The Evil Hours

by David J. Morris

  In Once a Warrior, Always a Warrior, Charles Hoge, a retired army psychiatrist and the author of an influential PTSD study in the New England Journal of Medicine, writes, “There are numerous new modalities of treatment being promoted for PTSD, and treatments du jour seem to be constantly springing up as the latest ‘answer’ to the PTSD problem. A lot of interest has been generated by increased government funding for research for both these conditions since the start of the wars in Iraq and Afghanistan . . . Some of these have been promoted in news stories, and many veterans have questioned why the DoD and VA have not adopted them for regular use. The reason is that these modalities have not been proven to be effective in rigorous research studies.” He concludes by saying, “The bottom line is that there is no ‘magic bullet’ for PTSD, and claims to the contrary should be taken with more than a grain of salt.”

  While I agree with Hoge about the absence of a magic bullet, my experience suggests that many nonstandard therapies have value, in part because they create what researchers call an expectancy effect, where the simple expectation of improvement communicated through the practitioner brings about healing. A guiding principle when shopping for therapies is that PTSD is an incredibly complex condition, and it manifests itself in people in a dizzying variety of ways. As the philosopher Roland Barthes wrote, “Each of us has his own rhythm of suffering.” In addressing one’s particular rhythm of suffering, one often must undergo a process similar to the one that Elise underwent, experimenting with different therapies, while paying close attention to your individual symptoms, eventually settling on the therapy (or therapies) that feels right for you.

  Another reason to consider one of the many alternative therapies out there is that they often offer a host of positive, difficult-to-­quantify social effects that are hard to find with traditional manualized therapies. For example, the idea of training people with PTSD to be cage fighters, as Iraq veteran Todd Vance is doing at the Undisputed gym in San Diego, seems ludicrous at first and potentially even damaging. What exactly, one might reasonably ask, is the point of exposing traumatized people to even more violence? For my part, I hated the hand-to-hand combat training I did in the Marine Corps and have long found the mixed martial arts subculture to be a parody of American hyperaggressive masculinity. But when I sat in on one of Vance’s classes upstairs at Undisputed, I found my mind changing.

  Watching a group of sweaty young vets working on various holds and groundfighting techniques, I saw that MMA does provide a structured social environment for young men (and women) and a way to achieve a state of flow where they can get out of their heads and focus on mastering a regimen of techniques, not entirely unlike yoga. Like yoga, MMA seems to offer a wealth of hard-to-quantify nonspecific therapeutic benefits of the sort that frequently drives researchers crazy when they compare PTSD treatment protocols. More to the point, yoga and MMA, as disparate as they might seem at first, both offer an opportunity to escape “the PTSD bubble,” a chance to get out of the house and interact with people, while doing something that helps them create a greater knowledge about their bodies, a process that psychologists refer to as interoceptive learning.

  In 2012, after finishing CPT, I took part in a VA study that examined mantram repetition as a PTSD therapy. The experiment, led by a nursing researcher, applied the teachings of Eknath Easwaran to the problems of post-traumatic stress. Easwaran, who was an English professor in India before he came to the United States in 1959 on a Fulbright scholarship, teaches that we all have inner resources for dealing with crises, and that by developing skills to cultivate an inner calm, we can transcend “the storms of life.” The study used group therapy to introduce Easwaran’s principles and took place in one of the outbuildings at VA La Jolla. For the first session, the six of us were given workbooks and copies of Easwaran’s book Strength in the Storm and told to read a few chapters for the following week. Much like CPT (and Buddhist teachings), Easwaran’s philosophy revolves around the idea that the world is a largely neutral place, and it is the human reaction to events that determines the outcome. As Easwaran wrote, “We can’t control life, but we can control how we respond to life’s challenges. The answer lies in stabilizing the mind.”

