The Evil Hours

by David J. Morris

  As the group sessions went on, we were asked to transfer the contents of our A-B-C sheets into “Challenging Questions Worksheets,” where we were encouraged to investigate our various stuck points on the basis of a number of questions. Is your belief based on facts? Are you thinking in all-or-none terms? Is your source of information reliable? Are you taking the situation out of context and focusing on one aspect of the event? Are your judgments based on feeling rather than facts?

  Interestingly, while a couple other veterans had concerns similar to mine, concerns that were labeled as revolving around “social trust,” a larger number were concerned with issues of “safety and security.” One of the recurring themes of the group involved what Tim described as his dislike of “people of different races,” specifically “Middle Easterners,” a group that seemed to include anyone wearing non-Western headgear. Tim would later recount a recent incident in which he’d assaulted a local Iraqi pawnshop owner after getting into an argument with him. Being yelled at in Arabic, he said, had set him off. His leg doing the sewing machine needle, he explained that he had recently gone off his meds and that on the day of the altercation he had been wearing a memorial T-shirt with the words INSURGENT HUNTER printed on it along with the name of a dead buddy.

  In response to all of this, Tim was asked to consider whether his response to hearing Arabic wasn’t a case of inappropriately applying knowledge specific to Iraq to the environment of the United States. Was it not also possible, Chloe asked, that behaviors that were possibly appropriate eight years ago in Iraq were not appropriate in present-day America? Continuing, she asked if he wasn’t taking the “situation out of context,” seeing a pattern that wasn’t exactly there, a phrasing that to me sounded suspiciously like apophenia.

  Fernando then told us how he’d stopped going to movies after seeing a group of “Middle Eastern” people gathered inside a theater. He was, he said, always “waiting for the other shoe to drop,” “waiting for another attack to come.”

  Later, toward the end of the twelve-week group, I talked with Fernando while we sat in the clinic’s waiting room. He told me that going to the group had helped him, and that he really appreciated being able to talk to Chloe and Heather, though he was upset that Heather had left the group at the midway point (her fellowship at VA San Diego had ended, and she had moved on to a new assignment within the VA), a reassignment that he called “fucked up” and that had upset everyone and corresponded with a sharp drop in attendance. He still seemed tentative, frustrated by his perceived lack of safety, and he still got upset when he saw women in what he called “full-on burkas” in Target, but he did seem more relaxed, less agitated.

  Like Fernando, I found CPT to be useful. It provided a set of skills and, for lack of a better phrase, a useful set of perceptual tools. And like him, I found the idea of filling out A-B-C sheets and thinking through my stuck point logs and connecting them up via a Challenging Beliefs matrix to be impractical and somewhat ridiculous. Would I need to reexamine every moment of my past in this way to achieve a kind of balance? Worksheet by worksheet? If by accident I remembered the Marine from 1/1 who’d told me about his need to tell his wife everything, the Marine who subsequently caught two legs full of shrapnel, was there an appropriate worksheet available for such a memory? A worksheet to describe the connection I’d made that day, that you needed to be careful who you told what? Was there an appropriate worksheet for all the things I tried to tell Erica but couldn’t? A worksheet to contain, to “reality test,” all the words I needed to say to her but didn’t?

  It struck me, as we sat talking amid the odd, junk drawer clutter of the waiting room, that CPT, whatever else it was, was an attempt to arrest the flow of time, to slow down the moments that had happened too fast, to impose an order and a rational meaning on them. To, in other words, strip them of their mystery, their capacity to haunt. (In my journal, I wrote, “If PE is like emotional chemo, then CPT is like a form of emotional tai chi.”) And I wondered how much of my resistance to it was simply my unwillingness to let go of the memories, to let go of the war’s mystery, its specialness. If I let it all go, if it became an experience just like any other, an isolated event, what was left? Who was I then? If the war was of no enduring moral concern, why was I still haunted by it?

  Fernando, a more practical man than me, asked before we broke for our final session, “So I am going to have to carry these worksheets around with me for the rest of my life?”

  Psychodynamic therapy, the therapeutic school that grew out of Freudian psychoanalysis, while never in vogue for the treatment of PTSD, has a respectable track record for treatment. Equally important, psychodynamic thinkers, many of whom practice outside of any major institution, continue to generate some of the most lucid and powerful ideas about human trauma. While the consensus among trauma workers today is that psychodynamic therapy is an anachronism, a historical curiosity not on par with evidence-supported treatments like PE and CPT, it’s worth remembering that the original psychiatrists who theorized PTSD—Chaim Shatan and Robert Lifton—were both working within the larger psychoanalytic tradition. Additionally, many of Freud’s original insights about adult trauma have stood the test of time, including his idea of the repetition-compulsion, which remains one of the most powerful concepts within the field of trauma studies. Nevertheless, the problem with the psychodynamic school with respect to PTSD has always been its overemphasis on childhood development and its reluctance to focus on adult-onset trauma. As Ghislaine Boulanger, a Columbia University psychologist and psychoanalyst, has written, “For most of the 20th century, psychoanalytic theory paid scant attention to those who had been wounded by reality.” Boulanger, who has worked with political refugees for decades, is one of a handful of theorists pushing the development of a psychodynamic understanding of PTSD, which she refers to as “adult-onset trauma.”

