idea of using flooding on PTSD patients occurred almost immediately after the condition was recognized by psychiatry in 1980. Because putting combat veterans back into wartime situations was not logistically feasible (or ethical for that matter), researchers began hunting for other ways to selectively reexpose PTSD-positive veterans to their traumatic memories. In 1982, Terry Keane, a psychologist at Boston University, began exploring the idea of using a directed reminiscence technique called “flooding in imagination” or “imaginals” to reactivate and, in some way, modify the traumatic memories of Vietnam veterans. A number of investigators continued to study the problem, and by the end of the 1980s, it was clear that flooding, or some derivation of it, held the potential to be a benchmark treatment for PTSD.
However, as any medical researcher can attest, the road from laboratory discovery to the widespread use of a therapy is often very long. Funding constraints, politics, institutional inertia, careerism, along with simple intellectual trendiness, intrude upon the scientific process in ways that can frustrate even the veteran investigator. With the increasing specialization of modern science, it is not uncommon for the most innovative researchers to be overlooked by influential funding bodies and the scientific press because they struggle to lobby for their own work. As one senior VA official lamented to me, “Often what passes for science is just simple popularity.”
Proponents of flooding and the various exposure therapies were also confronted with a unique set of challenges. Practicing therapists have always been deeply uneasy about subjecting traumatized patients to such an unusually arduous form of therapy. One of the recurring concerns raised by therapists was the possibility that the therapy might, in fact, be “retraumatizing” to a patient, a prospect that flew in the face of the clinician’s credo of reducing human suffering. Opponents of such therapies even theorized that flooding could cause psychosis in some patients, effectively destroying any hope for recovery.
One of those most excited by the possibilities of flooding therapy was Edna Foa, a psychologist at the University of Pennsylvania. Charismatic, media savvy, and possessing a seemingly limitless store of energy, Foa regularly crisscrosses the country delivering lectures and workshops on PTSD treatment. (One participant, describing one of her legendary workshops, said, “I didn’t see her sit down for four days.”) Born in Haifa, Israel, and trained in clinical psychology at the University of Missouri, Foa began investigating postrape interventions in the early 1980s, cobbling a variety of therapeutic techniques together. But she was frustrated by the lack of progress. It wasn’t until 2000, during a sabbatical in Israel with her husband, that the light bulb went on.
Just five days after they arrived, the Second Intifada began. A conflict that killed over four thousand people, it spurred Foa to shift her research toward the treatment of combat PTSD. Building on Keane’s work, she went on to refine the techniques of flooding and imaginal therapy, combining them with an “in vivo” component that allowed patients to apply techniques learned in a therapist’s office in the crucible of the real world. A number of studies, many of them overseen by Foa, have shown that PE can dramatically reduce PTSD symptoms. Sometimes jokingly referred to as the “doyen” of Prolonged Exposure, in 2010 Foa was named one of Time magazine’s one hundred most influential people for her work in treating post-traumatic stress.
However, not everyone was convinced about this new therapy, including Stanley Rachman, a psychologist at the University of British Columbia, who in 1985 warned against drawing a direct analogy between “fear acquisition” behaviors in animals and humans. As Jerome Kagan, a professor at Harvard, wrote, “It is not obvious that a rat’s display of an enhanced startle reaction . . . [is a] fruitful model for all human anxiety states.” The idea that humans enjoy a much richer and more complex inner life than other mammals, and that this fact might influence the onset of PTSD, was noted by a handful of other theorists.
In 1991, Roger Pitman, a professor of psychiatry at Harvard Medical School and an experienced PTSD researcher, released a case study of six Vietnam veterans treated with flooding that raised grave concerns about the approach. During a twelve-week course of treatment, two of the veterans became suicidal. Another, with a history of alcoholism, broke 19 months of sobriety shortly after beginning flooding therapy. Others became severely depressed. One patient began suffering panic attacks between treatment sessions. “Mr. B.,” a forty-five-year-old veteran, said, “Your research has worked on one level but has exacerbated problems on another dozen . . . it has opened up horrible holes in my personality that I had been successful in glossing over.” In the conclusion of the study, Pitman and his team raised a red flag, saying, “We feel we have accumulated sufficient experience to call into question the reassurance that flooding does not risk retraumatizing the PTSD patient.” A lengthier study by Pitman published in 1996 found that applying what amounted to a therapy
for simple phobias to a far more complex condition like PTSD had serious drawbacks, asserting that in addition to the unknown side effects of PE, “PTSD may not be amenable to modification by exposure.”
Similar research, conducted by Zahava Solomon, a leading Israeli investigator, and published in the Journal of Traumatic Stress in 1992, found that after flooding treatment, Israeli army veterans reported an increase in the “extent and severity of their psychiatric symptomology.” One of the most cited volumes on traumatic stress, edited by another Harvard researcher, Bessel van der Kolk, concluded its review of PE by saying that “it is important to emphasize that exposure may lead to serious complications.” In a recent phone interview, Pitman told me that after releasing his results, a number of his colleagues approached him confidentially, saying, “You’re right. We’re seeing the same things you are.”
In 2008, undeterred by these and other disturbing studies, the VA began a broad rollout of PE therapy that one Yale psychologist called “unparalleled in the mental health field.” To support this effort, the VA began holding workshops across the country, enlisting Foa as one of their lead trainers. (“To Foa, spreading the word is what matters most now,” wrote Jeffrey Kluger, her profiler at Time.)
Since the rollout, a number of trauma workers, both inside and outside of the VA, have expressed concerns about the safety of PE, arguing that it is at best unproven for combat PTSD and at worst unethical. One clinician quoted in Fields of Combat, a book-length study of the politics of PTSD treatment authored by a VA medical anthropologist in San Antonio, described its use on recent Iraq and Afghanistan veterans as “unconscionable.” Another said that it seemed “too atomized” to be effective on veterans because of its focus on onetime traumatic events. One research assistant at VA San Diego that I spoke to said she had heard other veterans complain about PE, describing the dropout rate as “very high.” An independent survey conducted by the health website 23andme.com in 2012 found that among 531 PTSD sufferers, Prolonged Exposure was rated as the least popular and least effective among 31 different treatments. One rape victim I interviewed, who completed a two-month course of flooding treatment, said, “Flooding. That’s about right. I am once again flooded with fear and paranoia.”
The Evil Hours Page 22