  For our next session, our leader, a kindly retired psychiatric nurse named Kathy, had us select a mantram from a list of ecumenical phrases (“mantram” is the correct conjugation of the Sanskrit, meaning “an instrument of thought”). I chose “Om Shanti,” a Sanskrit invocation for peace. The idea, Kathy explained, was to repeat our mantram as many times as possible each day, especially during relaxing times at first. As time went by, the mantram would become a personal codeword for inner calm and could be used in times of stress or fear to disrupt the fight-or-flight response.

  One of our group was a Marine I recognized from Iraq named Andy. Andy had, like Fernando, done seven overseas deployments since 9/11. “Forty-nine months I’ve been away from my family,” he explained. As the group progressed, I found out that Andy and I had another thing in common: we were both members of an elite, little-known fraternity within U.S. military circles. We were both former Marines who surfed. Andy, however, was no chilled-out surf bro who’d worn a uniform between paddle outs (which was how an old company commander once described me). One look at him and you could tell he’d been down some bad roads. I had run into Andy at a small base west of Fallujah six years before, and I remembered him even then as unusually angry and short-fused. Toward the end of the eight-week study, he was surfing again and thinking about quitting his job, a job he didn’t entirely need, and moving to a smaller house to shrink his mortgage.

  The group ended a couple weeks later. The consensus was that while it was not a miracle, mantram repetition was helpful. For a variety of reasons, mantram repetition didn’t really do it for me. I’ve always been restless and distractible by nature, and the idea of sitting in place and repeating the same three syllables over and over again for hours was, well, boring as shit. Reading for me is practically a biological function, and after about ninety seconds of saying “Om Shanti, Om Shanti, Om Shanti” in my apartment during my designated mantram times, my eyes would wander like heartsick lovers over to the nearest bookshelf, and before I knew it, my mind would be consumed by the plot of the latest Thomas Pynchon novel, not my mantram. Nevertheless, I was the only one in the group who didn’t find mantram repetition helpful. Andy, in particular, said that it had helped him a lot. I’m inclined to believe his testimonial, since it’s supported by the evidence of my observation. I’d seen him in Iraq, and he did seem slightly more at peace by the end of the eight-week study.

  With a few notable exceptions, alternative therapies are informed by premodern, prescientific traditions. Yoga and mantram repetition are arguably even antiscientific, being mostly unconcerned with the mind-body divide, instead focusing on ways to connect these realms. If one starts with the idea that modern trauma begins with the railroad, electricity, and industrialization, it’s not hard to see how these alternative therapies might work by putting us in touch with cultures and traditions that predate modern civilization. In that way, the charge leveled by Hoge and the VA is exactly correct, as alternative therapies tend to be more philosophy than science, standing in stark contrast to science, which works by isolating individual components in nature and subjecting them to experimentation. Elise’s story is instructive: while I know that she’s familiar with the workings of the amygdala and the hippocampus, the process that took her from being a haunted, hypervigilant young woman to who she is today had nothing to do with the miracles of modern neuroscience and was primarily concerned with reacquainting her with her breath and emotional processes, which have thus far eluded scientific scrutiny. Of course, simply because these healing and consciousness-centering traditions are older than the scientific method doesn’t mean that they can’t be tested by reasonably objective means.

  Which, it turns out, is exactly what Jill Bormann, the organizer of the mantram repetition study, did. All of us were given
a CAPS before and after the study. Bormann, whose results were published in April 2012, found that of the 146 veterans studied, 30 percent “no longer met the diagnostic criteria for PTSD, compared to only 14 percent in the standard care group.” Now, admittedly, as a self-reported measure the CAPS is a very limited tool, but if Andy was any indication, mantram repetition appears to work. Importantly, unlike PE (and the new virtual reality exposure therapy, which uses video technology to achieve the same end state), mantram repetition and yoga are cheap, risk-free, and portable.