  The VA, which sets the tone for PTSD treatment worldwide, has long emphasized strictly empirical therapies, like PE and CPT, and gives short-term psychodynamic therapy a “C” rating for efficacy, its lowest ranking and a stark reminder of the intellectual divide in psychiatry that pits the Freudians and the quasi-Freudians against the biological psychiatrists, pits the biological psychiatrists against those with a more cognitive-behavioral bent, and so on.

  As I quickly learned when I began interviewing clinicians for this book, the mental health field is a staggeringly Balkanized one where broad consensus on any major issue is almost nonexistent and where hard science increasingly has the upper hand. Freud and his acolytes may have articulated some of the basic concepts that led to PTSD, but one is unlikely to hear him credited or quoted at a trauma conference. One senior VA administrator I spoke to sees the current emphasis on biology and narrowly defined empiricism as essentially a self-fulfilling prophecy, arguing, “Biological research is where the money is, so that’s where the discoveries, if you want to call them that, tend to come from.” Though he was trained in psychoanalysis, he explained, “I don’t usually describe myself as having a psychodynamic background because it usually makes for an unproductive conversation.”

  The major complaint leveled at psychodynamic psychotherapy is that it is not evidence based. Columbia psychiatrist and Nobel laureate Eric Kandel, who grew disillusioned with psychoanalysis shortly after beginning his clinical training, wrote, “Sixty years after its introduction . . . psychoanalysis had exhausted much of its novel investigative power. By 1960 it was clear, even to me, that little in the way of new knowledge or insights remained to be learned by observing individual patients and listening carefully to them. Although psychoanalysis had historically been scientific in its ambitions—it had always wanted to develop an empirical, testable science of mind—it was rarely scientific in its methods. It had failed over the years to submit its assumptions to replicable experimentation. Indeed, it was traditionally far better at generating ideas than at testing them.”

  Despite the lack of a distinguished scientific pedigree, psychodynamic psy
chotherapy remains a wellspring of ideas and a viable option for treating people with PTSD, especially people who suffer from trauma-induced guilt and shame and what is sometimes referred to as “complex” PTSD, or PTSD caused by years of extended trauma. Russell Carr, a navy psychiatrist at Bethesda–Walter Reed in Washington, has developed a promising short-term PTSD treatment based on a contemporary psychodynamic therapy known as “intersubjective systems theory.” Carr, who spent a year deployed to Baghdad, pointed out in a 2011 article that while psychodynamic therapies lag behind PE and CPT in development and acceptance, there remains a powerful need to develop other types of therapies, if for no other reason than because many PTSD “therapies with the most empirical support have dropout rates as high as 54%.”

  Intersubjectivity theory, the school of thought that Carr employs, is derived from the work of Robert Stolorow, a Santa Monica–based psychoanalyst and philosopher. According to Stolorow, a person who survives a traumatic event often perceives life in a fundamentally different way than the rest of the world—a world populated by people Stolorow calls the “normals.” A traumatized person, in his view, no longer believes, or has an intellectual understanding, that the world is a dangerous place, but instead feels its danger and menace in a profound way. Over time, such people find themselves deeply at odds with the rest of the world. The survivor may feel trapped inside the moment of maximum danger, unable to escape its force. The present has ceased to exist. The “normals,” who are still living in a coherent world of past, present, and future, can never understand the dissociated moment that the survivor still lives within. As Stolorow sees it, everyone wants to be understood, so much so that traumatized people are inexorably drawn toward others who had similar experiences, what he refers to as “siblings of the same darkness.”

  In his military practice, Carr treats some of the most chronic and complex PTSD cases in the country, including snipers, forward air controllers, and special operations personnel who have killed Iraqis and Afghans in the line of duty and struggle with the guilt and shame associated with killing another human being. Carr argues that intersubjectivity, with its focus on empathy, the unique emotional life of the patient, and helping the patient find a “relational home,” is an extraordinarily powerful therapy. Having spoken to both Carr and Stolorow at length, I can attest to the fact that while intersubjectivity lacks an extensive empirical grounding, the basic ideas behind it offer a refreshing contrast to the robotic, one-size-fits-all protocols of PE and CBT.

  The problem is, of course, that intersubjectivity, like classical psychoanalysis, is more philosophically dense than PE and CPT, a fact that presents some challenges for its widespread use. Nevertheless, Carr, who was forced to truncate and condense many of Stolorow’s ideas while in Iraq, has found tremendous success with it. Like all psychodynamic therapies, intersubjectivity relies more on the art of therapy than the science, which forces the therapist to focus more energy on developing a connection with the patient. All of which seems to have worked for Carr, who, while in Iraq, had several soldiers tell him, “Doc, you get this more than anyone I’ve talked to about it.”

  I can see the point of people, like Eric Kandel, who argue that psychoanalysis isn’t based on science. The thought of putting a young Marine lance corporal on the couch is ridiculous. Still, talking for a few hours to practitioners like Carr, Stolorow, and Boulanger while researching this book helped me about as much as twelve weeks of CBT. The main thing I got from the psychodynamic psychotherapists I talked with was a deeper sense of the psychic cost of trauma, a humanist sensibility, as well as a refreshing willingness to think through issues relating to trauma in more than the rote terms of the manualized therapies. Carr, Stolorow, and Boulanger all got excited and emoted while in conversation, whereas the CPT and PE advocates I interviewed seemed to talk about trauma from a cool remove, as if by not engaging their own emotions they could somehow remain above the fray. Now, I’m a writer, and I experienced the war through the lens of an infantry officer turned journalist, so I’m hardly your average survivor, but I really benefited from talking about how trauma has altered my sense of time and hearing what Martin Heidegger thought about it.

  And while almost no one within the VA will admit it, these sorts of “nonspecific” effects of therapy, all the benefits a patient gets from connecting and developing a rapport with a therapist—even if they’re just English professors who’ve been briefed on a few therapeutic techniques—has a lot of empirical support. But from what I can tell, the VA and the Department of Defense, the eight-hundred-pound gorillas of PTSD treatment, aren’t terribly interested in that sort of thing. What they seem to want instead is mass-produced, scalable, scripted therapies that make for compelling PowerPoint slides. In a way, it’s a lot like what you see in the national debates over education. Every parent knows that it’s the passionate, sometimes eccentric teacher-artists who really make the difference in their children’s lives, but it’s incredibly difficult to institutionalize that kind of quality teaching, and educational administrators in the United States frequently view those brilliant Dead Poets Society–style teachers with suspicion because they fear the unknown.

  Still, there are signs of hope. The VA has begun training some veterans as patient advocates who sit in on group therapy sessions. In 2010, the Marine Corps began fielding a peer counseling–type program that trained noncommissioned officers in basic techniques of combating operational stress. There are also the roughly two hundred “retail”-style Vet Centers run by the VA, located in strip malls across the country, which offer what is sometimes dismissively referred to by VA researchers as “supportive” counseling. Several veterans I interviewed found the Vet Centers to be the better option because they are smaller and the waiting list is far shorter than at your average VA hospital.

  Most people cannot emerge from post-traumatic stress by simply gutting it out. Chronic PTSD is a life-threatening event and has to be treated or intensively managed by loved ones. During treatment, you must continue to fight, continue to seek insights into your experience, continue to read and to introspect, continue to seek out the company and advice of others. The community of survivors is a real thing. Researching this book has brought me closer to friends who have survived rape, just as it has brought me closer to other veterans and family members who have survived accidents in the wilderness. As I have attempted to demonstrate in these pages, going to therapy is not a sign of weakness, any more than going to a battalion aid station or an emergency room to have a broken bone set is a sign of weakness. Many of my heroes have struggled with post-traumatic stress: grizzled master sergeants, Medal of Honor winners, acclaimed mountaineers, poets, novelists, and artists of every stripe. Therapy saves lives, and the simple fact is, if you’re embarrassed about it, you don’t even have to tell anyone: just go. Just seeking out therapy has a proven salutary effect: researchers refer to this as the “expectancy” phenomenon. It’s a surprising thing to say, but even sitting in a waiting room can make you feel better because you’ve already taken one step away from the pain.

  One of the odd paradoxes of trauma is that it happens in a moment, but it can consume a lifetime. The choice as to how much time it is permitted to consume is usually in the hands of the survivor. I have interviewed a number of trauma survivors who speak of the time after being raped, or their time addicted to crystal meth after the war, as their “lost years,” as time that they pine for, time that they want back. I consider myself something of an enlightened stoic, someone who has found deep meaning in struggle, pain, and exertion. Some of my happiest moments in life have come after almost dying. Winston Churchill said, “Nothing is so exciting as being shot at without result.” Life is meaningless without suffering, but there comes a time when you have to accept the fact that not all pain is purifying or ennobling and that numbing out and isolating yourself from the world is counterproductive and destructive to yourself and your loved ones.

  As a former Marine and someone who has reported on war
for years, I see that we have come to the end of over a decade of seemingly never-ending bloodshed. With the end of horror comes the hope for insight. Ernest Hemingway, writing in 1946, the year after World War II ended, said, “We have come out of the time when obedience, intelligent courage, resolution and the acceptance of discipline were most important, into that more difficult time when it is a man’s duty to understand his world rather than to simply fight for it.”

  7

  DRUGS

  JIM MCGAUGH IS used to seeing his name on the sides of buildings, being feted, and seeing his portrait hanging in long hallways. But Jim McGaugh is no titan of industry, nor is he a star athlete or a financial wizard with a taste for philanthropy. Jim McGaugh is a neuroscientist. Into his eighties now, when he leaves his office at the University of California, Irvine’s Center for the Neurobiology of Learning and Memory (which he founded in 1981) on his way to the science library, he walks by James L. McGaugh Hall, a four-story lecture building completed in 2002. One of the first professors hired at UC Irvine when the campus opened in 1964 and a perennial Nobel favorite, McGaugh has devoted his entire sixty-year career to understanding the biological nuts and bolts of human memory.