  One therapy that has bridged the divide between alternative and mainstream is eye movement desensitization and reprocessing, or EMDR. EMDR was developed, or more accurately discovered, in 1987 by Francine Shapiro, a researcher in Palo Alto, and it works by stimulating both sides of the brain while activating memories of the trauma. The conceit behind EMDR is that trauma happens because the brain is so overloaded with information during the moment of maximum horror that it stops making memories in the normal way.

  As Shapiro describes in her 1997 book, “The seed of EMDR sprouted one sunny afternoon in 1987, when I took a break to ramble around a small lake. It was spring. Ducks were paddling by, and bright blankets full of mothers and babies were laid out on wide green lawns. As I walked along, an odd thing happened. I had been thinking about something disturbing; I don’t even remember what it was, just one of those nagging negative thoughts that the mind keeps chewing over (without digesting) until we forcibly stop it. The odd thing is that my nagging thought disappeared. On its own . . . I started to pay careful attention as I walked along. I noticed that when a disturbing thought entered my mind, my eyes spontaneously started moving back and forth. They were making rapid repetitive movements on a diagonal from lower left to upper right. At the same time, I noticed my disturbing thought had shifted from consciousness, and when I brought it back to mind, it no longer bothered me as much.”

  The therapy, which Shapiro has continued to articulate and develop since her day at the lake, is built on this basic principle of engaging disturbing memories while attempting to stimulate the different halves of the brain. Recent additions to the EMDR playbook include using other stimuli, like flashing lights, alternating sounds, and directed hand taps, all of which aim to aid the brain in information processing. From Hoge’s perspective, EMDR and much of Shapiro’s work suffer from what might be called the “magic bullet” fallacy, in that she consistently and often breathlessly describes it as “the breakthrough therapy” for a whole host of ills, claiming at one point that “84 to 90 percent of the people using EMDR—victims of rape, natural disaster, loss of a child, catastrophic illness or other traumas—have recovered from posttraumatic stress in only three sessions.” This tincture of snake oil hasn’t escaped the attention of VA-aligned researchers, and many of Shapiro’s assertions remain disputed by neuroscientists, particularly the idea that eye movements help reprocess traumatic memories. Despite these criticisms and complaints about how EMDR is being marketed to the public, a number of studies have found that EMDR is effective for PTSD. Some studies that have tried to isolate the active ingredients in EMDR suggest that its effectiveness has little to do with eye movements and more to do with the fact that EMDR is generally “client-centered,” allowing the patient to choose the manner and pace of the therapy.

  Clint van Winkle, an Iraq vet who underwent EMDR in 2007, wrote in his memoir Soft Spots that “the therapist lets you control your thoughts, and only steps in if it gets too rough in your head. We’re taking it slow, working our way into full-on war memories. When we get to that point, my neurotransmitters will be firing at the cyclic rate of a .50 cal . . . Why EMDR works, nobody really knows. Even practitioners have problems explaining the results they see in their patients. It’s possible that the process of watching fingers move side to side evokes some sort of placebo effect where patients just think things are getting better, wishing so hard for positive results that they actually feel they have found one in EMDR. Placebo, wishful thinking, whatever. I’ll take the help where I can get it.”

  EMDR exemplifies a recent trend in alternative therapies in taking a nugget of neuroscience and joining it with an anecdotal observation from real life to create something akin to a revolutionary cure. (Though a great deal of this inflation problem is the fault of the media, which has an awful habit of reporting virtually any emerging PTSD therapy as if it is the ultimate cure that will signal the end of human trauma as we know it. The New York Post, for example, in the days after 9/11 hailed EMDR as a “miracle cure.” Salon and other media outlets ran similar coverage.) EMDR occupies a unique position in the world of PTSD in that while many leaders in the medical establishment find its theories kitschy and even silly, it has also been designated by the VA as an evidence-supported treatment, making it nominally on par with PE and CPT. Nevertheless, there remains a detectable skepticism toward EMDR within the VA and the research it sponsors. Tellingly, when I asked around the VA system in Southern California (I called VA San Diego and VA Long Beach), I was told that EMDR was not available, nor were there plans to make it available any time soon.

  Obviously, we have much more to learn about the relationship of trauma to the brain, body, and spirit, and it would be a mistake to lean too heavily on any one type of therapy or on any one type of study. It would also be a mistake to assume that hearing the phrase “evidence-supported” before a given therapy means that it will work for you. “Evidence-supported” and “evidence-based” mostly mean that a lot of doctors happen to like it, oftentimes for reasons that have less to do with the actual value of a therapeutic protocol than with trendiness. And it’s worth remembering that, for a period of time, a lot of doctors liked the lobotomy as a post-traumatic treatment and inflicted that procedure on thousands of veterans during the 1940s. Indeed, the technique was so well liked that its inventor, Egaz Moniz, was awarded the Nobel Prize in medicine in 1949.

  What is most striking about how therapies are developed and implemented in PTSD-land today is how rarely one actually hears what patients think about it all. Perusing the technical literature of trauma, one almost never reads a patient’s individual account of a protocol they’re undergoing. If they’re mentioned at all, they’re spoken of as “subjects” or “female sexual assault victims” or, most often, merely as numbers, as n = 246.

  To be fair, this is how science is done—that is to say, impartially and clinically—and one can quite easily find testimonials for PE and CPT on the VA website and on YouTube, but they are just that: testimonials delivered by, you’ll forgive me, shills for the VA. There doesn’t seem to be any conspiracy at work here, just an assumption on the part of the psychiatric establishment that they know what’s best for their patients. In fact, the only consumer-type ratings of PTSD therapies by patients I’ve ever found were unscientific surveys conducted by third-party groups with their own goods to market at me.

  The abuse of power by psychiatrists is a fraught subject, ground that has been well tilled by the likes of Michel Foucault, Edward Szasz, R. D. Laing, and many others. I won’t attempt to rework that soil here except to say that it is exceedingly odd that virtually all the post-trauma therapies in use today were invented, refined, and implemented by American academics, far removed from the battlefield, far removed from the streets of Detroit or Mogadishu. Whenever survivors’ views are included in the policymaking process, it is inevitably well after the major decisions have been made and the clinical die cast. In shamanic societies, which represent some of the world’s oldest healing traditions, healers were often trauma survivors themselves. Wisdom was presumed to flow from the experience of surviving into the healer’s thought process. In the West today, the opposite is true. It is the most protected, the most insulated, the most innocent who are presumed to be the most knowledgeable about loss, terror, and moral chaos. Trauma workers today are schooled to look at survivors through the cold lens of modern medical pathology, adopting the same moral framework and the same lexicon that are used to trea
t malaria and measles.

  Chatting with Elise one day about this, she told me that she had seriously considered becoming a psychologist, but she abandoned that prospect because “clinical psychologists are just that. Clinical.”

  Many people have asked me if writing this book has helped me with my own post-traumatic stress. Generally speaking, I hate the idea of turning writing into therapy, and I did not conceive of this book as a therapeutic project, but delving into the history and literature of PTSD has, in fact, been extraordinarily useful. Writing about it has been difficult at times, but it has shown me unexpected facets of my own past. Using writing as therapy is a tricky business because it can so easily turn into an orgy of self-pity and navel-gazing. As Alice Sebold said, “My feeling is that therapy is for therapy and that writing can be therapeutic, but therapeutic writing should not be published.” Still, the process of writing, of trying to capture your experiences on the page, however skilled or unskilled you may be, can be extremely helpful, allowing you to see patterns in your life that were invisible before. It can also be incredibly cathartic.

  It was Ford Madox Ford who wrote, “You may well ask why I write. And yet my reasons are quite many. For it is not unusual in human beings who have witnessed the sack of a city or the falling to pieces of a people to desire to set down what they have witnessed for the benefit of unknown heirs or of generations infinitely remote; or, if you please, just to get the sight out of their heads.”